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The Royal College of Psychiatrists Improving the lives of people with mental illness

Further work needed to improve care for people with dementia in hospital, says national clinical audit

Embargoed until 12 July 2013

The second report of the National Audit of Dementia has identified continuing problems in the quality of care received by people with dementia in hospitals in England and Wales.


Although there has been positive change, the audit shows that many patients are not receiving key health assessments. While many elderly patients with dementia develop acute confusion during a stay in hospital, less than half of the 7,987 patients in the audit sample had been assessed for delirium, and only half had received an assessment of their mental state. The audit report describes these assessment rates as “alarmingly low”. A third of hospitals do not have guidance in place on involving the person’s carer and sharing information with them.


The audit also reveals that less than half of hospital executive boards are routinely involved in reviewing hospital performance data on quality of care received by people with dementia, and two in five hospitals do not provide dementia awareness training to new staff. Problems with the quality of information and communication are also an issue. The audit shows patients’ case notes often do not include information that could aid communication with them, and information important to future care is not routinely summarised at the point of discharge.


But encouragingly, the second report shows several aspects of care that have improved since the first report in 2011 There has been a 10% drop in the overall number of prescriptions of antipsychotic drugs, and patients are now more likely to receive as assessment of their nutrition. Overall results show that hospitals are working to improve the quality of care that people with dementia receive – but that further improvements are still required.


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 audit looked at data collected from 210 hospitals across England and Wales, including casenotes of 7,987 patients with a diagnosis or current history of dementia.


Key findings from the report include:


  • 41% of hospitals do not include dementia awareness training in staff induction. 40% of hospitals did not provide any awareness training to support staff (such as receptionists) in the 12 months prior to audit, and 11% did not provide this training to nurses.
  • 36% of hospitals now have a care pathway in place for people with dementia – up from 6% -and a further 51% have one in development.
  • Less than 50% of hospital executive boards are routinely involved in scrutinising hospital performance data on delayed discharges, readmissions and falls, relating to people with dementia. Previously less than 25% of boards reviewed this information.
  • Information important to future care is not being provided at the point of discharge. Less than half of the patients who had had symptoms of delirium, or of behavioural or psychological symptoms of dementia (including agitation, distress or aggression) during admission had this recorded in their discharge summary.
  • In a quarter of casenotes, there was no record that notice of discharge from hospital had been given to carers or family.
  • Case notes often do not include information that could help staff communicate better with the patient, and information relevant to future care is not routinely summarised at the point of discharge. There has been very little improvement in these areas.

The report restates many of the recommendations made previously in the first report of the National Audit of Dementia, and now also recommends that all hospitals should have a care pathway in place under the leadership of a senior clinician by June 2014. Other new recommendations in the second report include:


  • Dignity leads, dementia champions and dementia specialist nurses should be employed in all hospitals.
  • Ward managers should ensure that there is clear leadership and supervision available to staff on the ward regarding the care of people with dementia, and that this is supported with appropriate training and learning resources. A skills gap analysis should be conducted in each hospital, across different staff groups, and an action plan drawn up.
  • A personal information document (such as This is Me, published by the Alzheimer’s Society) should be in use throughout the hospital to ensure that staff are aware of each patient’s individual needs and preferences.
  • Any instances of discharge of people with dementia from hospital after midnight, or when carers/family receive less than 24 hours notice, should be reported to and reviewed by Trust Boards.
  • Hospital chief executives should ensure routine audit of in-hospital antipsychotic prescribing is carried out, allowing for comparison of practice between wards and departments.
  • The Director of Nursing in each hospital should regularly review protected mealtimes in the hospital.

Commissioners/Health Boards should ensure that liaison psychiatry services are in place to provide adequate access over 24 hours for treatment and referral of people with dementia in hospital.

Professor Peter Crome, Chair of the National Audit of Dementia Steering Group, said: “It is pleasing that the second National Audit has shown improvements in the care of people with dementia including a reduction in psychotropic medication prescribing. However much still needs to be done and there remains a large gap between what hospitals say should happen and what actually does happens. Everyone working in the NHS must accept that the care of people with dementia is a core part of its business. Hopefully, with strong leadership at all levels future audit will show further positive change.”

Professor John Young, National Clinical Director for Integration & Frail Elderly and advisor to the National Audit of Dementia, said: “The second round of the National Audit of Dementia has shown that hospitals are at last engaging with the special care requirements necessary to support people with dementia and their families. Important progress has been made across several fronts but many care gaps remain to be addressed.”




Two case study examples are provided below, courtesy of the Alzheimer’s Society:


Joyce in based in Orpington, Kent. Joyce is 76 and cares for Del, her husband of 57 years. He was diagnosed with dementia nearly two years ago and was recently admitted to hospital after a fall. She said: "There are not enough staff in hospitals for people with dementia to receive the care they need. Food is put down and left for patients to feed themselves. This is not acceptable and people are going hungry. It’s no good waiting an hour and taking away the tray when it hasn’t been touched. There is no excuse. You don’t even need to be trained in dementia care to know that someone with the condition might need help with eating and drinking. Del was in a dementia ward with four beds and we were told there would be a nurse or carer in the room around-the-clock. This was not the case and Del had four further falls during his stay. I have an amazing family and together we didn’t feel confident to leave him alone. At least one of us would sit at his side during the day. On one occasion, my granddaughter found the ward nurse asleep in her chair. She even took a photograph of it as she couldn’t quite believe it! People with dementia need one-to-one care and without more staff the situation will not improve."

Graham is based in Manchester. Graham is 63 and the main carer for his father, Tom, who is 86. Tom was diagnosed with vascular dementia around 4 or 5 years ago. In the last 18 months, he has been admitted to hospital three times: in October, in late December and most recently in June, for 4 days. He was admitted after having had a vacant episode causing him to freeze and be stuck on the stairs – he simply couldn’t move his legs. During his time in hospital Graham was aware of a number of issues: Graham said: "Most worryingly, the nurses in the hospital forgot to give my father his medication for dementia which he is due to take it in the mornings. After having pointed this out to the nursing staff, it wasn’t until the early evening that he finally received it. Surely medication is key and should never be overlooked, particularly in a hospital environment of all places."

Graham was also concerned when his father was found wondering with his bags out of the ward, unbeknown to the nursing staff and was also very angry when he discovered that his father was moved within the hospital at 3am in the morning.

Since the time of his father’s initial admittance, Graham has voiced his concerns about the quality of care to the hospital committee. Despite their assurances, the same problems have reoccurred. With this in mind he questions the quality of care that those with dementia receive whilst in hospital.



The audit is managed by the Royal College of Psychiatrists’ Centre for Quality Improvement, working in close partnership with professional and service user representatives. The collaborators in this project are the professional bodies for five of the main disciplines involved in providing dementia services, and one of the main voluntary sector providers of supports and services:

  • Royal College of Psychiatrists;
  • British Geriatrics Society;
  • Royal College of Nursing;
  • Royal College of Physicians;
  • Royal College of General Practitioners;
  • Alzheimer’s Society.

About the Royal College of Psychiatrists’ Centre for Quality Improvement: The College Centre for Quality Improvement manages an extensive programme of national clinical audits, clinical services accreditation and national quality improvement networks that involve nearly all mental health services in England and Wales.


About HQIP: The Healthcare Quality Improvement Partnership is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement, and in particular to increase the impact of clinical audit in England and Wales. HQIP hosts the contract to manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP). The programme comprises more than 30 clinical audits that cover care provided to people with a wide range of medical, surgical and mental health conditions.

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