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ANEURIN BEVAN COMMUNITY HEALTH COUNCIL
SCRUTINY COMMITTEE
REVIEW OF COMMUNITY/FRAILTY SERVICES PROVIDED BY THE ANEURIN BEVAN HEALTH BOARD
2012 - 2013
Shirley Evans, Deputy Chief Officer – Scrutiny 13 March 2013
ANEURIN BEVAN COMMUNITY HEALTH COUNCIL
REPORT
COMMUNITY/FRAILTY SERVICES REVIEW
CONTENT PAGE
Item Number
Item Page Number
1. SUMMARY 22. BACKGROUND 33. SCOPE OF THE REVIEW 4
3.1 Purpose 43.2 Work Programme 43.3
Review how ABHB’s performance compares with that of similar organisations
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3.4 Examine range and level of services 63.5 Review Discharge Planning arrangements 173.6 Review data on Delayed Transfers of Care 193.7 Review a range of patient experience 203.8 Examine waiting times for rehabilitation services 203.9 Assess the needs, views and experiences of users and carers 20
3.10 Assess how ABHB ensure that they understand and are responsive to patient views on the services they deliver.
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3.11 Examine ABHB’s strategic plans for service development to meet the national policy and strategic direction for the service.
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3.12 Examine ABHB’s compliance with national standards 233.13 Review the range and level of patient information. 253.14 Review ambulance audit data of incidents attended by the
ambulance service 26
4. CONCLUSION 275. RECOMMENDATIONS 276.
APPENDICES 1. Frailty Review Work Programme 2. Frailty Services Patient Experience Survey 3. Community Care Survey – May to September 2012 4. Literature Review 5. Abbreviations
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1. SUMMARY
1. The Frailty Programme commenced on 4th April 2011 and is a collaborative service model between Aneurin Bevan Health Board (ABHB), the five Gwent local authorities of Blaenau Gwent, Caerphilly, Monmouthshire, Newport, Torfaen, and key voluntary sector partners. 2. For the year April 2012 to March 2013 the Aneurin Bevan Community Health Council (ABCHC) conducted a formal review of the Frailty Programme and supporting community services, Frailty being a discrete service within the broader community services provision. 3. The shift from hospital based services to community services has provoked concern about how Community Health Councils will effectively monitor the planning and delivery of these services and seek the Patient/Carers views of these services they receive. The aim of this review was to identify the progress made so far by the Frailty Programme and associated community services, in particular to review evidence to show whether the Frailty Programme has been successful in either preventing unnecessary admissions of older people into hospital, or has accelerated their safe discharge home from hospital, and most importantly to ask patients for their experiences of this service. 4. ABCHC were concerned that obtaining patient experience feedback of patients being cared for at home would be a challenge and we were grateful to the ABHB who offered to distribute our questionnaires to patients who have received Frailty services. 5. The Frailty Programme commenced in April 2011 with core components detailed for delivery in the first year and with specific service areas to be added in years one, two or three depending on the needs of each locality and the range of services already in place in each locality. As an example, a falls service was not considered a priority for development within Frailty in Year 1 in some areas. The service components were agreed in partnership through Locality Implementation Groups. 6. As each of the five localities in Gwent was able to choose its priorities for the first year this has resulted in a somewhat disjointed service, particularly for the Falls Service, and the CHC understands that ABHB is taking steps to limit the inconsistencies to provide a more equal service to the population of Gwent, and to develop consistent data recording systems, leading to a more robust evaluation of the whole frailty service. 7. ABCHC understands that the Frailty service is a new service that will be developed over a three year time-frame. ABCHC would expect that the core care services provided to patients in their own homes after discharge from hospital, or for preventing hospital admission, would be in place and working well. 8. ABCHC conducted a survey, with a distribution of 1200 questionnaires into the homes of Frailty Service Users who had received and completed up to 8 weeks
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intervention from the Frailty Services. The CHC appreciate the ABHB’s assistance in distributing questionnaires, in sealed envelopes, which they addressed and delivered to ensure that the CHC had no knowledge of individual patients, to maintain confidentiality and anonymity of the patient. 9. Responses to the ABCHC survey indicated a high level of patient satisfaction with the Frailty services with the majority, 195 (76%), of patients/carers very appreciative of the services they have received, for which ABHB should be commended. 10. There are several areas, across the survey questions, where patients/carers expressed dissatisfaction with the service and ABCHC suggest action is required to improve the patient experiences. In particular ABCHC have concerns that issues raised by patients where needs are not met suggest that the discharge planning process is not being applied consistently for patients being discharged from hospital to the Frailty service. 11. Other issues which ABCHC believe require further action are reflected in the recommendations at the end of this report, and include discharge planning arrangements, information and communication, and pain relief; several patients responded that their pain was not managed adequately. 12. It was evident from many of the responses to the ABCHC Frailty survey that involvement of carers in discussions and communicating to carers details of care plans was a problem. Many responses suggest that it was assumed family members would provide care, but that this placed a high degree of pressure on families. Other carers, including family members, felt totally excluded from discussions around care even when the patients had limited ability to remember conversations with health care staff. There were responses from these carers suggesting that the pressure was so great it was having a detrimental effect on their health, feeling exhausted and without support. 13. The Frailty Programme has enabled many elderly frail people to either be discharged home early from hospital or to receive care at home to prevent admittance to hospital, 1000 patients on average a month. 14. ABCHC Scrutiny Committee were appreciative of the positive responses from ABHB to all requests for information, for providing overview presentations to Committee on services and for their assistance in distributing the survey to patients who have received care from the Frailty Service.
2. BACKGROUND
15. The Aneurin Bevan Community Health Council (ABCHC) agreed that a formal review of the Frailty Programme and supporting community services provided by the Aneurin Bevan Health Board (ABHB) and the 5 Local Authority areas would be carried out in the year April 2012 to March 2013.
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16. ABCHC Scrutiny Committee would carry out the review, requesting ABCHC Public Engagement Committee to obtain the required information to support the scrutiny function. 17. In order to accurately review this service Committee agreed they should work closely with the NHS. 18. ABHB area provides services to a total of approximately 600,000 people in Gwent made up of the populations of Blaenau Gwent, Caerphilly, Monmouthshire, Newport and Torfaen. 19. The purpose of this report is to identify the progress made so far by the Frailty Programme and associated community services, in particular to review evidence to show whether the Frailty Programme has been successful in either preventing unnecessary admissions of older people into hospital, or has accelerated their safe discharge home from hospital, and most importantly to ask patients for their experiences of this service. Scrutiny Committee agreed to review information and evidence and compare this to relevant national standards for the care of older people, as well as the expectations of the Gwent Frailty Programme contained within the Strategic Outline Case for the programme. 20. The review would seek to identify improvements to the services for older people, for their care in their own homes or in the community, and to highlight the areas where Scrutiny Committee believe there is a need to take further action. 21. The Gwent Frailty Programme Vision is ‘Supporting frail people in Gwent to be happily independent’ (Gwent Frailty Programme website presentation update August 2011).
3. SCOPE OF THE REVIEW
22. Scrutiny Committee agreed that they would set a programme identifying the scope of the review including timescales, actions and work streams (Appendix 1)
3.1 PURPOSE
23. To identify the level of service being delivered locally, the standards for the service and the views of patients/service users and/or their families and carers.
3.2 WORK PROGRAMME
24. The following areas were covered in the work programme:
1. Review how ABHB’s performance compares with that of similar organisations 2. Examine range and level of services 3. Review Discharge Planning arrangements 4. Review data on delayed transfers of care 5. Review a range of patient experience 6. Examine waiting times for rehabilitation services 7. Assess the needs, views and experiences of users and carers
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8. Assess how ABHB ensure that they understand and are responsive to patient views on the services they deliver
9. Examine ABHB’s strategic plans for service development to meet the national policy and strategic direction for the service.
10. Examine ABHB’s compliance with national standards 11. Review the range and level of patient information 12. Review ambulance audit data of incidents attended by the ambulance service
3.3 REVIEW HOW ABHB’S PERFORMANCE COMPARES WITH THAT OF
SIMILAR ORGANISATIONS
25. The Frailty Programme is in its early stages of development, and it is difficult to make comparisons with other health boards as different models of care in the home are being rolled out across Wales, with different timescales. 3.3.1 Wrexham Maelor Hospital – Wrexham Frailty Fast Track Pilot Project
26. The Gwent Frailty Programme was referred to in Welsh Assembly Government Web News item 1/7/10 when reporting on the Health Minister’s visit to Wrexham Maelor Hospital to view the Wrexham Frailty Fast Track Pilot Project. The project is similar to the Gwent Frailty Programme and commenced as a pilot in October 2009 to enable early discharge of older frail patients to their own homes. The news item states that hospital lengths of stay have reduced and patients are ‘much happier with the service and care they are receiving’. From information received by ABCHC this is similar to the ABHB experience of the impact of the Frailty Programme and the majority of patients responded to the ABCHC survey that they were happy with the service. 3.3.2 Collaborative working with Abertawe Bro Morgannwg Community Health
Council (ABMCHC) 27. Early in 2012 ABCHC and ABMCHC agreed to carry out a review of similar services with the aim of comparing the different models at the end of the year. However as it became apparent that the ‘frailty’ service model being progressed for ABMHB is not at a stage that would offer a reasonable amount of data the ABMCHC took the decision to review a different service this year. 3.3.3 Falls Services 28. ABHB Falls Service is developing at different levels within each of the Gwent Community Resource Teams (CRT) with patients either being seen by a hospital consultant in a hospital clinic, specialist community clinic or by Falls service nurses, occupational therapists or physiotherapists (health or social care). Therefore it is difficult to compare with services in other areas. 3.3.4 Ambulance Crew response to falls in the community
29. Gwent ambulance crews responding to emergency calls assess falls patients and decide on action based on their Falls Protocol; arrangements may be made with the CRT or to take the patient to hospital as appropriate.
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30. In 2012 Cardiff and Vale University Health Board undertook a pilot exercise with the ambulance service to have a dedicated nurse presence when ambulance personnel responded to an emergency call relating to a fall in the community. The evaluation of this service has been completed, and ABCHC have received the following update, which includes details of a second pilot: “ The first pilot involved a nurse accompanying a paramedic in a car “falls van”
for a week. Evaluation showed that this was a very expensive measure, as the nurse saw few patients although did make one referral to the Elderly Care Assessment Service rather than an attendance at the Emergency Unit.
The second pilot involved 11 days of WAST step-up referral to the Community Resource Team. The CRTs worked extended hours (early in the morning till later in the evening). The paramedic assessed the patient who had fallen for obvious injury (using the 6 Red Flag criteria for conveyance to the Emergency Unit). If assessed as being safe to leave at home, but requiring further input, WAST paramedic phoned the CRT staff member with the mobile phone to discuss referral. If the CRT accepted the referral, a visit was made within 2 hours. Home Care support from Cardiff City Council and Age Concern were available. There were few referrals made to the CRTs in the short span of the pilot. Cardiff and Vale University Health Board is awaiting the formal evaluation of the pilot undertaken by WAST and Abertawe Bro Morgannwg University Health Board (ABMU) before making any decision as to whether to roll out the pilot “ (Welsh Ambulance Services NHS Trust – WAST)
3.4 EXAMINE RANGE AND LEVEL OF SERVICES 3.4.1 Evidence to Scrutiny Committee
31. Over the twelve months of the Scrutiny Committee review of Frailty Service and supporting community services Scrutiny Committee has requested and received a range of evidence and information. 32. ABCHC Scrutiny Committee received requested evidence throughout the review from ABHB, as well as through presentations by senior ABHB officers around:
• Overview of Frailty Programme • Falls Service • Chronic Conditions Management
And • Welsh Ambulance Trust: presentation on the Ambulance Falls
Protocol 3.4.2 Overview of the Gwent Frailty Programme 33. The development of the Frailty Programme is as a response to requirements coming out of the Welsh Government, as in ‘Designed for Life’, ‘Doing Well, Doing Better’, ‘The Wanless Report’, ‘Setting the Direction’ and more recently ‘Together for
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Health’. These documents, and other documents reviewed by the ABCHC Scrutiny Committee Members can be found in Appendix 4 – Literature List. 34. With an ageing population and pressures on the acute care in secondary care Health Boards and other agencies to work together to provide multi-agency care in the community with care plans in place to either prevent admission to hospital or to facilitate early discharge to a patient’s own home, or care home if appropriate. ABHB, the five local authorities in Gwent and key voluntary sector partners work collaboratively to provide the Gwent Frailty Service. 35. The Gwent Frailty Programme core standards provide for up to six weeks of free care against set intermediate care criteria for this service, which may be extended to a maximum of eight weeks, and is provided by Community Resource Teams for each locality in Gwent. Providing care in this way is aligned to the views and wishes of older people who were consulted on what was most important to them when needing care, as detailed in ‘Towards Independence for Older People in Gwent – Key Findings from the 2009 Older Peoples Experience Workshops’. 36. The Frailty Programme commenced on 4th April 2011 and is a collaborative service model between ABHB, the five Gwent local authorities of Blaenau Gwent, Caerphilly, Monmouthshire, Newport, Torfaen, and key voluntary sector partners. 37. The aim is to ‘keep people happily independent in their homes as long as it is safe for them to do so’ and ensuring equitable access to care services in Gwent’ with a focus on prevention and looking at the holistic needs of patients. 38. The Frailty Programme is an “Invest to Save” programme, which must be sustainable after each year, with those staff that were employed last year, to be funded by the Health Board and 5 Local Authorities this year, and this applies for each of the three years of funding. after three years the programme must be sustainable by the Health Board and Local Authority partnership. A total of up to £9M was made available for the Frailty Programme, and £7M has been received for this project for the three-year period, which has to be repaid to the Welsh Government within five years. (a) Referral into the Frailty service 39. There is a Single Point of Access (SPA) for the frailty service, through referral to the Community Resource Teams and currently only health and social care professionals can refer into the Frailty service, for example General Practitioners, Nurses and Social Workers. ABHB and the 5 Local Authorities will be doing more work to ensure that where appropriate General Practitioners refer patients into the Frailty Service where appropriate instead of arranging patient admittance to hospital. 40. ABHB had experienced early problems with the SPA, which had been expected when introducing changes and bringing together different organisations/ agencies with different operating methods in place. The SPA service has been reviewed and ABHB will be considering the recommendations to determine any actions required.
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41. Discussions are also being held with the Welsh Ambulance Service NHS Trust (WAST) to address their access into this service. ABCHC had highlighted a problem where ambulance crews take falls patients to hospital rather than access Frailty. Ambulance referral criteria for this service are currently being revisited to ensure patients are transferred to the most appropriate place for care or treatment. At a meeting of the ABCHC Scrutiny Committee this issue was also mentioned by WAST as it would be beneficial to their ambulance crews to actually know whether their referral decisions were the most appropriate for the patients. (b) The Gwent Frailty Programme 42. As a franchise model, the frailty service is not entirely consistent across all of the five localities in Gwent, but they are working to achieve consistency with the core standards which must be met. These Core Standards require the service to operate a Single Point of Access, to be available from 8 to 8 daily over 365 days a year, to have a response time of 0-4 hour for health and social care urgent components, to provide up to 6 weeks of rehabilitation and review, to provide falls assessment and onward referral of patients where required. 43. There are still differences in how each service is covered with some areas fully operational in the 8 to 8 service hours but others having on-call arrangements at weekends. The aim is for all areas to operate the full service hours. The main elements of the Frailty Programme are:
- Rapid Urgent - which is for medical assessment and intervention - Rapid Other – including nursing and emergency social care - Reablement - Falls Management and Prevention
44. In Year 2 the Frailty Service will evaluate the five frailty models to determine which model is best suited to delivering the service. The partners will also be developing performance indicators and standards as a priority to provide the evidence of the impact of the service on patients. (c) ABHB and the 5 Local Authorities Key Achievements 45. The following is information provided to ABCHC by ABHB in July 2012 on the key achievements of the Frailty Programme in Year 1: “
• All teams are co-located and fully integrated • The CRTs have a full compliment of staff in line with the investment plan for
Year 1 • Development and implementation of IT systems, to support staff to share
information across organisations and professionals • Using IT to work more efficiently within the community • Reduction in bed days, without any rise in Delayed Transfers of Care (DToC) • New generic worker ‘support and well being workers’ • Integration of Community Occupational Therapists • Flexible working with therapy staff
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• Development of falls assessment and prevention services • Social Worker integration with hospital team • Increasing demand in referral numbers
” 46. An update to the Frailty section of the ABHB Clinical Futures website (May 2012) (http://www.gwentfrailty.torfaen.gov.uk/ ) states that “by April 2012, the Frailty Programme had provided care to over 10,000 individuals, and that number is growing month by month”. ABCHC understand that the average monthly number of individuals receiving care is at least 1000 and this was evidenced in the data supplied by ABHB to the CHC. 47. Referrals to the Frailty Programme are expected to result in:
• A reduction of 50% in two day or less length of stay • A 50% reduction in the number of people in an acute bed for more than 10
days (under 75 years old) and 14 days (over 75 years old) • A 50% reduction in people in a community hospital bed for more than 21 days
(under 75 years old) and 28 days (over 75 years old
This would enable the closure of approximately 60 acute beds and 40 community beds to close, generating savings which would be transferred into Frailty. 48. The number of bed days around admission avoidance has increased slightly and ABHB believe this relates to the number of people still coming into hospital that might have more complex needs and be managed differently. The ABHB and 5 Local Authorities plan to locate nurses in the General Practitioners’ bed management unit to respond to general practitioner telephone requests for a patient to be admitted, and for the nurse to suggest alternatives if appropriate. Two bed management units now have nurses on a limited basis successfully diverting some patients to Community Resource Teams and there are plans to expand this approach. (d) Rapid Medical and Rapid Other 49. ‘Rapid Medical and Rapid Other’ response target is 4 hours and ABHB believe this target is being met. Within this the care of the patient sometimes transfers to the Frailty clinicians whilst the acute phase is managed. When appropriate this is transferred back to the GP. The patient’s care through the Frailty service includes up to six weeks of rehabilitation (if needed) and review through the Frailty Team, with no financial contribution from the patient for this service during this six-week period. 50. ABCHC were informed that approximately 15,000 bed days savings, comparing bed days used in 2010/11 and 2011/12, had been made, equating to about 45 beds and ABHB were satisfied that for a new service, with continuing staff recruitment throughout the year, this was good progress.
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(e) Reablement service 51. ABHB informed ABCHC Scrutiny Committee that the reablement service, working across health and social care, has proved very successful in developing staff skills and the service to meet the needs of patients, providing early discharge to their homes. (f) Referrals into Frailty by component 52. Information was provided to ABCHC on referrals to the service, as follows:
• Falls: The number of referrals is relatively low to this service but this would be expected as the falls service has not been rolled out in all areas at this stage of the Frailty Programme.
• Rapid Medical: Numbers are steadily increasing
• Rapid other: Numbers are increasing but more work with General
Practitioners is being planned to improve referrals.
• Reablement: Referrals into this service are very good and increasing. The Year 2 plans are being reviewed to ensure that the correct level of staff is available.
53. ABHB highlighted the challenges the Programme has faced since commencement of the Frailty Service, including problems with recruitment, which has been slower than expected but is now resolved, with nursing staff now moving from secondary care into community. (g) Information Technology and Communication 54. All Staff have a Blackberry mobile through which they can receive referrals via a secure portal and share information across organisations and professions.
55. ABCHC enquiries at the start of this review revealed that development and implementation of information technology systems included the collecting of data from use of digipens although this took time to develop; in January 2013 confirmation was received from ABHB that the system is now rolled out across Gwent and working well. The use of these ‘smart’ pens means that reports are recorded immediately for all involved in the patient care. A paper copy is left at the patient's home, for the patient and all involved in the care to access. (h) Information Sharing 56. The Gwent Frailty Programme partners have agreed an Information Sharing Protocol ‘Wales Accord on the Sharing of Personal Information – Information Sharing Protocol for Gwent Frailty: single Point of Access (SPA) and Community Resource Team (CRT) – June 2011.
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(I) Gwent Frailty Programme – Impact 57. ABHB provided details of the overall impact that the Frailty services are having, and that, in respect of total Medical Emergency Admissions, there has been a reduction, which resulted in a significant overall reduction of bed days. Similar details were provided for Emergency Medical Admissions and Discharges via Accident and Emergency Departments relating to Community Hospitals showing a reduction in overall patient numbers admitted. 58. The impact of the Gwent Frailty Programme on the acute services was evidenced by reference to data showing that the average length of stay was higher in 2011/12 compared to the previous year but ABCHC heard that the reason for this is that patients staying longer in hospital now are those with more complex needs. 59. ABCHC referred to the possibility that the number of bed closures resulting from patients being referred into Frailty Services might move too quickly and be a risk. ABHB explained that ABHB and the Local Authorities are looking at all the evidence and ensuring all elements of the wider health and social care services are working well together. 60. ABCHC were concerned to have received comments relating to a number of cancelled elective patient appointments over the last two years, and the numbers of beds in comparison, with more patients going to Accident and Emergency. This might suggest that there are not enough beds to cope with the people who need them; ABHB responded that more work is being carried out around the overall bed planning and the CHC would receive updates on this, including action plans for the Accident and Emergency. (j) Day Centres 61. ABHB advised that they have no general day centres. (k) ‘Map’ of local community care services 62. The Health Board informed ABCHC that it does not have a map of community services currently but referred to the outline components of the Community Resource Teams and that these will change as the teams develop.
3.4.3. Falls Prevention and Management (a) Falls Service Implementation 63. In August 2012 Scrutiny Committee received evidence from ABHB Falls Service and learned that the Gwent Falls Services commenced as a component of the Gwent Frailty Programme, in November 2011 and are currently at different levels of development in each area. ABHB follows the National Institute for Clinical Excellence (NICE) Falls Guidelines and ‘1000 Live Plus – Reducing Harm from Falls How to Guide’, which describes the falls care bundles.
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(b) Patient Experience (Falls) 64. ABCHC intended to undertake a survey specifically of falls patients’ experience of the service by attending the consultant Falls clinics, but later learned that only approximately 5% of falls patients are seen in Consultant Clinics. This would only have provided a small sample of the most complex cases and would not have been representative of the patient experience of the pathway through the whole Falls service. ABCHC therefore included questions around the Falls Services within the Frailty survey.
(c) Progress so far 65. ABHB gave background detail to falls services provided over the last few years, emphasising the progress made so far, and explaining that there is still some way to go before the Health Board are happy that the services, aligned to Frailty, are being delivered as envisaged. This service is important to Frailty as many older people sustain falls at home or in the community which lead to mobility and confidence issues, escalating to loss of independence and, for some patients, isolation. (d) Impact of Falls 66. ABCHC Scrutiny Committee heard that research data suggests that approximately one third of people over 65 years old will have a fall, and in Gwent the ABHB deal with 650 fractures every year. Falls have a direct impact on patients, with 50% remaining at a lower level of independence than before the fall, and with hip fractures 7% may die within a month and approximately 25% may die within a year. (e) Assessment 67. The falls service is essential to provide fast assessment and referral to treatment as well as to falls clinics for exercise/advice to help the patient avoid further falls and to promote independence. ABHB are in discussion with Care Homes, and recommend that risk assessment should be carried out as soon as a new resident arrives at the home. (f) The Falls Care Model 68. The model has four tiers offering from Tier 1 health promotion and information, Tier 2 management through CRTs, approximately 70% of fallers, Tier 3 fallers managed in Falls Clinic by multi-disciplinary teams, with doctors, nurses, therapists and social workers involvement, and Tier 4 likely to see approximately 5% of fallers described as complex, with balance/dizziness problems, who will be managed by a consultant geriatrician along with other members of the Falls Service clinical team. The model ‘aims to maximise independence and move individuals down the care tiers wherever possible’
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(g) Evaluation 69. The Falls Service does not currently have resources to record and evaluate data for the whole of Gwent and ABCHC believe this is one area where ABHB should take urgent action to ensure that the falls service has a consistent model across Gwent, and that resources are provided to enable the service to record data and evaluate the service, including recording of patient experience. (h) ABCHC patient experience survey 70. ABCHC’s survey of patients being cared for within Frailty, and specifically the questions relating to the Falls services, asked whether patients were happy with the service they received. Responses were mixed, with slightly higher numbers happy with the service, and comments were positive, examples as follows:
• They have been extremely helpful and kind at all times, all staff from doctor, nurses and physios are very professional
• Most helpful and sensitive workers • Physio at home very good
71. As each area is at a different stage in developing a falls service, the professional carrying out an assessment of the falls patient may be different at present. If following a fall a patient goes to see their GP, the GP will carry out a 3-point assessment, which is risk scored. A patient with a low risk may be referred for a community exercise programme and a high risk patient referred to the local CRT.
72. The ABCHC survey asked patients what their experiences were of referral to the falls services for first appointment and most patients responding were seen within 3 weeks; a minority suggested longer waits but with no actual length of time indicated. The majority of patients were happy that they had received a full explanation of the outcome of their assessment following a fall, example of comments:
• Yes Doctor was excellent so were the nurses • Ok, but too much information. • Yes - from physio
73. Some of the patients who were offered referral to falls clinics to help prevent further falls responded to the ABCHC survey as follows:
• Exercises demonstrated at home • Physio has given exercises to strengthen leg/hip to help prevent
further falls • Declined offer - feel enough is done personally • Did not wish to attend exercise class
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(j) Unscheduled care 74. ABHB referred to problems they have in identifying patients as ‘falls patients’ if a patient arrives through unscheduled care. The hospital coding system will record the injury sustained but not necessarily the fact that the patient had fallen. This makes it difficult to evidence the real number of older people affected by a fall. 75. Frequent attenders: Patients attending hospital following frequent falls, will be assessed, and if appropriate will be referred to the CRT for care and treatment in the community within the Frailty service. (k) Recruitment, data records and Care Home Pilots 76. Recruitment of the falls co-ordinators to each of the areas has taken time and in the Caerphilly area previously held falls data was lost when the Caerphilly District Miners Hospital closed and Ysbyty Ystrad Fawr opened. At the time ABCHC received this evidence ABHB had almost completed the setting up of clinics for each area and were in the process of recruiting consultants to Frailty teams. Pilots have been set up for Care Homes to produce guidance and training programmes in Care Homes, and working with Neighbourhood Care Networks (NCN), health and social care and others. (l) Falls Service Achievements 77. ABHB gave the achievements to date of this service as having a falls steering group which guides and supports the localities, there is now a level of standardised documentation and a standardised approach with pathways nearing completion, the service promotes falls awareness and falls services that were medical or therapy led now go through CRT. However if a GP instigates therapy this might be to a community physiotherapist and this is not captured by CRT data input. As with A&E coding of falls patients there will be cases where CRT are asked to assess a patient at home because the patient is not well, and only when being assessed will the patient perhaps be identified as having had one or more falls which had not been reported previously. Once known the patient would be assessed to identify whether the patient should be referred to the falls service. Capturing data on the number of falls patients seen however remains a challenge. The aim is for an equitable service for all falls patients and for this to be achieved by seeing these patients through the CRT. ABHB provided the following detail for falls services: 78. The Monmouthshire area has a dedicated falls co-ordinator and for this area ABCHC received details for April 2011 to May 2012 that 277 falls were recorded, but that only 144 were compliant with the criteria for referral to the falls intervention service. There were a number of reasons why the remainder did not go through the falls intervention service but were referred to other services for example admission to hospital, referral to day hospital, patient declined assessment. 79. Of a random sample of 125 cases, 100 were compliant and 25 non-compliant; the reason for non-compliance was that 25 were not willing to follow advice. ABCHC
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were informed that there has been a definite improvement in the extent of falls and injuries, but that at the moment the data is not robust enough to quote from. The Monmouthshire data shows that for quality of life, 69% of service users/families had decreased stress level and 89% reported better quality of life. Where intervention had not been taken up by patients there had been an increase in the number of falls after assessment, including further attendance at A&E. 80. In Torfaen area, there were 425 referrals April 2011 – May 2012, with only 217 considered suitable for the falls intervention service. The total referrals were made up of GP’s 283, A&E 147, Consultants 43, Physiotherapists 18, Occupational Therapist 7, Nurse 6 and Social Workers/WAST/CRT 4.
81. The Torfaen Falls team carried out a survey of 68 people who had fallen in their area and contacted 46 by telephone. Of this 46, 43 did not have a further fall, 3 had fallen once with no fracture injury, 1 person was admitted to hospital, and 3 had cognitive impairment. Satisfaction with the service was reported as good with 39 of the 46 responding that it was an excellent service and the remaining 7 that it was a good service. 82. Caerphilly is the largest area in Gwent, and in this area development of the Frailty service and the new hospital, Ysbyty Ystrad Fawr, were proceeding at the same time. Data from falls clinics has been collected for the period July 2011 to June 2012, showing that 302 fallers were assessed. 83. Evidence that patients are often coded for something other than a fall, but are then picked up through CRT referrals was highlighted by the fact that from May 2012, 17 patients had been coded as Falls but the actual number of patients assessed for falls was 56; this suggests that the actual number of falls may be under-reported. ABHB also added that with the delays in recruitment of falls co-ordinators across all areas it has proved difficult to capture data for adding into the 1000 Lives data collection. 84. The issue in the Newport area has been that more patients were being seen in falls clinics (203 patients) and only 87 through the CRT. It is expected that this situation will change in the future. The Newport CRT Team has had a full-time member of staff whose role includes the input of data; this goes back to 2008/2009. ABHB suggested that evidence over a 3 to 6 month period shows a 30% reduction but without the evaluation tools and resources ABHB are not in a position to check whether this was likely to continue. 85. Some of the main challenges to the falls service for the future are around engagement with Care Homes, rolling out the assessment tools, implementing care pathways and to resolve the issue of collecting and inputting data to evidence outcomes for patients. 3.4.4. Chronic Conditions Management 86. ABHB delivered a presentation to the ABCHC Scrutiny Committee focussing on the new responsibilities from the Aneurin Bevan wide perspective in terms of community service and primary care. The focus of the presentation centred on how
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ABHB would make changes to meet expectations through community and frailty services. ABHB are engaged in work to improve the outcomes for people with chronic conditions, and this includes the introduction of a disease register with indicators for services to be delivered against and a range of health promotion and health prevention work. 87. For circulatory disease ABHB area has similar levels to the rest of Wales but across Gwent there is still work to be done to reduce the inequalities gap. ABHB approach to Chronic Conditions Management is to keep patients well at home for as long as possible, and to review end-of-life care to avoid patients being admitted to hospital if they prefer to be managed at home or community. 88. When looking at the impact on health of lifestyle issues four of the five localities in Gwent, Monmouthshire being the exception, have some of the highest incidences of chronic conditions in Wales and ABHB referred to the challenge this placed on the Health Board to redesign services which would meet all the needs of patients. 89. ABHB has developed Neighbourhood Care Networks in addition to the 6 Community Resource Teams, as well as Chronic Conditions Management. The CHC received information of developments in the chronic conditions management service for high risk patients, as well as prevention work being undertaken in general practice, diagnosing patients and teaching patients how to manage their health condition through the Expert Patients Programme (EPP). 90. ABHB has also completed an education project specifically around Chronic Obstructive Pulmonary Disease (COPD) patient management by Practice Nurses, with a Respiratory Nurse consultant advising on patient care within clinics. Scrutiny Committee were told that there has been much interest in the preliminary data from this project internationally. ABCHC was informed that the length of stay for patients with COPD has reduced dramatically. 3.4.5. Welsh Ambulance Services NHS Trust - Falls Protocol (a) Ambulance Services Falls Protocol 91. The Welsh Ambulance Services NHS Trust presented the Ambulance Falls Protocol to Scrutiny Committee Members, explaining the criteria for assessing patients who sustain falls in the community. Ambulance crews have links to the Community Resource Teams (CRT) and will contact the CRT if the assessment suggests that a patient does not need to be transferred to an Accident and Emergency Department but would benefit from support through the CRT. Patients taken to hospital will be assessed using a quick assessment tool which allows for immediate e-referral to a CRT if appropriate. 92. The Ambulance officer suggested that Ambulance crews would benefit from being provided with feedback from the health services that for each case they refer that the referral had been to the correct place; this would give ambulance crews confidence when using the referral criteria for falls patients.
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(b) Accident and Emergency – Falls 93. ABCHC requested information from Unscheduled Care to identify where falls occurred and the actions taken when falls patients are transported to Accident and Emergency Departments. ABCHC hoped to establish from this information whether transporting falls patients to A&E is always necessary or appropriate. Although it was not possible to provide an answer as to whether patient referrals to A&E were always necessary, the analysis provides some detail of the impact that falls have on unscheduled care and add to the importance of ensuring that patients are seen in the most appropriate setting; this is particularly important for older frail people if their injuries do not require treatment in A&E, and they could be given treatment/care in their own homes through the CRT. 3.5 REVIEW DISCHARGE PLANNING ARRANGEMENTS 94. A copy of the ABHB Discharge Policy was provided to ABCHC and a copy of the Welsh Health Circular WHC (2005) 035 dated 13 May 2005 entitled ‘Hospital Discharge Planning Guidance’ was accessed via the Welsh Government website. 95. The Frailty Programme operates a ‘Pull’ system for facilitating early discharge of patients from hospital to home, from the Medical Assessment Units and Accident and Emergency Departments and wards, with a multi-agency staff and a dedicated Care Co-ordinator determining which patients to discharge in this way to Frailty. There is a joint agreement to the use of an all Gwent unified assessment tool and frailty assessments should be in line with this process. 96. Referral to Frailty via Medical Assessment Unit/Accident and Emergency departments (MAU/A&E): There are appropriate assessment processes in place for all patients who are referred from MAU/A&E to Frailty, either by clinicians/nurses before leaving the unit, or at home if discharged same day. All patients will have had an assessment and plan completed by a doctor while in the MAU/A&E. Some patients will be referred by clinicians to the SPA for assessment by Rapid Medical nurses. For uncomplicated cases an initial assessment and care plan is carried out in the home by the nurse present, with a telephone handover. Rapid nurses assess COPD patients before they are accepted for Frailty. If a patient needs reablement they are reviewed by the Occupational Therapist based on MAU, with the assessment and care plan being completed in the patient’s home. 97. The ABHB Discharge Policy states that all necessary arrangements must be in place before discharge and that patients/carers should be aware of the arrangements, and that the patient and carer should have a copy of the care plan. 98. The Welsh Health Circular, ‘Hospital Discharge Planning Guidance’ NAFWC 17/2005 WHC (2005)035) details the discharge processes depending on the patient’s condition/needs and it is clear that assessment will take place before discharge, with a plan for future care, before a patient is transferred to a different service to ensure a smooth transition. The following is a quote from the circular:
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“ Background and Context 13. People being discharged from hospital are entitled to expect and receive a smooth transition from one stage of care to the next. A lack of coordinated and person centred planning for discharge can lead to poor outcomes for patients, possibly jeopardising health and safety or leading to inappropriate readmission to hospital. From a wider perspective poor discharge planning not only contributes to delays in the discharge process and extended and inappropriate lengths of stay in hospital, but can also lead to premature discharge and possible readmission.” And “15 ……The Unified Assessment approach to assessment will facilitate the sharing of information between health and social care professionals and should be co-ordinated by a care co-ordinator. The assessment should build a rounded picture of the patient and carer’s needs culminating in a service delivery plan which will provide the framework of care and support for discharge.”
99. ABCHC looked at a range of information relating to patients referred into the Frailty Service including the Referral Criteria for Frailty, the ABHB Discharge Planning Policy and another document outlining the ‘Pull’ system for Frailty to facilitate early discharge of patients from a hospital setting back into their own homes with care from the Frailty Service. 100. Age Cymru Factsheet February 2012 “Hospital Discharge Arrangements In Wales” (p.5, No 3) sets out the key steps in the process for hospital discharge the last step of which is No 7 – ‘Delivering and monitoring your care plan’. 101. Although the majority of Frailty patients responded that they were happy with the service provided, ABCHC were concerned to note that many of the responses to questions across the survey contained comments which indicate that the discharge planning arrangements do not appear to be working adequately. In some cases patients feel let down, receive unannounced visits from staff unknown to them and there is a real risk to these patients from not having their needs assessed appropriately. Issues highlighted in the survey responses included inadequate toileting arrangements, help required at meal times, patients waiting for aids/equipment, others finding it difficult until the CRT assessment identified and acted on any unmet needs. There was also some extremely worrying feedback of patients being locked in from early morning after carer visit to the time of the evening carer visit which compromises patient safety. 102. For appropriate care and aids/equipment to be in place on discharge home under the Frailty Programme our survey asked whether a care plan was discussed and available on discharge. The response was mixed as seen in the following examples, using responders’ own words:
• I am my Mother's carer and all was done to make sure my Mother came home safely.
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• I was kept informed through the whole process. The doctors and nurses explained everything fully.
• There was talk of a "care plan" but never recall seeing it or
commenting on its contents on behalf of my mother, as her main carer.
• No plan was given to us. We had to take care of dad the best we
could. 103. There is evidence of poor communication around referral to the Frailty Programme, by hospital or GP, leading to a risk to the safety of patients, examples follow:
• I didn’t know there was such a thing as a "Frailty Programme" a
very pleasant middle aged woman appeared that evening when my husband was in bed and I ready for bed. She asked if I needed help and I said no.
• The doctor sent by yourselves, unannounced and without warning,
came as a shock. I thought he was a con-man that visits elderly people.
104. Where there were cases with a level of concern requiring urgent attention ABCHC referred these to the ABHB immediately. 105. ABCHC were informed that ABHB are currently working on a review of discharge planning for the Community Services Division and results will be shared with the CHC around Springtime 2013. 3.6 REVIEW DATA ON DELAYED TRANSFERS OF CARE (a) Performance 106. ABCHC received performance data as requested during the review, and also evidence through a presentation to the ABCHC Scrutiny Committee that since the Frailty Programme commenced there has been a reduction in hospital bed days, and that this had not resulted in an increase in delayed transfers of care. 107. ABCHC requested information relating to known concerns around the level of delayed transfers of care and were informed that the delayed transfers are not Frailty-related, but relate to other areas of service, notably Elderly Mentally Infirm (EMI) nursing home placement requirements and capacity within Nursing Homes. ABHB are in discussion with a number of nursing homes to try to resolve capacity issues, which are also linked to Local Authority funding issues.
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(b) Delays in Ambulance handover times 108. The ABCHC actively monitors ambulance handover times and over a six month period it was evident that Falls patients had long waits in this respect. This is an area that needs specific monitoring. 3.7 REVIEW A RANGE OF PATIENT EXPERIENCE 109. ABCHC studied a range of patient experience as reported in section 3.9 below, which included
• ABCHC survey on our website asking for patient experience of community services
• ABCHC A larger survey distributed to patients who have received care through the Frailty care programme (also posted on our website)
• Analysis of complaints received by ABCHC • Analysis of enquiries received by ABCHC • Communication through ABCHC website
110. A small amount of data around patient experience was received from one Gwent locality Frailty Team but apart from information provided within presentations the ABHB were unable to evidence patient experience as they had received very few patient satisfaction responses from patients who had been cared for by the Frailty Service. 3.8 EXAMINE WAITING TIMES FOR REHABILITATION SERVICES 111. This service is now provided through the Community Resource Teams. 3.9 ASSESS THE NEEDS, VIEWS AND EXPERIENCES OF USERS AND
CARERS 112. ABCHC assessed a range of information received through the CHC office, including complaints and enquiries, as well as two surveys. (a) Frailty Service Survey (Appendix 2) 113. In October 2012 ABCHC questionnaires were distributed by ABHB to 1200 patients who had received services through the Frailty Programme. Having the assistance of ABHB to address and distribute these questionnaires protected the confidentiality of patients and also resolved the problem the CHC perceived in actually reaching this group of patients in their own homes. 114 The Frailty questionnaire was also posted on the CHC website; no responses were received by this method. 115 297 patients/carers responded or contacted the CHC to respond, with 256 returning completed the questionnaire.
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The following are some of the areas of care referred to in the survey:
• Hospital Discharge Planning • Equipment/Aids availability • GP Assessment and referral • Communication and Information • Assistance with daily needs eg personal hygiene, dressing, toileting • Mealtime support • Falls Services • Care provided by family/others • L
evel of service and support provided 116. Overall the majority of patients receiving care through the Gwent Frailty Programme were appreciative of the care they had received. There are some notable areas where ABCHC believe urgent action is required and that many of the negative issues raised by responders to the survey would be resolved if all patients who are discharged early from hospital into the service received a full assessment of their needs and that this was acted on before the patient is discharged home. Carers should be kept full involved in discussions or informed of the care plan arrangements. 117. ABCHC believe that on no account should any patient receive unannounced visits to their homes particularly given the concern generally of the risk to older people of answering the door to unknown persons. (b) Online Survey – Experiences of Care Provided in the Community
(Appendix 3)
118. Between May and September 2012 ABCHC posted a 6-question survey on its website asking “What is your Experience of Care Provided in the Community?” Response to this survey was small but as with the distributed Frailty survey the overall feeling was that the care received at home was welcomed, but with some patients or carers not feeling that they did receive enough care. Not all of these responses were from Frailty patients but where frailty is mentioned this is indicated in the analysis at Appendix 3. There is a common theme in responses to our surveys that a high number of carers do not feel involved either in the care discussions or in considerations of the amount of pressure caring places on them. (c) ABCHC Complaints
119. There were no complaints to ABCHC which directly relate to services provided through the Frailty Service.
(d) ABCHC Enquiries
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120. Generally there did not appear to be any enquiries into the CHC which directly related to care received at home. However during the period when the main ABCHC survey was distributed into patients own homes this did result in calls into the office for advice. This might suggest that patients being cared for in their own homes do not have access to information detailing who to contact for independent help. The ABCHC survey sent to patients included our Community Health Council leaflet explaining our role and giving contact details.
(e) Internet feedback
121. A patient’s relative informed the CHC that the GP referred the patient to the Frailty service and that they were more than happy with the service provided by everyone, ending with “I can't praise them enough”.
3.10 ASSESS HOW ABHB ENSURE THAT THEY UNDERSTAND AND ARE
RESPONSIVE TO PATIENT VIEWS ON THE SERVICES THEY DELIVER 122. ABHB informed ABCHC that they receive at least one formal written letter a month about frailty, saying how good the service is. 123. ABHB Executive leads meet regularly with the CRT managers who report that the service is improving and copies of patient and staff member stories were provided to ABCHC. 124. ABHB highlighted the difficulty they have in collecting patient experience as patients do not complete and return their questionnaires which are sent to all patients at the end of their Frailty period; ABHB stated that they therefore welcome the CHC survey. A copy of ABHB’s questionnaire was requested and ABCHC received a copy of a Reablement Questionnaire from the Caerphilly area. 125. ABHB does not currently have any reports available to identify any actions taken based on patient feedback on care provided through the Frailty Programme. This ABCHC report will include recommendations for actions following our survey of patient experience and will be followed up with the Health Board. ABHB indicated that the CRT receives many compliments, and if there are complaints they would be reviewed through the ABHB Quality and Patient Safety mechanisms. 126. It is significant to note the high level of response to the ABCHC survey compared to the ABHB previous experience of patient satisfaction survey returns.
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127. The Monmouthshire Community Resource Team – Reablement Service provided a very brief analysis of two questions to patients, as follows:
2009/10 2010/11 2011/12
Percentage of users of the reablement service who say ‘staff encourage me to do things for myself and support my independence and choice’ (score 4 or 5 on scale)
94% 93% 97%
Percentage of users of the reablement service who say ‘overall the service is of high standard’(score 4 or 5 on scale)
100% 100% 97%
3.11 EXAMINE ABHB’S STRATEGIC PLANS FOR SERVICE DEVELOPMENT
TO MEET THE NATIONAL POLICY AND STRATEGIC DIRECTION FOR THE SERVICE
128. The following is a quote from ABHB document ‘Clinical Futures Community Resources Teams and the Gwent Frailty Programme. Clinical Futures - the Next Five Years Clinical Futures - Community Resource Teams and the Gwent Frailty Programme:
“The Gwent Frailty Programme is a core component of the Clinical Futures Strategy. It aims to support patients to remain as independent as possible, receiving the majority of their support and care close to their homes. “
3.12 EXAMINE ABHB’S COMPLIANCE WITH NATIONAL STANDARDS 129. Doing Well Doing Better – Standards for Health Services in Wales (April 2010): ABCHC identified from evidence received and from patient experience survey responses that ABHB comply with many of the standards in the above document, however the following are areas where ABCHC have received mixed responses from patients which would suggest more work is required: 130. Standard 18 Communication – many patients were not aware of the Frailty service, and confused this with the Reablement component. Communication problems relating to discharge planning with patient and carers was highlighted in responses to the ABCHC survey of frailty patients. Patients should expect to know if they were to be visited by a member of the CRT, but this was definitely not the case for two respondents to the survey. There were examples where some patients had been involved and received good communication but this needs to be consistent across all areas. Some carers in particular responded that they were not involved in discussions.
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131. Standard 10 Dignity and Respect – dignity issues highlighted by patients and carers include lack of adequate toileting, aids not provided in timely manner. 132. Standard 22 Managing Risk –the issue here relates to cases where no care plan is in place which leads to late assessment and provision of equipment as well as patients receiving unannounced visits, and others being ‘locked in’ in-between visits from CRT/agency staff. 133. Standard 19 (d) which refers to using data that is robust – ABHB have systems in place to record patient treatment and care, for use by all involved in the care of a patient, but ABCHC were not convinced that there was adequate quality data from which to inform an action plan for improvement. The ABCHC review of the Gwent Frailty Programme will include recommendations for action by ABHB. 134. The top four outcomes in the Standards of Care priorities, derived from consulting people on what being happily independent means, were that people should “Be able to remain living in their own home with support, receive services in their home, be listened to by people who are responsible for providing services to assist them and have their health and social care problems solved quickly and considered as a whole” rather than as individual components. 135. The Framework for adults expects assessments for hospital discharge should be in line with Unified Assessment ensuring that the needs of the patient and carer are considered and included in the service delivery plan prepared to support the patient’s discharge from hospital. Further consideration should be taken where additional support, on a short-term basis for rehabilitation, may be required or longer-term for continuing care.
136. It is clear from the Framework that all required care should be identified through a unified assessment process and that all care options and planning should be included in the service delivery plan ie the plan that is put in place before the patient is discharged from hospital. Examples of these care options may include single agency or shared packages of care in a patients’ own home or community setting. 137. Setting the Direction Primary and Community Services Strategic Delivery Programme (2010) outlines the Welsh Assembly Government’s vision that community services would support all, but particularly the frail and vulnerable, to remain independent at home for as long as possible and for their carers to also feel supported. 138. The majority of patients/carers who responded to the CHC Frailty survey were happy with the service, and many gave additional comments of appreciation. As a new service, still implementing its three-year programme the Gwent Frailty Programme would appear to be meeting many of the needs of patients requiring support in the community across each of the five areas of Gwent and continuing to improve the service.
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139. Fundamentals of care All-Wales Audit Tool refers to service users’ care “regardless of where or why they need this care”. ABHB confirmed that they are currently working on the tool for District Nurses, but that for CRTs this will be considered in phase 2, which will not be for some time. 140. The 12 aspects of care for adults measured against our survey responses indicate that the areas of communication/Information, alleviating pain, and toileting, need more work, but compliance with other areas would appear to be reasonable.
141. The Bevan Commission Report ‘Forging a Better Future’ states that treating people with dignity and respect and ensuring they have relevant information to feel confident about services are key issues. The Gwent Frailty Programme is mentioned as a major example of partnership working. The Bevan Commission highlights the challenges of moving to a better integrated service, including the shift from hospitals to community care, and having systems in place to share a patient’s record. The document emphasises
“There is a danger that we forget, amidst all the discussions and statistics, economies and efficiencies that at the heart of the NHS are people in distress, in need and in expectation of care and support which meet their needs.”
142. The key issues mentioned here of being treated with respect and dignity and having relevant information are issues which featured in the responses to the ABCHC survey of Frailty Services patients. Lack of clear information was a problem for some patients/or carers and the fundamentals of care requirements which were not met would have impacted on the dignity and respect issue, for example inadequate toileting support, inadequate pain relief, waits for equipment/aids after return home, lack of care plan or discussion on care plan WITH relative/carer. 3.13 REVIEW THE RANGE AND LEVEL OF PATIENT INFORMATION 143. Research was undertaken to find out what is available to patients/service users relating to the Frailty programme, Community Resource Teams and related services. (a) Frailty Programme Service User Leaflet 144. Originally ABCHC were advised that all patients referred into the Frailty service receive a leaflet explaining about the frailty service. However, during the course of review it became apparent through the ABCHC survey that not all patients/service users were aware that they were receiving care from this service. Further information from ABHB confirmed that the leaflet had been withdrawn, and in January 2013 ABCHC received a copy of the draft generic document, as well as a copy of a similar leaflet being used in the Newport CRT. ABHB and the 5 Local Authorities are currently deciding on a generic leaflet for the whole of Gwent and ABCHC will recommend that all patients/service users either being discharged from hospital or referred into the service, to prevent hospital admission, should receive details of the Frailty Programme service.
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(b) Reablement Services
145. The H.A.R.T – Caerphilly Reablement service leaflet. (Home Assistance and Reablement Team) is a very comprehensive leaflet and ABCHC understands that all patients referred to reablement in Caerphilly receive a copy of this document. (c) Patient Information for other areas of Frailty 146. ABCHC requested copies from ABHB of any patient information, ie leaflets or information provided to patients accessing the service and an indication of when patients receive these. Apart from the leaflets provided the response received from ABHB is that each of the components of the new Community Services Division will be reviewed in time and they will prioritise work to fill any gaps which are evident in information available to patients. ABHB will keep the CHC informed of progress. (d) Website Information (i) ABHB, Gwent local authorities, Age Concern 147. ABHB, Gwent local authorities and Age Concern websites all have information either about the Frailty Programme as a whole or around discharge planning and reablement services. (Find references and keep for evidence). (ii) ABHB Clinical Futures Programme 148. This website includes a section on the Frailty Programme and it’s important to Clinical Futures Programme plans for the next five years (iii) The Frailty Programme 149. This website offers comprehensive information on the setting up of the programme, and associated documentation, newsletters etc, but has not been updated for some time except the performance section. Regular references to Frailty are contained in Health Board minutes on their website and in the Health Board’s Clinical Futures section where it is highlighted that the Frailty Programme is one of the services integral to the success of the Clinical Futures programme. 3.14 REVIEW AMBULANCE AUDIT DATA OF INCIDENTS ATTENDED BY THE
AMBULANCE SERVICE 150. A high number of patients who have sustained a fall in the community are taken by ambulance to A&E departments at the Royal Gwent or Nevill Hall hospitals. From data for June to August 2012 there were approximately 270 falls patients per month attending Royal Gwent A&E, and approximately 170 at Nevill Hall A&E. At both hospitals handover of over half of the patients each month did not meet the 15 minute handover target. ABHB are currently revisiting the criteria for ambulance crews to use when attending any fall in the community which might be better referred to CRT; this would avoid unnecessary attendance, with long waits at A&E, and relieve pressure on the A&E departments.
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4. CONCLUSION 151. In its review of the Gwent Frailty Programme ABCHC have looked at the data/statistics provided to it and collected some quantitative data throughout this project but consider that the most important evidence we bring to this report is the experiences of patients, in their own words. 152. The Frailty programme is still in the process of being implemented and evolving to provide a consistent service across Gwent. ABHB have limited feedback from patients to assess their experience of the service but have provided evidence through presentations, data and information that the Frailty Service is having a positive impact on length of patient stays in hospital, provides preventative care to keep people out of hospital, providing support and care to many older frail people in Gwent. 153. There are several areas where ABCHC believe action is required, and these have been included in Recommendations, and highlighted in the responses to the ABCHC survey (Appendix 2). Discharge Planning, communication, safety and carer support were some of the areas suggested for action. 154. The falls service component of frailty has been implemented but is not yet consistent across all areas of Gwent. One of the main issues for this service is the lack of resources to record and evaluate data. 155. The service as a whole has some good outcomes and responses to a question around satisfaction with the service in the ABCHC survey show that the majority of patients/carers were happy with the care provided and there were many comments expressing appreciation for individual health and care staff as well as for the care provided by staff generally.
5. RECOMMENDATIONS
156. Aneurin Bevan Community Health Council’s recommendations to Aneurin Bevan Health Board: Recommendation 1
157. Discharge Planning: That all patients should be given a written care plan. This relates to patients being discharged from hospital into the frailty service, or if being referred to the service by the Medical Assessment Unit, Accident and Emergency Department, a GP or other professional. The care plan should include clear concise information and be given to the patient and/or carer.
Recommendation 2
158. The ‘Pull’ system should be clarified to identify the assessment process in place before a patient leaves hospital, to ensure that the patient’s needs will be met in the community.
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Recommendation 3
159. That relatives/carer should always be involved in care plan discussion and ABCHC would expect to see how the Health Board will monitor this.
Recommendation 4
160. That all care services or equipment/aids which the patient requires on immediate return to home should be in place before the patient is discharged from hospital, or when they leave hospital eg from MAU/A&E Units.
Recommendation 5
161. That pain and anxiety management is reviewed to ensure all patients being cared for within Frailty have been assessed and are receiving appropriate levels of treatment.
Recommendation 6
162. That prior arrangements should be made with a patient or their carer before a member of the CRT makes a visit to a patient’s home. The patient should be provided with the name/s of any CRT staff visiting.
Recommendation 7
163. That ABHB addresses as a matter of urgency, the issue identified in the patient survey of Frailty patients being ‘locked in’ after carers' visits.
Recommendation 8
164. That it is essential through discharge planning, or CRT (if referred into the service from a community setting) that a full assessment is undertaken and action plan produced, to ensure that the toileting needs of a patient can be met at home.
Recommendation 9
165. It is essential that ABHB provide adequate assessment of patient experience and satisfaction of the Falls Service, and we would expect a plan to be in place in the relatively near future to achieve this.
Recommendation 10
166. That communication and information for patients and carers must be improved, in particular, that on referral, all patients should receive a leaflet describing the Frailty service, and each component, and what individual patients should expect to be delivered through their care plans.
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Recommendation 11
167. That the Falls service should be consistent in their delivery across Gwent, with the ability to provide more meaningful data to evaluate the service and the patient experience.
Recommendation 11
168. That ABCHC will consider carrying out a further review of Frailty and/or the Falls Service at some time after the 3-year implementation period.
Recommendation 12
169. It is essential that the Carers’ needs are assessed and fully considered and specifically identify whether the carer is willing and able to provide this caring role and that it is not assumed that they will provide the care because they are living at the patient’s home.
Recommendation 13
170. That it is essential for the Health Board to establish more effective means of eliciting the views of Frailty patients. We would welcome an opportunity to work more closely with the Health Board to achieve this.
Recommendation 14
171. The Health Board should be undertaking a full evaluation of the service, how and from where patients are referred, and how it impacts on reduced lengths of stay in hospital as well as the avoidance of admittance to hospital.
Recommendation 15
172. That ABHB put in place an action plan to take account of any actions required that have been identified through patient experience surveys, complaints and evaluation of the service.
Recommendation 16 173. The ABCHC actively monitors ambulance handover times and over a six month period it was evident that Falls patients had long waits in this respect. This is an area that needs specific monitoring.
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6. APPENDICES APPENDIX 1 ABCHC FRAILTY REVIEW – WORK PROGRAMME
Actions 1 Review how ABHB’s
performance compares with that of similar organisation
1.1 Undertake a literature review of:
(a) Policy (b Frameworks (c) Strategies
2 Examine range and level of
services 2.1 Produce a ‘map’ of local community care services
2.2 Request/research for copy of Frailty Model for each Gwent locality.
2.3 Request from ABHB information on rehabilitation services (all therapies)
2.4 Request from ABHB information on falls for patients arriving at A&E –how many patients treated or admitted or sent home without treatment
2.5 Request from ABHB information on Falls Service
2.6 Research information provided to patients being cared for in own home.
2.7 Request ABHB Officers to present on Frailty, Falls and Community Care general. Also WAST to present on Ambulance Trust Falls Protocol.
2.8 Voluntary Sector Services 2.9 Day Centres 2.10 other support services including GP
services/District Nurse, pharmacy 3 Review Discharge Planning
arrangements 3.1 Equipment/Aids in place
3.2 clinics/therapies appointments 4 Examine statistics and on
delayed transfers of care 4.1 Review performance data
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5 Review a range of patient experience
5.1 Research
5.2 Arrange survey
6 Examine waiting times for
rehabilitation services 6.1 Review performance data
6.2 Request from ABHB criteria/access to rehabilitation services.
7 Review data on Delayed
Transfer of Care 7.1 review performance data for Delayed Transfers – reasons and level of delays
7.2 Review Community Care Resources for patients.
8 Assess the needs, views and
experiences of users and carers
8.1 review and report on trends in complaints
8.2 review and report on trends in Enquiries
8.3 Analysis of patient surveys 8.4 Receive evidence from patient support
groups 9 Assess how ABHB ensure that
they understand and are responsive to patient views on the services they deliver.
9.1 Request ABHB communication strategy to collect patient experiences.
9.2 Request ABHB patient experience
9.3 Request progress reports on any actions taken based on patient feedback.
10 Examine ABHB’s strategic
plans for service development to meet the national policy and strategic direction for the service.
10.1 Request ABHB Continuing Care services strategy
11 Examine ABHB’s compliance
with national standards 11.1 Research relevant publications and check for compliance.
12 Review the range and level of
patient information.
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15 Review ambulance incident screen data
1.1 in particular falls data
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APPENDIX: 2
ANEURIN BEVAN COMMUNITY HEALTH COUNCIL
SURVEY OF PATIENT EXPERIENCE OF THE GWENT FRAILTY SERVICE
RESPONSES TO QUESTIONNAIRE SEEKING EXPERIENCES OF PATIENTS WHO HAVE RECEIVED HEALTH CARE AND SUPPORT THROUGH THE FRAILTY PROGRAMME This survey was carried out as part of the Aneurin Bevan Community Health Council’s (ABCHC) 2012-2013 annual review carried out by the Scrutiny Committee, this year in relation to community services and more specifically the Frailty Programme. The Scrutiny Committee were concerned that it would be difficult to elicit the views of patients being cared for in their own homes and Committee appreciate the help offered by the Aneurin Bevan Health Board to address and post our survey to 1200 patients who have received the six-week frailty care. Number of Questionnaires sent out 1200 Returned 297 Percentage 24.75% Of the 297 responses received: Forms returned completed (including 11 where relatives completed questionnaires relating to deceased patient).
256 (21%)
Forms not completed: Responses included telephone calls to say patient did not receive frailty service, or patient ‘gone away’ or other.
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Responses related to deceased patients. Telephone calls or returned forms to tell us that their relative had died and form not completed.
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ABCHC wish to thank everyone who completed the questionnaire
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COMPLETED QUESTIONNAIRES ANALYSIS QUESTION 1: RELATIONSHIP (PERSON COMPLETING THE SURVEY) Patient 157Partner 24Relative 56Carer 22Other 8In some cases more than one box was ticked eg partner/carer or patient/relative. QUESTION 2 – PATIENT GENDER % based on 256 completed questionnaires Number %Male 96 38Female 160 63Not answered 2 1Note: The above table includes 2 responses indicating both male and female
QUESTION 3 – PATIENT AGE GROUP % based on 256 completed questionnaires Number %Up to 64 yrs. 32 1365 yrs. or over 220 86Not answered 4 2
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QUESTION 4 (A): FOR PATIENTS DISCHARGED FROM HOSPITAL INTO THE FRAILTY PROGRAMME - DID YOU HAVE A CARE PLAN IN PLACE? % based on 256 completed questionnaires Number %Yes 115 45No 51 20Don’t Know 17 7Not applicable 65 25Not answered 8 3% rounded up/down to nearest whole number Of the 256 completed questionnaires received only 45% patients were aware of having a care plan in place on discharge from hospital. The following are examples of comments received from patients responding that they had a care plan in place on discharge from hospital:
• I was seen by Physiotherapist the night before I was sent home • For 4 days Resource Team • Frailty was instigated immediately on despatch from hospital - by referral. • Not sure if Mum was on the Frailty programme. She was discharged from Ty
Clwyd with Reablement.
• There was a plan and with some adjustment has proved ok, but we weren't advised of all the details possible early enough.
• Hospital arranged carers. • My mobility is very restricted and the physiotherapist at Nevill Hall made
arrangements for me to have a walking frame. • When my mother was discharged from hospital, she wasn't well or fit enough to
return home. She went to a nursing home, has settled well and remains there. Her house is now up for sale.
The following comments received relate to patients who reported that they did not have a care plan in place on discharge from hospital. In several cases care plans were made available, but some time after discharge from hospital, and at times without relatives involvement.
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Comments: • I am a man, can’t walk, only crawl around the flat to the bathroom and round the
flat from ‘a’ to ‘b’.
Note: This patient responded that he was satisfied with the care that he received, he had sustained several falls but did not need any carer support as he was happy with the care provided by his family. He had no aids/equipment supplied.
• There was talk of a "care plan" but never recall seeing it or commenting on its contents on behalf of my mother, as her main carer.
Note: Other comments from this carer suggests that the carer was not involved in any care advice or actions, even though the carer’s mother would quickly forget what she had been told.
• We received the care plan for Mam 2 months after she was discharged from
hospital and we received it from her social worker. Assessments not made until after discharge left some patients or their relatives/carers with the dilemma/challenge of finding out about available services themselves, with the risk that patients’ immediate needs were not met. Examples of comments received: • Sent home in pain had to get doctor out and specialist nursing teams to get pain
relief
• Was told at the Heath Hospital but got transferred to the Royal Gwent. I asked the same question but nothing happened. Local doctor sorted things in the end but wasn't happy with the outcome. Promises at hospital never got looked at
• No plan was given to us. We had to take care of dad the best we could
Note: Daughter gave up work to care for father; someone did call round to their home and suggested move bed downstairs (but toilet upstairs) and father severe disabilities.
• Very disappointed as my wife has been left to care for me while my daughter has
to care for her
• No written plan was given; we were told that the district nurse would call.
• Care plan was organised after my mum left hospital • I was discharged from hospital with nothing in place but the frailty team were
brilliant and sorted everything out and really looked after me.
• Yes later on after visit from health staff - very caring and helpful.
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One very concerning issue which came out of the responses was that unannounced visits from the support services were made to patients’ homes, in one case late in the evening. These cases were particularly concerning considering the advice given to vulnerable people not to answer their doors to strangers. Comments: • Did not know anything until they came out to visit us
• I didn’t know there was such a thing as a "Frailty Programme" a very pleasant
middle aged woman appeared that evening when my husband was in bed and I ready for bed. She asked if I needed help and I said no.
• The doctor sent by yourselves, unannounced and without warning, came as a
shock. I thought he was a con-man that visits elderly people. QUESTION 4B – WERE YOU OR YOUR RELATIVE/CARER INVOLVED IN DISCUSSIONS FOR YOUR CARE PLAN? % based on 256 completed questionnaires Number % Yes 149 58 No 44 17 Don’t Know 14 5 Not applicable 48 19 Not answered 1 0 % rounded up/down to nearest whole number Comments received indicate that relatives/carers were satisfied when they were involved in care plan discussions. However a high number of relatives/carers were not involved, or were unaware of these discussions. The following positive comments were received: • Discussed with family what we thought I and they could do and
frailty/physio/occupational therapy what would be helpful etc once discharged home.
• The family met up in a meeting with services and then she went to Valley View Care Home
• My daughter is a support worker on the frailty programme and dealt with my discharge from hospital
• I am my Mother's carer and all was done to make sure my Mother came home
safely • I was kept informed through the whole process. The doctors and nurses
explained everything fully.
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The following comments were received from relatives/carers who did not feel fully involved in the care plan, or who were not happy with suggestions received: • My partner asked about a care plan and was told there would be one. This
happened on two occasions at the Heath, Cardiff and at the Gwent, Newport.
• Yes, about carers, but not asked about frailty department. Asked a number of times about social worker. After numerous telephone calls husband came under frailty department in August 2012 (Note: this patient was referred into Frailty in July 2012).
• Told of discharge plans but no discussions - only very positive on discharge. Did
not inform of possible problems. • Somebody came to the house and suggested that we fetch a bed down to the
living room. This was not a very good suggestion as the toilet is upstairs. QUESTION 5A – DID YOUR CARE PLAN INCLUDE ARRANGEMENTS FOR ALL OF THE SERVICES, EQUIPMENT/AIDS YOU REQUIRED ON DISCHARGE? % based on 256 completed questionnaires Number %Yes 149 58No 30 12Don’t Know 17 7Not applicable 56 22Not answered 4 2% rounded up/down to nearest whole number There was a mixed response to this question, as some patients were assessed for their needs before leaving hospital and had aids/equipment in place on discharge, and others receiving aids/equipment after discharge appear to be content. Responses from other patients suggest that their needs were not considered in a timely way, or they had to make requests to other agencies. Patients happy that everything was available on discharge: • I was discharged with two crutches for my use by physio. The hospital
occupational therapist assessed me to see if I could wash and dress myself and I had no problems with eating but they showed me easy ways to make tea and meals in the hospital department.
• A couple of Zimmers provided on discharge and extra aids added after discharge. • All accommodated - everything completely satisfactory.
• The district nurse suggested aids that would help my wife and she contacted
'care in the community'.
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• Care and Repair gave a friendly and excellent service in relation to all aids required.
• Other patient/relative comments received: very helpful, excellent service, first class, very good service
Patients who appear content - where aids/equipment received after discharge: • A bed, night and day care were all in place within 48 hours. An excellent service.
• I asked for a chair for bathing and it was provided within a few days. I purchased
a wheelchair.
• The provision of a new stair hand rail and hand rails for front steps were completed a couple of days after hospital discharge.
• Equipment was received but seemed to be arranged by the community/district
nurses visiting patient. • After discharge visited by occupational health/physio to discuss needs. Was
alright to go home with family input. • But not on discharge - they arranged everything for me as soon as possible. Patients where aids/equipment were not in place on/after discharge: • My wife ‘phoned the local Councillor and he gave a number which my wife
‘phoned. Since being involved with lady from Occupational Health Team things have started to move forward and help both me and my wife.
• We have had no equipment except a Zimmer which he had 12 years ago. He is an above the knee amputee with arthritis in his other leg and hands.
Note: This patient is cared for upstairs in the bedroom as there is no downstairs toilet
QUESTION 5B – WERE ALL THE AIDS/EQUIPMENT YOU REQUIRED AVAILABLE TO YOU WHEN YOU NEEDED THEM? % based on 220 responses Number %Yes 194 88No 26 12% rounded up/down to nearest whole number The majority of patients were happy that they received aids/equipment when required; however 26 patients did have problems in accessing aids/equipment.
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Comments from patients/relatives who were happy with the service received: • Provided within a reasonable timetable. • The nurses supplied all necessary drugs and equipment for when intravenous
antibiotics were used. • I have found that I have experience better care since I was discharged although
my general condition has deteriorated. • Aids supplied after home assessment by frailty clinic. • Yes outstanding • All equipment/aids were put in place before Mam was discharged from hospital. • All items were delivered within days. • Mainly yes.
• A check was made for all her needs in the care home. Some patients/relatives had issues with the supply of aids/equipment, included in the examples of comments given below: • I did have to wait about two weeks for pickups, pulling socks on and they have
now a safe wire a spare key. This has put my mind at rest - two people have the code so no more being locked in.
• Only when I got home from hospital did they send Care and Repair to fit a handle
in the shower for me. • I had to make a request and then wait for the item • It has taken time and my wife having to investigate the help available - things are
now moving since meeting with lady from Occupational Health Team. • Equipment generally available but had to wait 6 months for stair lift to be fitted
and for bath adaptation because there was no cash available until the next financial year (2012-2013). Fitted in June 2012.
• On original discharge no aids were provided - we had to subsequently ask for
assistance several times from social services until the GP intervened. • No care except when specialist nursing team called in. • Had to have an assessment few days after arriving home. • Special bed with air mattress needed to be ordered.
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• Some things promised but never arrived e.g. pads • Believe so - but no one sat down and told "carers" what was available. Patient
would say she just wanted to come home regardless of what was in place to support her.
• Tablet changeover was described but not made before departure. • Not offered any • Did not receive anything.
QUESTION 6 – IF YOUR GP REFERRED YOU INTO THE FRAILTY SERVICE WERE YOU ASSESSED FOR ALL YOUR MEDICAL AND OTHER NEEDS? % based on 161 responses Number %Yes 112 70No 49 30% rounded up/down to nearest whole number Although 112 patients were assessed for all of their medical and other needs, there were a significant number of patients (49) responding that they did not have an assessment. Patients who were assessed for their medical and other needs, gave the following positive comments: • Doctor was concise, thorough and very helpful.
• I received service from GP and the hospital. Both offered an excellent service.
• My husband was taken ill when we came back of holiday. The doctor visited him
and arranged for the Frailty unit to visit and check on him every day. Patients who were not clear on the details of their assessment, or had issues with the care provided by their GP, commented as follows: • Doctor refused to come out to see me or my wife when we both fell
We believe that patient was assessed at the Royal Gwent. • I believe my GP referred us but I was unaware of it at the time. • My GPs not involved in any way - only to arrange for district nurse visits. I did not
know at any time that I was referred to the frailty service
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QUESTION 7 – WERE YOU GIVEN THE FOLLOWING INFORMATION WHEN YOU WERE REFERRED TO THE FRAILTY SERVICE? Although percentages for the responses to each of the following questions were based on the 256 completed questionnaires, it is accepted that these may not have been relevant for all of the 256 patients. Comments received suggest that patients did not feel totally satisfied with some elements of the services and of particular note is that only 50% patients had a co-ordinator contact name and telephone number, and also there was an issue with the variable times of nurse visits to patients. (% based on 256 completed questionnaires)
Number %
Emergency contact details 128 50
Name and contact details of your health co-ordinator, as your main point of contact
129 50
Dates/times of nurses and care staff expected visits 153 60Your medicines and how to take them 111 43Appointment dates for clinics 85 33
Transport arrangements to clinic appointments 49 19
% rounded up/down to nearest whole number Comments received to each section for Question 7 follow: Emergency Contact Details
• No emergency contact details given.
Health Co-ordinator details
• My daughter had a social worker’s name and number. • I have since been given a health co-ordinator who is very helpful. • If Frailty refers to district nurses given contact details.
Nurses/Care Staff visits
• Times for nurses were approximate and could differ by many hours.
• Times of nurses varied daily. • Kept informed when physio and nurse expected. • When Frailty department contacted us on the 1st August they
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said team included occupational therapist who would contact us in the future, but if not heard within next 2 weeks contact them again on Civic Centre number. Occupational Therapist contacted us on the 6th Aug 2012.
• On the whole not too bad, but found that some of the nurses
thought they were more important than the patient. • Very satisfactory treatment for ulcerated leg.
• Times of nurses varied daily • First week Age Concern, first team of carers were any time from
7am to 10pm any time from 12 - 2 pm and anytime from 7 to 10pm second team, times were given, much more convenient.
• Early mornings every day, care staff • I received excellent care from nurses who were polite at all times
after my biopsy wound burst with an abscess.
Medicines Information
• My mother is unable to understand her own medications - the Home dispenses these to her. Any appointment my Mum needs to attend, I take her myself.
• These were given me on the ward before discharge. I was given
the GP letter with all the information on for myself and a copy for the district nurse. I was shown how to inject myself for 10 days. My daughter took the letter to GP and arranged with her for district nurse to give me intramuscular injections at homes x3
• Others not known or had to read labels on medication • Had problems with medicines and how to take them.
Clinic Appointments
• No, still waiting for further details after initial clinic assessment. • Dates sent by hospital. • Follow-up appointments were made by hospital.
Transport
• I don't go to the local medical practice because I can't walk very far - I lose my balance and fall.
• Transport for clinic appointments is good but now you no longer can have an escort - in my case I need an escort.
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• Transport for my husband is very difficult.
• Dates sent by hospital, transport arranged by myself
General Comments:
• Age Concern (Gwent) Hospital Discharge Service called to see me and gave me help and advice.
• Not aware of "frailty service", at time Mum was living independently pre November 2010, resident in care home since then.
• I thought I was referred to reablement not Frailty. • No I do not remember. Only the therapists and daily help for 6
weeks. Further mental health help to start soon. • 2 further responses to say never heard of Frailty service. • 3 responses to say information provided was good/helpful
• 4 responses to say no information received
QUESTION 8 – DO YOU FEEL THAT YOU RECEIVED THE LEVEL OF SERVICE AND INFORMATION YOU REQUIRED? % based on 256 completed questionnaires Number % Yes 200 78 No 28 11 % rounded up/down to nearest whole number One comment below is extremely concerning is the unacceptable practice described of the patient locked in all day between carer visits. The majority of patients/relatives responded positively to this question; examples of some of the comments received follow: • Satisfactory
• First class. The nurses were brilliant and their work ethic second to none • GP service excellent and also social worker • In an understanding way • Could not be faulted, first class • Excellent service
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• Very good • Help was swift, efficient and caring and much appreciated • Following assessment, the right level of care was put in place • Many thanks • Has improved now as physiotherapist has informed hospital about health issues
and an appointment to see hospital doctor arranged • Service informed were absolutely first class. Could not have been better • Many thanks to all concerned • Excellent Service • Outstanding help • Above expectations, we received everything we needed quickly • Very good. My answer yes to this question is because both my doctor and the
frailty team cannot do much more for my condition • What patient has had off social worker and care staff who helped her when she
was ill, was very good • I was surprised at all the care provided Respondents were asked to give details if not happy with the service and information they received, and the following comments were made: • Only given 1 carer for 30 minutes at 9am and 30 minutes at 6pm. My father was
locked in the house by the carer in the morning and unlocked at 6pm. If there had been a fire he would have been trapped. (Note: this patient now in residential accommodation)
• Information re emergency contact details, not at first.
• The problem was the appalling lack of communication between the community
services with the hospital for me to have the information.
• A patient was discharged from a hospital in England to a Unit in Gwent, for an assessment of need and to assess her home. There was confusion as wrong address was given for the Unit expecting the patient, and patient was very unhappy at delay finding the unit, on what was a cold day.
• Left to care for our Dad on our own. His daughter gave up work to care for him
and his son-in-law, her husband has a knee replacement and pace maker. • I have been left to defend for myself.
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• Did not receive anything at all. • Could have had more detailed information of what to expect. • Nurses occasionally informed carers what was happening. • Some district nurses much better than others with this. • No arrangement for doing washing. • From Occupational Health Team only, nowhere else. • I think that a district nurse to check over operation wound would have been a good
thing just after operation, but this was not done. • I put yes, but it took a long time to get there and I still think there is a little bit of
attitude of they were more important than the patient. • Wanted information as soon as husband out of hospital - 9th July 2012 and not
have to wait until 1st August. • Fortunately the help and advice received from the carers of Allied Services was
superb. • Partly - communication as carers limited - patient would not be able to remember
what she was told so did not pass it all on. QUESTION 9 – IF REQUIRED THE FOLLOWING HELP, WERE YOUR NEEDS MET: % based on 150 responses Number %Bathing / Washing Yes 133 89 No 17 11
% rounded up/down to nearest whole number
% based on 138 responses Number %Dressing / Undressing Yes 117 85 No 21 15
% rounded up/down to nearest whole number % based on 87 responses Number %Cleaning teeth/ dentures Yes 52 60 No 35 40% rounded up/down to nearest whole number
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A high percentage (40%) of patients reported that they do not receive dental hygiene care as required. A large proportion of patients/relatives commented that all care was provided by partner/relatives or in some instances the patient preferred to retain independence even though carrying out some tasks was difficult. Where assistance was provided, the following positive comments were received: • Having this help in the morning with my Mam has made a big difference to me
• Carers at the home help my mum with all of this, in hospital mum was helped
when needed • All the care staff were super - no problems • Care agency already in situ through Social Services • Day care calls daily • Great support • Very helpful • My wife who is also my carer, is able to assist me with most of the above, but the
hand rails and step up in the toilet which were provided have been much appreciated by both of us
Where patients/relatives had issues with care received, the following comments were given:
• Most of the time received the help needed
• Nothing was done except make breakfast • Different carers came each time - he did not know what to do • After initial few weeks, the aids provided were sufficient • We are just about managing • Not until requested • With difficulty I still look after myself • Social Worker, occupational therapist needs more training • One hour out of 24 is inadequate
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QUESTION 10 – IF YOU REQUIRE ASSISTANCE TO USE THE TOILET WAS THIS PROVIDED? % based on 117 responses Number %Whenever you required assistance? 57 49Yes, but not always when required 23 20No
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% rounded up/down to nearest whole number Responses suggest that over half of the patients requiring assistance with toileting are not adequately provided for, as identified in the comments below: • Unable to have help for toileting at lunchtime
• Never know when the help would be needed - we manage • Help sometimes slow in arriving • Only given a short time early morning • We were told by Social Services in Torfaen that only four calls a day would be
provided as a maximum level of care in the community • Problem for my Mum is that she cannot get to the toilet alone.
She tries to go now when the carers are there and this is ok for now. I suspect it will get to be a problem in due course.
• Always waiting A high number of patients had equipment such as grab rail, commode or raised toilet seat, and others had pads or were catheterised. Where equipment/aids had been installed the following comments were received:
• I didn't need personal help - only a grab rail in downstairs toilet. Care and repair put it in 2 days after discharge from Cwmbran house.
• Toilet frame provided to enable me to use it unassisted. • Provided with raised toilet seats after discharge (but able to manage prior to
receiving them) but realised how much a help they were after installed and still use them.
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QUESTION 11A – DO YOUR REQUIRE HELP AT MEAL TIMES? % based on 214 responses Number %Yes 54 25No 160 75% rounded up/down to nearest whole number Responses to ‘Yes’ and ‘No’ indicate that a high number of patients are supported at mealtimes by partner/relative. The following comments relate to patients responding that they do require assistance: • Someone to cook meal and cut up food
• Have meals provided • Help to prepare and encourage • Preparing meals • Unable to use hands much, need food to be cut up small to be able to pick up on
spoon. Can’t use knife and fork. • Yes - Mealtime assistance is required however Mondays provided but due to
fluctuating assistance this proves difficult - we have asked for a carer to call at lunch time to no avail to prevent potential falls
• For Breakfast • Part of care plan
• Some help in preparation and cooking would have been very appreciated • Help with cooking and medication • Microwave help • To prepare light meals twice a day - I have this now • Heating meals and making hot drinks • through lack of mobility I cannot prepare meals for myself • Preparation/plating up - already receiving assistance
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QUESTION 11B – MEALTIMES: WHICH OF THE FOLLOWING APPLIES TO YOU: % based on 256 completed questionnaires (patients may have ticked more than one box in this section)
Number %
I do not require help to prepare meals or at mealtimes
83 32
I am provided with food and drink I like when I want it
81 32
I get adequate food and drink at acceptable times 64 25I am not always provided with adequate or timely food and drink
8 3
N/A 36 14 Comments received suggest that a high number of patients receive assistance from partner/relative. In one instance the response suggested that ‘it was naturally assumed’ that husband would provide this assistance. Other patients received meals on wheels, help from carers or were in Extra Care Housing. Quite a few patients referred to having ready-made microwave meals which were more manageable. Patients who did not feel they receive adequate or timely food and drink commented: • As in previous comments my dietary needs are not met, so I cannot have a lot of
the food on offer
• Discharged home - unable to get drink from tap or make tea. Unable to lift jug of water not happy with this discharge.
• Cold meals The comments below are given as examples of how patients have become more independent through receiving support, including aids/equipment: • I was helped with mealtimes and they helped me get back to doing it for myself
• Initially on discharge I was not able to prepare a meal but Age Concern arranged
meals on wheels and breakfast or supper were prepared if needed • Once moveable the use of the kitchen trolley and perching stool that the
occupational therapist supplied were invaluable.
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QUESTION 12 – HAVE YOU HAD A FALL WITHIN THE LAST TWELVE MONTHS? % based on 256 total completed questionnaires Number % Yes 149 58 No 87 34 Not answered 20 8 % rounded up/down to nearest whole number Many patients sustained more than one fall in the last twelve months. Reasons given were varied, for example:- • Dizziness • Balance • Fell on stairs • Fell in bathroom • Falls out of bed • One patient fell first when trying to manage his meals on wheels, then later
another fall when using commode
Responses received where provision of aids/equipment has made a difference: • But not recently, because of the provision of a Zimmer, which I was very reluctant
to use but I would not be without it now
• My balance is affected but I have a Zimmer and walking stick I also have a rail on the walls which make it easy to get to bedroom and bathroom also the kitchen - I live in a bungalow
QUESTION 13A – AFTER YOU HAD A FALL, WERE YOU REFERRED TO THE FALLS SERVICE? % based on 170 responses Number %Yes 44 26No 91 54Don’t know 35 21% rounded up/down to nearest whole number Responses to this question were varied as falls services across the five localities in Gwent are not at the same stage. Some areas have a full falls service whilst others may not have commenced this in the first year of frailty, with patients’ having treatment provided by other services/agencies. It is not expected therefore that all patients/relatives would be aware of this service.
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Referrals to the Falls Service: • My husband attended the falls clinic at Canalside where he was directed to have
a MRI scan in the Royal Gwent. The doctor at the clinic said that there was nothing to be done (he is in his 90's) and as he was unable to exercise we didn't go anymore
• Falls service phoned to cancel my appointments not heard from them since • Via GP
• Have attended Falls Clinic previously (about 18 months or 2 years ago • Physio input to assessment • Visiting physio
• Yes whilst at Royal Gwent Hospital No knowledge of Falls Service or no referral: • A number of responses were received stating that patient/relative had never
heard of the Falls Service
• What is the Falls Service?? We press his red button and an ambulance arrives - I can't get him up on my own, he is a big heavy man - I am small
• Did not know that there was a falls service and no one mentioned it (including my GP who I visited shortly after discharge
• Never been referred to falls service never offered • No knowledge of a falls service Not willing to be referred: • He refused to see anyone QUESTION 13B – HOW SOON AFTER YOUR FALL WERE YOU REFERRED TO THE FALLS SERVICE? Most patients indicate that they were referred ‘immediately’, ‘quickly’ or within three to four weeks. Other comments received: • When patient refused hospital admission, frailty workers most helpful in
persuading patient it was in her best interest to go to hospital
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• Still waiting for a date to see somebody • A few months after because I wasn’t well • 2 responses stated 6 months or over QUESTION 13C – WHO REFERRED YOU TO THE FALLS SERVICE? The majority of those patients who were referred to the Falls Service were referred by their GP or hospital. A minority responded that they were referred by paramedic, community nurse, carer, social worker. QUESTION 13D – HOW SOON AFTER REFERRAL WERE YOU SEEN AT THE FALLS CLINIC? Responses suggest that patients were referred to the falls clinic either immediately or up to 3 weeks. Responses were not specific but a minority of responses refer to having waited several weeks, or months for an appointment. QUESTION 13E – DID YOU RECEIVE A FULL AND SATISFACTORY EXPLANATION OF THE RESULTS OF YOUR HEALTH ASSESSMENT AT THE FALLS CLINIC? % based on 33 responses Number %Yes 27 82No 6 18% rounded up/down to nearest whole number Comments received: • Yes Doctor was excellent so were the nurses
• Ok, but too much information. • Yes - from physio • Having seen a very nice Doctor at the clinic I presume I did, sorry my memory not
what it was. • Very satisfactory
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QUESTION 13F - FROM INVOLVEMENT WITH THE FALLS SERVICE HAVE YOU BEEN INVITED TO ATTEND AN EXERCISE PROGRAMME AT HOME OR AT A CLINIC? % based on 71 responses Number %Yes 29 41No 42 59% rounded up/down to nearest whole number Comments received: • Exercises demonstrated at home • Mum was offered this service but would not co-operate • Physio has given exercises to strengthen leg/hip to help prevent further falls • Declined offer - feel enough is done personally • Did not wish to attend exercise class • Not able to • I had exercise programme at home - which was very good • Physio at home • Due to mobility would be unable • Very good QUESTION 13G – DO YOU FEEL YOU HAVE BENEFITED FROM BEING IN THE FALLS SERVICE? % based on 63 responses Number %Yes 34 54No 29 46% rounded up/down to nearest whole number The responses above to this question indicate a mixed level of patient satisfaction with the falls services, however most of the comments received, given below, were favourable.
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Comments received: • We were very impressed with our visits to the Canalside falls clinic where my
husband received a really comprehensive examination but as we realised he would only get worse we decided to "just mosey on"
• Only received assessment, cannot comment on benefits • The nurses were marvellous also the doctor! • They have been extremely helpful and kind at all times, all staff from doctor,
nurses and Physios are very professional
• Most helpful and sensitive workers • Physio at home very good • But early days to see benefits • Very helpful • A great help • As I have not been informed of the falls service I do not know what it entails QUESTION 14 – WHICH OF THE FOLLOWING APPLY TO YOU? PAIN: % based on 156 responses Number % I have no pain or discomfort 36 23 My pain is managed appropriately by medical staff 81 52 My pain is not managed well enough 39 25 % rounded up/down to nearest whole number
ANXIETY/DEPRESSION % based on 78 responses Number % I am not anxious or depressed 48 62 My anxiety is well-managed by medical staff 18 23 *Depressed or anxious 12 15 % rounded up/down to nearest whole number *No section provided for patients to respond ‘I am anxious or depressed’ therefore the number of comments were taken into account.
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The responses received to this section highlight that many patients discharged to their own homes have inadequate pain relief, and others suffer from anxiety and/or depression. Responses referring to questions relating to Pain: • He seems to be in permanent pain, back, stomach and feet • Although I am very pleased with the service I receive, my mobility is affected by
painful knees • I am in constant pain • Dad is in a lot of pain. He suffers phantom pains in his "non" leg. Arthritic pains
all over the rest of his body • My husband has constant pain in his back which he has put up with for years but
I would say that heart failure is the primary factor in his disability • I have a lot of pain in my legs and my feet • Mum is constantly very unwell and experiencing pain (patient had care plan on discharge from hospital) • Always in pain, manage well some days other times have to live with it. • Still have pain only cause of action is oromorph which I have declined • I am anxious and depressed by my level of pain • During the final week of my father’s life all those units and staff including St
David’s Nurses, District Nurses were wonderful in every way as also were the GPs from Belle Vue Surgery
• My pain is constant but it does have varying degrees of severity • I suffer a lot of health problems and belong to the Grange Clinic Malpas, and
have excellent care from them • Pain is managed by painkillers- not all the time • I’m in constant pain • I have been suffering increasing pain seems to have developed from old injuries
to my right hand, wrist and shoulder leading to poor and writing • I have been suffering increasing pain seems to have developed from old injuries
to my right hand, wrist and shoulder leading to poor and writing • I have pain and discomfort
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• Both as sometimes no pain from lymphedema, other times very painful • Mam is in a lot of pain and discomfort. She takes pain medication which
sometimes works • I am on pain relief medication but it does not take all of the pain away Comments relating to Anxiety/Depression: • Yes I get very depressed
• Suffering from long-term depression • I suffer with anxiety and depression since losing my husband and also having to
undergo major surgery • Depressed • My wife cannot be left alone as she is very nervous so I am with her 24/7 • I am anxious and depressed • I get anxious at times • I am very anxious much of the time • Anxiety and depression are bad Other Comments: • No discussion with my Mum, only keen to send her home and empty beds for
bank holiday? QUESTION 15 – DO YOU RECEIVE ANY PRACTICAL HELP ON A REGULAR BASIS FROM YOUR HUSBAND/WIFE, PARTNER OR RELATIVES? % based on 256 completed questionnaires Number % From someone living in your household 111 43 From someone living in another household 92 36 Not answered 53 21 % rounded up/down to nearest whole number Several patients receive help from more than one person. The responses identified that a wide range of people provide support to patients, for example, son, sister, daughter and family, wife, husband, care home, granddaughter, brother , sister in law, neighbour, godson, friend, daughter in law.
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It is evident from the responses that there are services or support which patients believe would be helpful for them to remain independent and that these go beyond the usual services highlighted of meals, toileting, personal hygiene and health support. The following are some of the examples of care provided to patients by others: • My daughter does my shopping weekly and is in touch by phone. • Not consulted about help we were able to give.
As both myself and my brother live away - yet services seemed to rely on us.
• My sons are in touch and help by putting the bins out. For seven weeks I have had private help to clean my house arranged by my daughter and paid for by myself. This has now ended.
• I see my mum at least 5 days a week and take her out regularly. Her life has
improved from being in a Care Home • My partner has to get me out of bed in the morning and also out of the bath.
When I have to get up off the settee to go to the toilet, I struggle. I do not have enough strength to do the things I want to do
• Son and partner cook meals and help • As necessary from relatives only when I am at my worse • I have my cleaning and ironing done by a friend • Keeping garden tidy, dealing with paperwork, keeping an eye on general health
and ensuring carers and home help are providing agreed services
• Help from friend with shopping etc. • Carers take care of meals, dressings etc.
• My niece who cares for me lives at another address
• Godson is very supportive of all my needs
• Daughter shops, pays bills, does washing and ironing
• My daughter-in-law is wonderful with me
• I am totally dependent on my husband • My sister helps with shopping and meals (she is 87 years old).
• I have a friend who does my cleaning.
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• My husband lifts me into the car when we go to the doctors and also lifts me into a wheelchair to get to the car and helps me upstairs
• My wife helps with my medication but as she is suffering from advanced state of
multiple sclerosis (ms) she is immobile and attends Rookwood Hospital on a 3 month basis
• My friend helps with housework, take me shopping and cooks some meals
• Now living in Residential Care because at home was inadequate.
• Having to sell house to pay for it. • I pay a lady to give a good clean up once a week QUESTION 16 – ARE YOU SATISFIED THAT YOU, THE PATIENT RECEIVED THE HEALTH HELP, CARE AND SUPPORT THAT YOU NEEDED AT HOME? % based on 256 completed questionnaires Number %Yes 195 76No 21 8Not answered 40 16% rounded up/down to nearest whole number Not all patients/relatives who completed the questionnaire responded to this question, but of the 76% who were satisfied, the following positive comments were received. Comments: • All agencies were wonderful. • My father has made good progress, even though he is 91, his mobility has
improved. The GP, nurses, physio and frailty team were marvellous • We were really pleased with the care and support my husband received.
If it was not for this service he would have been admitted to hospital. It is a brilliant service
• First class • Speaking on behalf of my husband he received excellent care in the 48 hours he
was home before he passed away. I also had excellent care and support I would recommend all people who helped with my care be rewarded in some way by the Health Council during the times that they came to me - they were excellent
• The care was wonderful and fully appreciated
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• I was given all help and care at home. All who came to me were very kind understanding and very helpful. (excellent)
• The nursing team which came to treat me twice a day were very professional,
friendly and caring. An excellent example of team work. • It was so much better to be able to have the medication I needed at home rather
than be in hospital for 2 weeks • Yes at the time I did not want to be admitted to hospital and was glad of the frailty
team for the short time before I had no choice but to go into hospital. Thank you frailty team for your help
• I am more than satisfied with the help I received • Pharmacy collect my prescriptions and deliver my drugs. • The only member of community team calling was the physiotherapist who called
weekly to help me with exercises for mobility that has now been discontinued. I have exercise programme from her to follow.
• Care and Repair have referred me to handyman service and I have had lots of
small jobs done by them which I have paid for and they were satisfactory. • All Health care is now done by Practice Nurse and injections every 3 months in
surgery. • We are very pleased with the service provided by Q care. The carers are
efficient, kind, polite and are very helpful indeed • I was very well cared for by the Community Team who came to look me, and help
me • excellent care • When I came out of hospital I was very glad to have carers coming in to help me
wash and dress. They also made my bed and were kind and caring. They all asked what else they could do for me. Thank you for this service. Also visiting nurses
• Brilliant care thank you Where patients indicated they were not satisfied with the service provided (8%) the following comments were received: Comments: • Very Poor • The Saga Carers Service could have been better organised e.g. not turning up,
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only one carer when two were required • Well could have better help for bathing/shower! • It’s now started but I needed help for a long time.
• The hospital hasn't done anything to help me at home • It took time to get it sorted but it could have been quicker if we had the healthcare
that was promised at both hospitals. We felt let down a bit because she needed it so badly.
• There are other aids and help that would make life easier for me and also relieve
some burden from my wife • I think a district nurse visiting post-operation would have helped just to check
over operation wound • I need more help QUESTION 17 – PLEASE WOULD YOU INDICATE BELOW WHICH MONTH/S YOU RECEIVED CARE AT HOME THROUGH THE FRAILTY SERVICE? The majority of completed questionnaires related to care provided in 2012. Additional comments: • my wife passed away (June 2012). On the previous 10 days the care and
consideration she received was second to none and made her passing a lot easier to bear for all her family
• Both my parents have had help from the Frailty both at various stays over the last few years - for falls and other general health problems. As a family we’ve been generally pleased - even impressed by the service and what is available.
• I had great help from a team in Pontypool my CPN was great – she went out of
her way to help and all her team were fantastic • The frailty team were fabulous • September 10 days - then into residential care home and 5 weeks later died. • Super service - but not suitable for my Mum, need to involve relatives and listen
to their concerns - as we were only there to help and wanted best for Mum. Told Mum up to living at home this was not true and was dangerous from the start. Plus problems with Bank Holiday.
• My husband is very poorly - I am not coping.
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• One complaint - carer came when patient was in bed, rushed him, did not help him, only put socks on patient's feet.
• Left dirty gloves on settee (didn't want any more after that) • No help from frailty service only family and I am happy with my family help
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APPENDIX 3
Aneurin Bevan Community Health Council
COMMUNITY CARE SURVEY
On the ABCHC website between May and September 2012
Questions Have your community based services been of a high standard and appropriate to your needs? The responses suggest that where Frailty service was implemented then the patient/carer had a good experience; one respondent referred to the professionalism, friendliness and good work of the Frailty team. In contrast one respondent was unhappy and highlighted that admission to hospital would have been avoided if the GP and District Nurse had attended and treated the patient; they failed to visit. Have they been regular and reliable? Mixed responses included frustration with getting through to an answer machine, late arrivals, but also others happy they receive a regular and reliable service. Are you are able to contact the community team caring for you and do they listen to your views? The feedback on this question was limited with some patients/relatives happy they had contact, and one response ‘What community team?’ Has your GP played any part in your care? Three respondents were happy with the GP service, with two indicating that their GP had referred the patient to the Frailty service. Refusing to visit a patient with several health problems, and another not happy with GP support were issues raised. Would you welcome more treatment and care delivered in your own home? One respondent was definitely not happy with what was provided, but all other responses welcomed more treatment and care delivered at home. Do you have any other views you would like to add? Comments varied between very happy with the service provided to a feeling of being let down by the NHS, GP or the appointment system. One particular response highlighted that some carers do not feel fully supported in their role, as in comments from a carer who, despite frequent requests for help was frustrated that no help was received. This resulted in having to call the emergency service to take a relative to hospital instead of having a GP visit. This carer had other family pressures, was
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working full time and felt ‘crushed’ trying to keep the patient at home with what was perceived as little understanding from the GP.
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APPENDIX 4
LITERATURE REVIEW Initial research centred around national publications to provide Committee with background information on Community Care provision in Gwent, Quality Standards, Guidance, Policies, Strategies and Frameworks. 1. 05/2005 Welsh Assembly Government: Healthcare Standards for Wales
– Making the connections – Designed for Life 2. 05/2005 Welsh Assembly Government: Designed for Life: Creating world
class Health and Social Care for Wales in the 21st Century. 3. 04/2010 Welsh Assembly Government. Doing Well, Doing Better Standards
for Health Services in Wales 4. 05/2005 WHC(2005)035 dated 13 May 2005: The National Assembly for
Wales – Hospital Discharge Planning Guidance. 5. 03/2012 The King’s Fund – continuity of Care for older hospital patients – a
call to action 6. 03/2012 The King’s Fund – The care of frail older people with complex
needs: Time for a revolution 7. 01/2012 AGGCC/CSSIW Growing old my way – A review of the impact of
the National Service Framework (NSF) for Older People in Wales. 8. 2008/2013 Welsh Assembly Government – ~The Strategy for Older People
in Wales 2008-2013 – Living Longer Living Better 9. 20/09/2010 AGGCC CSSIW – Protection of Vulnerable Adults Monitoring
Report 2009/2010 10. 06/2010 Institute of Welsh Affairs (IWA) – Adding life to years – Welsh
approaches to aging policy 11. 06/2012 All Wales Fundamentals of Care Audit Tool 12. 05/2011 NHS Wales: Forging a better future – A report by the Bevan Commission 2008-2011 13. 10/2008 Welsh Assembly Government: A Strategy for Intergenerational Practice in Wales
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14. 2008 AGGCC CSSIW – Fundamental Review of the National Service Framework for Older People in Wales 15. 2009 AGGCC CSSIW – Review of the Impact of the National Service Framework for Older People in Wales Phase 1 (2008-2009). 16. 2010 ‘1000’ lives – Intelligent Targets Reducing Harm from Falls ‘How to’ Guide 17. 2010 The King’s Fund – Avoiding Hospital admissions, lessons from evidence and experience – seminar highlights 18. 2006 WAG: NSF for Older People in Wales , and Executive Summary
(March 2006) 19. 2010 WAG: Setting the Direction – Primary and community services Strategic Delivery Programme 20. 2011 ‘1000 Lives’ Improving Care, Delivering Quality 21. 2011 Welsh Government: Together for Health – A Five Year vision for the
NHS in Wales
22. 05/2010 Welsh Assembly Government: Continuing NHS Healthcare: The National Framework for Implementation in Wales May 2010
23. 03/2009 Towards Independence for Older People in Gwent – Key findings from the 2009 Older Peoples Experience Workshops
24. 04/2002 The Wanless Report – Securing our Future Health: Taking a Long-Term view
25 Clinical Guideline 21 – 11/2004: National Institute of Clinical Excellence -
Falls: The assessment and prevention of falls in older people 26 Expert Patients Programme (EPP) A RANGE OF GWENT FRAILTY PROGRAMME DOCUMENTS FROM WEBSITE: http://www.gwentfrailty.torfaen.gov.uk/
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APPENDIX 5
ABBREVIATIONS
ABCHC Aneurin Bevan Community Health Council
CHC Community Health Council
ABHB Aneurin Bevan Health Board
GP General Practitioner
NHS National Health Service
ABMCHC Abertawe Bro Morganwwg Community Health Council
WAST Welsh Ambulance Services NHS Trust
CRT Community Resource Team
ABMU Abertawe Bro Morgannwg University Health Board
SPA Single Point of Access
DTOC Delayed Transfers of Care
IT Information Technology
QOF Quality Outcomes Framework
NCN Neighbourhood Care Networks
A&E Accident and Emergency
COPD Chronic Obstructive Pulmonary Disease
EPP Expert Patient Programme
MAU Medical Assessment Unit
EMI Elderly Medically Infirm
H.A.R.T. Home Assistance and Reablement Team
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