Health and social care support for people with dementia

What is the impact of workforce issues and pressures?

Capacity

The pressures on the NHS workforce are well documented, and this is reflected in the Adult inpatient survey. Respondents reported poor experiences in the oversight and care from staff during their hospital stay, saying they or their loved ones were left alone for long periods with no one attending to them and relying on their family carer to have their needs met.

Staff used Learning from Patient Safety Events to record low staffing levels having an impact on their ability to monitor people with dementia, which in turn put patients at risk of wandering, falls, or other risks to themselves or others.

We were also told about issues with capacity in adult social care through Give feedback on care. Comments received highlighted concerns that low staffing levels could affect the quality and safety of care for them or their loved ones. People reported that they had visited family members in a care home and found it difficult to locate a staff member, with people left alone, distressed and wandering and exposed to risk of harm, such as falls. There were instances reported of people leaving their care home unexpectedly without staff knowing, due to a lack of supervision, with one person reported to have exited out of a window, with another walking out of the care home through an open door. 

Similar issues were reported for homecare services. People said that care staff could turn up late to appointments, did not fulfil the contracted time for care and missed agreed appointment times.

Consistency in care staff was also raised as an issue. It is important for people with dementia to be familiar with the people who care for them so they can build a relationship with them. It also supports staff to understand what their needs and preferences are.

I was promised no more than 3 carers would visit my dad. But over 22 visits there were 15 different carers that visited. My dad would not be able to form a bond with so many ‘strangers’ as he called them visiting. How could they get to know him to provide adequate care? I didn’t feel the needs of my dad with his dementia were understood.

Recruitment

Challenges in recruiting staff was a theme emerging from our analysis of provider information returns. Concerns included a reliance on overseas workers, for whom the recruitment process can be lengthy and complex, and the rising costs of transport, particularly for homecare. 

Providers say there can be further challenges in being able to recruit people who have the appropriate level of skills required to care for people with dementia.

Adult social care provider information return:

We have seen an increase of dementia residents looking for placement, and an increase of needs for the current residents living with dementia. Fortunately, we have recently allocated 2 members of the team as Dementia Leads, who will attend focus groups to improve the experiences for our residents.

Training

The Alzheimer’s Society report, Because we’re human too, describes why good quality, evidence-based, consistent dementia training for care workers matters. Despite the prevalence of dementia in the adult social care sector, as demonstrated in our notifications data above, the report highlights Skills for Care data that only 29% of the care workforce in England have had any kind of dementia training.

The National Audit of Dementia also identified staff training as an area for improvement. It found that 42% of hospitals were unable to provide figures for staff working on adult wards who had received dementia training at Tier/Level 2.

Key stakeholders we engaged with for this review identified that there is a dementia skills and knowledge gap across the health and social care workforce, linked to a lack of training. They indicated that even some senior staff do not understand dementia well. As a result, they can themselves be a barrier to good pathways to diagnosis and post-diagnosis support. They identified a need for a clear baseline understanding of dementia for everyone who works in health and social care, at all levels.

The dementia skills gap was echoed by people with dementia, their families and carers through the Adult inpatient survey. For example, one person said:

Dementia training needs to be vastly improved. Asking questions of dementia patients doesn't work – i.e. "Can I take your blood pressure?" Also drinks and food should not just be left on tables. Dementia patients are not aware they are there. More and better training.

Similar sentiments were gathered through Give feedback on care regarding adult social care:

My mum was with this care provider, our experience with this company was awful the majority of the time. It was evident to see that in some cases very little training had taken place. One carer told me she'd had no training and did a few shifts shadowing carers then was just left to it – her words not mine.

The importance of having the right knowledge, skills, values and behaviours to work in adult social care is highlighted in Skills for Care’s Workforce Strategy for Adult Social Care in England. This recommends that, “All workers should have dementia training aligned to the Dementia Training Standards Framework and roles within the Care Workforce Pathway”. The Care Workforce Pathway in turn sets out that “someone working in a dementia setting will need to have dementia care knowledge and skills”.

What supports a good approach to staffing and training?

The positive impact of good staffing

Give feedback on care comments about adult social care suggest the best care for people with dementia is provided by well-trained professionals who understand how best to relate to people who have dementia or similar conditions.

Although it is encouraging to receive positive feedback from family members and carers about their loved ones’ care, it should be noted that often they are describing the sort of care and support that people should be able to expect. 

Mum is always clean and well kempt whenever we visit. Her clothes are clean and she is bathed and her hair washed regularly. The menu is updated every day and we can see the meal choice she has. She is never hungry or thirsty and she has gained weight (which she needed) since her stay.

I am so impressed with the staff that look after her. They are patient and kind and spend time chatting to her even though they probably have very little understanding of what she is saying. They encourage her to keep mobile and to get involved in regular exercise and entertainment sessions. I sense that there is a real bond between them.

As described above, consistency in care staff is important for people with dementia and helps staff to understand people’s needs and preferences. This enables them to provide person-centred care that takes the specific needs of each person into account, in a caring and compassionate manner.

At first there was a number of different ladies calling on Mum but now as she's advanced in her disease we have the same few ladies calling on her. We feel that this is greatly helping her condition. Mum has gone from being unsure of the carers calling on her to now welcoming them in, even watching and waiting at the window for them to call.

Improvements to recruitment

Adult social care providers used their information return to share with us how they are tackling the recruitment challenges described above. This includes, for example, the increased use of social media.

Adult social care provider information return:

Most of the residents at [care home] are living with dementia and require specialised care and support from staff that know them and the residents are able to build a good rapport with the staff in return. With such high use of agency, we can sometimes miss the little things that matter, which was why a recruitment drive using social media and word of mouth was so important. We have employed over a dozen new members of staff. I have seen an improvement in staff morale and shift coverage. With our expanding social media, we have had an increase in occupancy, recruitment and our links with the local community have improved. The level of care the residents are receiving is higher than it was; care was always good but is now improving to be more holistic.

Some providers included people with dementia in the recruitment and interview process. As well as being able to directly assess the dementia-specific skills of potential care workers, this can support people with dementia to engage previous life skills and to directly influence their care home.

Adult social care provider information return:

Residents are involved in staff recruitment by suggesting specific questions to ask the candidates. This provides a wide range of features to promote engagement, communication, and person-centred care to make the delivery of daily tasks more effective and enjoyable.

Improvements to staff training

Providers have recognised that staff need to improve their knowledge of effective dementia care. To address this, some adult social care providers have enrolled their staff on specific training. 

Adult social care provider information return:

We have introduced training support from a registered mental health nurse to support staff with information and training specific to people with dementia. Staff have worked on encouraging positive distraction techniques.

Our inspectors reflected on the benefits of experiential training, when combined with skills-based training, with one saying, “Staff were passionate about this and told us how they had increased their understanding of people. Staff had changed the way they approached people, always introduced themselves and were aware to minimise unnecessary, startling background noises such as doors slamming.”