Welcome to our second Care Update report which looks at the quality of health and social care provided to people between April and December 2012.
We've brought together the findings from our inspection reports and themed reviews, the views and experiences of people who use services and data from other sources to produce this report.
The report focuses on the impact that dementia is having on the quality of care that people receive. You'll also find out about the number of services that are providing a good quality of care compared to those that need to make improvements, and the progress that services have made since the findings in Our first Care Update.
What does care look like in England?
By the end of December 2012, we had inspected 24,276 adult social care, NHS, private health care and dental services.
This can be broken down by:
Impact of dementia care
Reviewing the Health Episode Statistics
We carried out a review of data called the Health Episode Statistics to look at how long people with dementia stayed in hospital, how often they were readmitted and how often they died in hospital, compared to people without dementia.
According to Alzheimer's Society, longer stays in hospital can lead to:
- a worsening of the effects of dementia and physical health.
- a greater likelihood of being discharged to a care home instead of the patient's own home.
- a greater likelihood of antipsychotic medication being used.
What did we find?
In more than half of primary care trust areas in England, care home residents who have dementia are more likely to go into a hospital with a problem such as a urinary infection, than people without dementia.
Overall, those with dementia who are already in hospital are more likely to stay there longer, be readmitted and die in hospital than others in similar circumstances who do not have dementia.
Alzheimer's Society, a charity which works to improve the quality of life of people affected by dementia, say: "This could firstly be an issue of training. Many care home staff are not adequately trained to work with people with dementia, so people with dementia may deteriorate and need hospital care.
"It could also highlight that integrated care is not happening. If community and local NHS services were supporting care homes, this could prevent an admission to hospital."
Indentifying dementia
Hospital services must also improve the way they identify dementia and the training that their staff need to care for patients.
In almost a third (29 per cent) of hospital admissions, staff did not record dementia as a condition that the patient was suffering from, even when it had been recorded in the past.
Alzheimer's Society commented: "This leads to hospitals underestimating the number of people with dementia that they are caring for, and not prioritising the right treatment and support or ensuring that the right systems including care pathways are in place.
"Training would help staff to identify the person with dementia and reduce length of stay by helping staff to respond effectively to dementia, for example by ensuring their nutritional needs are met."
How has this type of care impacted people with dementia in hospital?
The chart below shows the percentage of NHS hospitals where people with dementia are significantly impacted by the care they are given, compared to people without dementia.
Younger people and dementia
Our findings show that patients aged 18-54 are affected most by dementia care.
Unrecorded cases of dementia were three times more common in people of this age group compared to those over the age of 75. People in this age group are also more likely to stay in hospital longer, be readmitted and die in hospital than those in the same age group who don't have dementia.
This again highlights the importance of staff training around identifying the signs of dementia.
Case study: Services that are making a difference
Many services are rising to the challenge of improving the care they provide to people with dementia.
Here are two examples of initiatives that show what can be done.
University Hospitals Bristol NHS Foundation Trust
University Hospitals Bristol NHS Foundation Trust have worked with North Bristol Trust to develop an agreed dementia champion role.
Dementia champions are in place in all clinical areas and come from a multitude of backgrounds, including porters, nurses, housekeepers, occupational therapists and pharmacists. Additionally, study days are held twice a year for champions to come together from both trusts to hear about new developments and share learning.
Among many other improvements, clocks and calendars have been installed in all wards and departments to help orientate patients.
University College London Hospitals NHS Foundation Trust
University College London Hospitals NHS Foundation Trust has set up an older adults assessment team to continue the drive for person-centred care which incorporates improved assessment and planning, and patients and carer involvement.
They have secured funding to change a bathroom into a dining area on their older people's ward and to establish dementia friendly areas in accident and emergency, the acute medical unit and orthopaedic wards.
NHS
By 31 December 2012, 650 (83 per cent) of NHS services that we had inspected were meeting all of the National standards we checked.
An additional 125 services were not meeting at least one standard and we took enforcement action against another four NHS services.
What were NHS services doing well?
Hospitals and community services provided by the NHS were better able to plan and deliver care and treatment to patients. 90 per cent of inspections of hospitals and 92 per cent of inspections of community health care services showed planning and delivery was being done better.
We also found that many of these services did more to protect people from the risk of abuse and were able to prevent it from happening.
Community services and mental health and learning disability services had improved the support for their staff. 92 and 95 per cent of inspections of these services showed that staff were being supported through training, supervision and appraisal.
What needs to improve?
The number of hospitals that could ensure the quality of care they provided to people had decreased by two per cent by the end of December 2012 - in the first nine months of 2012/13, 88 per cent of services could ensure the quality of care they provided, compared to 90 per cent in the whole of 2011/12.
We found that a number of services were not checking the quality of care effectively because they weren't capturing the views of patients - or when they did, they weren't using the findings to drive change. In addition, other services were not following up care audits with staff training and learning.
Mental health and learning disability services struggled to maintain adequate staffing levels that were needed to treat patients. Only 80 per cent of services had adequate staffing in place in the first half of 2012/13, compared to 91 per cent in the previous year.
Case study: Improvements made following an inspection
The case study below shows you the improvements that a NHS mental health service made following an inspection.
Findings from our first inspection
Following a visit to a mental health service, our Mental Health Act Commissioner (MHAC) recommended improvements around care planning.
They looked at six care plans based on the medical treatment and nursing care being provided to find out what each patient's needs were and how they should be met.
However, the care plans were not presented in a person-centred way and we saw limited reference to patients being involved.
One patient told us: "They say I'm here for assessment but I don't know what they're assessing, I don't feel like I'm getting treated for anything."
Another patient said they did not have confidence that they had been given all available information about their care and treatment. They told us: "We have had meetings, and discussions have taken place but then the information dries up and I'm not sure what's going on now."
Improvements found following our follow-up inspection
The service wrote to us in March 2012 and confirmed they had fully implemented the action plan we asked for.
During a follow-up visit, we looked at care plans on one ward. We saw that people who used the service were being fully involved in their care plans, and when they weren't, there were clear reasons explaining why. Care plans also contained some good person-centred running records.
There were now regular weekly opportunities for people to discuss their care and treatment.
The provider was also in the process of implementing a more person-centred care plan system and was providing staff with training about what makes for a good person-centred care plan.
Adult social care
By 31 December 2012, 15,160 (80%) of social care services that we had inspected were meeting all of the National standards we checked.
An additional 3,749 services were not meeting at least one standard and we took enforcement action against another 149 services.
What were care homes doing well?
A higher number of nursing homes and residential care services were providing better care by the end of December, compared to March 2012.
These services were also doing more to support the needs of their staff, assess the needs of their residents and give them the care and support they needed.
In particular, there was an increase in the number of residential and nursing homes that were protecting people from the risk of abuse. 89 per cent of inspections of nursing services and 94 per cent of inspections of residential services showed that people were being protected - both figures had gone up by six per cent by the end of December 2012.
What were home care services doing well?
We also saw some improvements in the way that home care services planned and delivered care that people needed. 89 per cent were planning and delivering care appropriately to people, compared to 86 per cent by the end of March 2012.
94 per cent of home care services were protecting people from abuse, compared to 90 per cent the previous year.
In our inspection programme (called the Review of home care services), we found that many services were delivering a very good service. Overall, 74 per cent of services (184 out of 250) met all five areas that we had inspected as part of the programme.
What needs to improve in home care services?
Our concerns around home care services are around:
- late and missed visits.
- lack of consistency of care workers.
- lack of support for staff to carry out their work, and failure to address the ongoing issues around travel time.
- poor care planning and a lack of regular review.
- staff understanding of their safeguarding and whistleblowing responsibilities.
Small versus large social care services
We also looked at the performance of large providers (those that operate more than 20 services) compared to small and medium ones.
In most areas, large providers were providing a better quality of care. The only exception to this was around staffing, where small and medium providers were recruiting adequate numbers of staff compared to large providers.
Overall, the size of a home care provider did not affect the quality of the service provided.
However, the medium and large providers (those that provide care to more than 100 people) were more likely to need to make improvements than small providers.
Private health care services
On 31 December 2012, 1,262 (89 per cent) of private health care services that we had inspected were meeting all of the National standards we checked.
The number of services that were not meeting at least one standard had decreased by seven per cent – from 18 per cent in March 2012 to 11 per cent by the end of December.
We also took enforcement action against seven services where we found serious concerns.
All private ambulance services that we had inspected by the end of December were treating patients with respect. In 97 per cent of cases, these services were providing good care and treatment as well.
However, there were 15 services that were not meeting at least one standard at the end of December.
What were private services doing well?
Private hospitals and community health care services were better able to plan and deliver care and treatment that patients needed. They also did more to protect them from the risk of abuse.
Private community health care services had improved the support they gave to their staff through training, supervision and appraisals. By the end of December, 95 per cent were providing adequate training to their staff, compared to 91 per cent in the previous year.
There was also an eight per cent increase in the number of private mental health, learning disability and substance misuse services that were treating people with respect and involving them in decisions about their care – from 85 per cent to 93 per cent by the end of December 2012.
What needs to improve?
The care provided in private mental health and learning disability services needs to improve, especially when compared to the performance of private hospitals and community services.
Compared to the rest of the private health care sector, fewer people in private mental health and learning disability services were:
- involved in discussions and decisions about their care.
- treated with dignity and respect.
- fully assessed to ensure their needs were met.
We are also still seeing too many private mental health and learning disability services that are not delivering care that puts people first.
These services still have some way to go to provide a good quality of care, and we expected improvements to be made quicker than they have been.
Our main concerns about the care that private ambulance services provide are around:
- the cleanliness of ambulance vehicles.
- recruiting staff effectively and carrying out thorough checks on them.
- supporting staff through training and supervision.
- monitoring the quality of care to make sure people are safe.
Dental care services
By 31 December 2012, 2,772 (92 per cent) of dental services that we had inspected were meeting all of the National standards we checked.
An additional 244 services were not meeting at least one standard, and we took enforcement action against another five services that we had serious concerns about.
What were dental services doing well?
Our inspections of dental services focus on:
- respect and involvement.
- care and welfare.
- keeping people safe from abuse.
- cleanliness and infection control.
We found that dental services were providing very good care compared to other types of health or social care services.
What needs to improve?
There are two areas where we have noticed dental services performing less well.
Only 85 per cent of inspections showed that dental services had recruited staff effectively and carried out thorough checks on them. In addition, only 81 per cent of inspections showed that patient records had been kept up to date, safe and confidential.
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Care Update: Issue 2 (Large print)
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