The first full report of the National Audit of Dementia has identified a need for significant improvements in hospital ward environments, staff training and the overall approach to care delivery for patients with dementia.

Although the majority of wards meet basic safety requirements, the audit shows that many had not addressed simple measures that could lessen the distress caused to dementia patients by an unfamiliar and confusing hospital environment.

The audit also reveals deficiencies in staff training. Less than a third of staff said that their training and development in dementia care was sufficient. Observations of care carried out for the audit found that care is often delivered in an impersonal manner, by staff who did not fully understand the needs of patients. This resulted in staff not greeting or talking to patients during care, explaining what they were doing or offering choice. Sometimes, staff were seen failing to respond to patient’s requests for help.

The audit was commissioned by the Healthcare Quality Improvement Partnership (HQIP) and carried out by the Royal College of Psychiatrists’ Centre for Quality Improvement in partnership with other organisations. The main audit looked at data collected from 210 hospitals across England and Wales. Ward level data was collected from a sample of 145 wards across 55 hospitals. This included 2,211 staff questionnaires, and 105 observations of care on the ward, carried out by hospital staff.

Key findings from the report include:

• Only 6% of hospitals had a care pathway in place for people with dementia – although 44% had one in development at the time of the audit.
• Only 32% of staff said that their training and development in dementia care was sufficient. One staff member surveyed said: “I have never had any training related to caring with patients with dementia or Alzheimer’s. As staff have not had training, I feel that these patients do not receive the specialised attention that they deserve, or understanding and time from staff.” Interim audit findings released last year showed that only 5% of hospitals had mandatory awareness training for their staff.
• 50% of staff felt they had not received sufficient training in communication skills specific to people with dementia, and 54% felt they had not received sufficient training in dealing with challenging or aggressive behaviour.
• Very few wards demonstrated a culture which was “person-centred” – this is one which treats the person with dementia as an individual and takes their perspective into account in a supportive environment.
• 59% of wards reported that personal items (such as family photographs or cards) were not situated where the patient could see them for reassurance.
• Only 15% of wards used colour schemes to help patients with dementia find their way around the ward. Only 38% of wards said that signs in the ward were large, bold and distinctive.

The report makes a series of recommendations to help address the problems, including:

• All staff should be provided with basic training in dementia awareness, and a specified proportion of ward staff should receive higher level training.
• Assessment of staffing levels must take account of the additional support needs of people with dementia.
• A Senior Clinical Lead for dementia should be in place in each hospital with designated time in their job role to develop, implement and review the dementia pathway. These clinicians should identify Dementia Champions in each department in the hospital and at ward level.
• Ward managers should make sure that staff can involve people with dementia and their carers in discussions on care, treatment and discharge.
• Systems for guidance, supervision and support should be in place for staff caring for people with dementia.
• Health departments in England and Wales should provide guidance on dementia-friendly ward design. These should be incorporated as standard into all refurbishments and new-builds.
• Simple and effective improvements to the environment should be carried out in all wards admitting older people, including orientation aids such as colour schemes and personalising bed areas.

Hospitals have begun work locally to address problems after receiving local reports from the audit team earlier in the year. Many have submitted action plans detailing key actions for improvement, including:

• Awareness training for staff (59 hospitals)
• Identifying Dementia Champions (25 hospitals)
• Development or review of the care pathway (36 hospitals)
• Improving involvement of carers (18 hospitals)

Staff on audited wards are working on actions to improve the experience of care, including making sure that staff understand the preferences and needs of the people with dementia they see, encouraging positive communication and conversation, and making sure that leadership from champions and role models is in place to support front-line staff.

Professor Peter Crome, Chair of the National Audit of Dementia Steering Group, said:

This report provides further concrete evidence that the care of patients with dementia in hospital is in need of a radical shake-up. We have a provided a number of recommendations that if implemented will enable patients and their families to have confidence in their hospital treatment. It is good to see that several hospitals have responded to the results of the interim findings with programmes of quality improvement. Hopefully real change will be seen in the results of the next national audit, which is due to be published in June 2013.

Dr Kevin Stewart, Clinical Director of the Royal College of Physicians’ Clinical Effectiveness and Evaluation unit, said:

We have a lot of work to do to make sure that patients with dementia get the best possible care in hospital. They deserve no less, and we are delighted that the NHS in England has made the care of this group one of its top priorities. The Royal College of Physicians will work with clinicians, health service managers, the Department of Health and the wider NHS to ensure that we bring standards across the country up to the best achievable.

Report of the National Audit of Dementia Care in General Hospitals 2011 (PDF). Royal College of Psychiatrists, 16 Dec 2011.