Dr Rekha Elaswarapu

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Caring for Dignity
The way forward

• Dr Rekha Elaswarapu
• Lead - Older people Strategy
• 25 November 2008

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Background and rationale

• NHS spends 45 of its expenditure on older
  people.
• Older people are the highest users of the acute
  services.
• Anecdotal evidence indicates that older people
  are often not treated with respect and dignity.
• Older people told us that maintaining respect and
  dignity is of paramount importance to them.
• Living well in later life a joint national
  report on older people services highlighted this
  as an issue of concern

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AHC - Providing assurance that older people are
being treated with dignity and respect
Standards for Better Health Core
Standards
C13a
Healthcare organisations have systems in place to
ensure that staff treat patients, their
relatives/carers with dignity and respect
C15a
Healthcare organisations have systems in place
to ensure that patients are provided with a
choice and that is prepared safely and provides
a balanced diet
C15b
Where food is provided, healthcare organisations
have systems in place to ensure that patients
individual nutritional, personal and clinical
dietary requirements are met, including any
necessary help with feeding and access to food
24 hours a day
C20b
Healthcare services are provided in environments
which promote effective care and optimise health
outcomes by being supportive of patient privacy
and confidentiality
By assessing compliance against these core
standards as part of the annual health check, we
get an overview of how well each organisation is
achieving the general standards of care that the
Department of Health requires.
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Responsive Surveillance focused on Standards
More detailed look at targeted sample of trusts
declaring compliance with relevant standards
Annual Health check Compliant trusts
Notification if not compliant

• Screening on evidence sources
• NHS surveys
• ERIC
• PEAT
• Complaints

High risk trusts visited
Action plans Monitored by us and SHA
Local intelligence
23 trusts visited, two wards in each trust
selected based on local intelligence, included
interviews/observations,
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Key findingsCaring for dignity the building
blocks

•  
• involving older people in their care
• delivering personal care in a way that ensures
  dignity for the patient
• having a workforce that is equipped to deliver
  good quality care
• strong leadership at all levels
• supportive ward environment

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Key findings Workforce

• Older people consider staff to be instrumental
  in maintaining their dignity which includes
  nutrition.
• Staff need to be aware and trained in dignity
  issues. We identified gaps in certain areas
  especially with dementia patients.
• Staff are not always supported in practices
  such as protected meal times and adequate
  staffing. This has an impact on the dignity of
  patients
• Difficulty in accessing specialist staff thus
  delaying assessment
• Staff struggle to provide assistance if complex
  patient mix

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Key findings Leadership

• Board-level commitment is essential for making
  dignity including nutrition a high priority.
• Implementation of several policies relating to
  dignity (and nutrition) was fragmented and left
  to the discretion of individual wards, which
  caused variations.
• Reports on dignity/nutrition were not always
  received and considered by the boards of many
  trusts.
• Some concerns about systems of monitoring
•  

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Key findings ward environment

• Many trusts struggling to provide single sex
  accommodation. Some patients such as those with
  MRSA being nursed in mixed sex bays
• Inadequate arrangements around appropriate
  curtains and locks on toilets and wash
  facilities
• Not all trusts providing private areas for
  spiritual needs
• old style wards posed difficulties in providing
  privacy
• Some good examples of innovative ways
•  

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Caring for dignity our recommendations

• Dignity is integral to basic care. It
  is also a human rights issue.
• Dignity must be discussed at board meetings
• Strong leadership at all levels can make a
  difference.
• Clear communication to staff about the trusts
  commitment to dignity is needed.
• Trusts should provide and promote a culture for
  staff and patients to enable them to report
  compromise in dignity without fear.
• Trusts should provide a supportive environment
  for staff to provide care with dignity.
• Trusts should improve links with community
  organisations to make services responsive to
  the needs of their diverse population.

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Improving dignity the framework

• Policies to ensure that dignity is
  maintained (for example, dignity in care,
  nutrition policy, training, whistle-blowing)
• Practices that translate these policies
  into working guidelines (for example, protected
  meal times, provision of adequate staffing,
  provision of adaptable cutlery)
• The readiness of staff to deliver care
  that respects patients dignity (for example,
  skills awareness and training in issues relating
  to dignity for older people)
• Assurance for the trust that policies
  on dignity in care are working (for example,
  monitoring, observation of care, reflection on
  practice, reports to the board, feedback from
  patients)

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Improving dignity it can be done!

• Protected mealtimes - Heart of England NHS
  Foundation Trust, Birmingham
• Investing in workforce Queen Victoria
  Hospital, West Sussex
• Fridays with a difference Guys and St Thomas
  NHS Trust, London
• Learning from practice Christie Hospital NHS
  Trust, Manchester
• Working with volunteers Stafford General
  Hospital , Stafford
• Gowning around at the Royal Brompton Hospital,
  London
• Reducing the incidence of mixed bays Ashford
  St Peters NHS Trust Surrey

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Implementing recommendations1(some examples)

• Dignity is now included in the mandatory training
• Each ward has a coordinator to make sure
  patients are
• appropriately positioned and are getting
  required help. The
• coordinator is an experienced band 5 nurse.
• A food and nutrition strategy is also to being
  developed.
• Dignity in care audits have been rolled out
  across the
• organisation in addition to annual PEAT
  inspections.

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Implementing recommendations2

• Breaches of single sex accommodation are taken
  seriously and have now reduced, and a bed
  management policy with clear guidance for staff
  is being developed.
• A Carers Workshop, in collaboration with the
  local Carers
• Centre, for staff from each Directorate, to
  gain an insight into the
• needs of Carers, and to develop expertise in
  different areas.
• Caring for Dignity - Let them know you care
  Practical Guidance Issued by the Director of
  Nursing October 2007 in response to the
  Healthcare Commission Report Sept 07
• .and many more

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Levers and challenges
Care Quality Commission
Darzi Review
Health and Social Care Act
Commissioning
Dignity metrics
Nutrition Action Plan
NHS constitution
new registration criteria
Mental Capacity Act
Human rights
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