Designing services informed by the experiences of older adults in Central and Eastern Cheshire Bernadette Bailey COMMISSIONING MANAGER – CENTRAL AND EASTERN CHESHIRE PRIMARY CARE TRUST Ken Clemens CAMPAIGNS AND POLICY MANAGER – AGE CONCERN CHESHIRE Dr Corinne Thomason RESEARCH CONSULTANT – AGE CONCERN CHESHIRE

Dignity a basic human right “Human rights rests on human dignity.” Human rights represent all the things that are important to us as human beings, such as being abler to choose how to live our life and being treated with dignity & respect. Local and national context of this work The most pertinent overall policy direction: Dignity and Quality. Dignity in Care Campaign - Launched 2006. Dignity Challenge - Social Movement of now over 5,500 dignity champions.

Dignity a basic human right Campaign Aims Raise awareness of dignity in care Inspire local people to take action in support of the campaign. Share good practice and give impetus to innovation. Transform services by supporting people and organisations in commissioning and providing dignified services. Reward and recognise those organisations, staff and teams that make a difference and go the “extra mile”. Minister called for a dignity impact assessment, beginning April 09 and reporting in Sept 09. Project underway in the DH to deliver a suite of Performance Indicators from which the next iteration of the NIS and PSAs will be drawn.

Dignity is integral to all that we do not an optional extra. Personalised care improving patient Experience enhanced choice control and autonomy Quality Putting quality at the heart of all we do Drivers for Dignity Privacy and dignity World class NHS must give a new priority to dignity and respect for patients alongside high quality medical care.’ Engagement -Capturing the voice of older adults User reported experience Dignity is integral to all that we do not an optional extra.

What is the National Dignity Challenge? The National Dignity Challenge is a clear statement of what people can expect from a service that respects dignity. It is backed up by a series of ‘dignity tests’ that can be used by providers, commissioners and people who use services to see how their local services are performing.

What is the National Dignity Challenge? High quality services that respect people’s dignity should:- Have a zero tolerance to all forms of abuse. Support people with the same respect you would want for yourself or a member of your family. Treat each person as an individual by offering a personalised service. Enable people to maintain the maximum possible level of independence, choice & control. Listen & support people to express their needs and wants. Respect people’s right to privacy. Ensure people feel able to complain without retribution. Engage with family members & carers as partners. Assist people to maintain confidence & self esteem. Act to alleviate people’s loneliness & isolation. (SCIE 2006)

What we did and where we did it? A Dignity Audit of Older Adult Beds WHY To provide the necessary information to enable the PCT to meet its “Dignity Challenge” of ensuring that only services which respect dignity are commissioned, (as per the PCT quality schedule 7.6 and quality standard 4A. To inform and be incorporated into the contracting round. WHEN Conducted September – December 2008 Central and Eastern Cheshire A sample of Older Person’s Services were audited in four different Trusts. Mid Cheshire Hospitals NHS Foundation Trust- Acute services East Cheshire NHS Trust-Acute services Cheshire and Wirral Partnership NHS Foundation Trust - Macclesfield and Leighton sites Cheshire East Community Health - Community team based at Frederick House and Santune House. WHERE

Details of the audit To examine the extent to which commissioned services are measuring up to the National Dignity Challenge; To promote positive change by sharing and celebrating best practice FOCUS METHOD Boundaries of the work prescribed by the National Dignity Challenge 10 challenges and 41 associated questions Audit comprised a series of smaller audits Environmental audit Practice audit Policy and procedures audit Lived experiences audit-1:1 interviews, focus groups, video diaries, questionnaires. SAMPLE SIZE 228 respondents were involved in providing evidence for this work and environmental and observational audits in 9 service areas.

Female aged 65-74 at Age Concern Cheshire AGM Defining Dignity “ I think of myself, wanting care, preferably in my own home. A carer who listens and does not try to persuade me to do things I do not want to do. I prefer a carer who has had some training and respects my home and my independence and has a sense of humour… Female aged 65-74 at Age Concern Cheshire AGM ” ”

Female patient aged 65 Mid Cheshire Defining Dignity “ Care, gentleness and respect on the part of carers when handling / touching the body. Real effort to communicate - time listening and talking. Female patient aged 65 Mid Cheshire ”

“ ” Defining Dignity It was too noisy and confusing on the bay but she is isolated in the side room. She is at risk of infection and has already had one. She is very frail and weak but I don’t like the thought of her calling out, nurse, nurse when I am not here to help. Relative talking about the care of her 98 year old Mother, East Cheshire ”

Senior administrator- Acute setting Defining Dignity “ Not pigeon-holing people, not treating them as all the same; asking them what is important for them and how they would like to be cared for. Senior administrator- Acute setting ”

Barriers to Dignity in Care Senior Nurse Educator-Acute setting “ Time is a major problem. We have good education but we need smarter ways of learning. We are tied up in bureaucracy. We say, ‘ I haven’t done all my washes’. We have to start saying no matter, we can do them in the evening. We are also getting better at telling people when they have done something well. Senior Nurse Educator-Acute setting ”

Barriers to Dignity in Care Health care assistant, acute setting “ There is a constant staff shortage. We often stay over and take our hours back another time. Team spirit is unbelievable and it can get very stressful because we do a lot of bed baths. Health care assistant, acute setting ”

Barriers to Dignity in Care Senior Discharge Nurse-Acute setting “ Targets force us into decisions which we wouldn’t want to make. It often comes down to targets versus local situations - you’ve got to meet targets - if you don’t have the vision you get your P45. Senior Discharge Nurse-Acute setting ”

Barriers to Dignity in Care Senior Nurse-Community setting “ Customer care is really important. It’s no good having a sister at the desk writing notes who never looks up. It’s a caring job you need the right attitude and you need to be doing it by choice. Senior Nurse-Community setting ”

“ ” TRAINING Factors which promote dignity in care Bank staff are a hindrance to permanent staff as they are much slower. It’s hard to work as a team, they need to be C&R trained, it is a scary environment if you are not trained. We can spot things, there are signs and we are de-escalation trained. If staff are not permanent they may not know the triggers and this is very important. Permanent staff are very good and would not want to put you in a difficult position. Senior Nurse Manager-Mental Health setting “ ”

Factors which promote dignity in care Female patient 71. Mid Cheshire ATTITUDE The age and facilities (good or not) of a hospital can be over-ridden by kind, friendly, professional staff. Female patient 71. Mid Cheshire “ ”

“ ” Factors which promote dignity in care When staff get moved around you can end up with people who don’t really want to work with older people. If that is the case that member of staff shouldn’t be forced to come. Ward sister, Mid Cheshire, Mental Health ”

Factors which promote dignity in care Social Worker-Community setting “ She is a pivotal personality - she has clout and is passionate and very fair with everyone. She can spearhead new initiatives and troubleshoot, mediating between non medical staff and consultants. She listens, takes on board concerns and works to resolve them. Social Worker-Community setting ”

“ ” Factors which promote dignity in care Lots has been done to support staff to ensure we get things right. Leadership and the role of matrons are very important. Senior Nurse Manager-Acute Hospital setting ”

Celebrating services in Central and Eastern Cheshire We do a really good job here, our Health Commission scores have gone up to fair to good on management and quality this year. Senior Administrator-Acute setting “ ” ” “ The trust has picked itself up from being slated in the national and local press. It is now in the limelight for good practice. Middle manager-Acute setting ” “ Patient care is improving, we are more patient- focused and more quality – focused but it is an ongoing project. Senior Nurse manager- Acute setting

Celebrating services in Central and Eastern Cheshire Some people described it in terms of better communication, awareness, involvement and openness. “ We are better at listening and responding. We welcome the involvement of volunteers which makes things more transparent because they see what we do and tell us if something is wrong. Consultation event-Acute setting ”

Celebrating services in Central and Eastern Cheshire “ Reading back the words of service users to staff so that they own what happened is a really powerful tool for change. Some people get really upset when they know what the patient and carer went through. Patient Experience Manager- Acute setting ” Others described the achievement of changing perceptions:- I would like to celebrate multi-disciplinary working because it helps when we all sing from the same hymn sheet because we are working closer together – we can pool resources and understand each others roles and problems? Social Worker- Acute Hospital setting “ ”

Measuring up to the Dignity Challenge What was good A commitment to individualised care A willingness to report abuse Cleanliness Innovative training A willingness to engage with the public Clearer priorities disseminated throughout the organisation Dignity champions and dignity leads Protected mealtimes and the red tray scheme No secrets campaign Emphasis on quality Shared training

Measuring up to the Dignity Challenge Where further work needs to take place Robust care management systems Dignity in death The impact of competing priorities Sufficient daily occupation/social contacts The impact of multiple ward moves Discharge policies/seamless services Better mechanisms for capturing the patient voice Empowering older adults to raise their expectations All staff need training which focuses on issues round the care of older adults

Recommendations for change customer care service development Information, help and advice Respect for individuals Focus on the person Getting the basics right the importance of training Building confidence and self-esteem Competing priorities Being involved and having choices Knowledge about patients Personalised care Helping people to express themselves

The relevance and importance of this work National Nursing Review of metrics and practice. Essence of care data. Darzi Clinical Pathway dignity and quality findings. The importance of independence So that dignity is embedded in all implementation activity and the profile of dignity is raised,(Commissioning, next stage review, Ageing Strategy, Personalisation, Dementia Care, End of Life Care, Mental Health etc.) Capturing the authentic voice of older adults

Conducting your own audit - introducing our dignity tool Utilise this to embed across all services, turning all user reported experience into “intelligence”. Discuss these findings with providers to make clear your expectations on the dignity standards. Use financial incentives to drive up quality. Support training and incorporate it into main workforce development. The importance of listening to people who use the services. Dispersed Leadership, Strong vleadership at all levels…from floor to board. Maintain and grow a supportive environment….enabling and supporting change. Show and share what is good and innovative….building a wider perception. A start to the process not the end Conducting your own audit - introducing our dignity tool