SCIE Practice guide 09: Dignity in care

Ideas from practice

Knife and Fork Symbol (United Bristol Healthcare NHS Trust)

Under this system, a knife and fork symbol is placed above patients’ beds. This gives staff the same signal as the Red Tray system, indicating which patients need support during mealtimes.

For further information contact

Toni Williams, Chief Dietician, Food Policy, United Bristol Healthcare NHS Trust. Tel 0117 9283006. Email toni.williams@ubht.nhs.uk

Learning from patients (Royal Surrey County Hospital, Guildford)

The older people’s champion and the manager of the Surrey 50+ Network invited members of the Surrey 50+ Network to meetings on four topic areas: environment, training, communication and telling their story. Members acting as 'mystery shoppers’ explored all areas of the hospital and made recommendations for improvement. Eight people also recounted their stories as patients. Problems were identified in the following areas: mealtimes; cleanliness; sensory impairment; patient information; personal dignity; and the environment. A number of solutions were achieved, for example modified training and induction for staff; front hall design was influenced by the group, and signage and notice boards have been made clearer. Members are now also involved in reviewing patient information leaflets. This project marks the beginning of a partnership between older people and hospital staff built on mutual respect and a growing awareness of the complexities of hospital service delivery.

Key learning points:

• Often, minor changes can have a huge impact on patient at minimal cost. Frequently the solution to patients’ concerns is about delivering a service differently - not necessarily about spending more money.
• Keep the concerns in the picture but make working on solutions the focus.
• Active user participation requires commitment to make it real engagement.
• Staff were committed in principle but require the support and drive from senior management in order to make progress.

For further information contact

Mary Foster, Manager, Surrey 50+ Network. Tel 0208 541 8594. Email: mary.foster@surreycc.gov.uk

Life Story books (St Pancras Hospital, London)

The Evergreen Unit at St Pancras has developed Life Story books to support and inform the care they give to their patients. Where patients are able to contribute they do, but many have cognitive impairment and difficulty with verbal communication, so relatives are key in providing the information and are actively encouraged to be involved in completion of the books. The Life Story books help staff to engage with patients who have complex needs and are used to inform many aspects of care planning, from personalising bedrooms to meeting personal needs in a way that respects the person’s wishes and promotes their dignity. The books, which were developed by the staff on the unit including nursing staff, occupational therapists and the psychologist, are also a guide to providing meaningful occupation. All new staff are taught how to use the books during their induction process. The books are given to the relatives/next of kin when the person dies and these have been welcomed as a 'nice reminder’ of the person.

For further information contact

Colin Owen, Email colin.owen@camdenpct.nhs.uk or Judith Greening, Email Judith.greening@camdenpct.nhs.uk

Related documents

• Life story book: Part 1 (388kb PDF file)
• Life story book: Part 2 (251kb PDF file)

Linking Essence of Care into reviewing complaints (Derbyshire Mental Health Trust)

The Essence of Care lead attends all meetings about complaints and matches these complaints to the Essence of Care standards, so appropriate action can be taken. This is fed to the trust board, matrons and to ward teams.

For further information contact

Kim Shield, Essence of Care Coordinator. Tel 01332 362221 ext 3783. Email: kim.shield@derbysmhservices.nhs.uk

Local Care Centre Cafe (Plymouth Primary Care Trust/Mental Health Partnership)

The Local Care Centre is a new development in Plymouth that provides a range of health services for the local community. The building’s foyer houses a cafe, run by local mental health service users and coordinated by a local carer. The initiative is a joint venture between Plymouth PCT, users, carers and the voluntary sector, set up to enable people with long term mental health problems to gain access to paid employment. Within the first nine months of the scheme, two people found substantive employment.

Reports from service users suggest that the opportunity to work voluntarily in a supported - yet real - work environment has improved their confidence and enabled them to consider work as a real option.

For further information contact

David Macauley, Plymouth PCT/Mental Health Partnership.

Maintaining dignity despite incontinence (Housing Improvement Learning Network

The Housing Improvement Learning Network is developing a factsheet on dignity in housing, which includes some examples where dignity issues have been addressed. The following example (from Hanover SmartChoice, a service that helps care providers assist older people and people with disabilities to maintain their independence and remain safely in their own homes) demonstrates how assistive technology can help restore dignity.

Mrs J is a resident of an Extra Care scheme. When carers noticed an increase in her incontinence, the standard approach was for carers to enter her room at night and feel her bed to see if she had soiled herself. This was unsatisfactory for all. The solution was to use an enuresis pad, which issues an alert if Mrs J is incontinent. This allows for carers only to enter her room when an incident occurs, and if she is incontinent she is assisted with her toilet needs and bedclothes are changed straight away. It also enabled carers to examine records of alerts. They could see that a pattern of incontinence developed between 2 and 3 am. Using this information carers can now assist Mrs J to the toilet at 1.30 am and promote Mrs J’s continence.

For further information

Visit the Change Agent Team: Housing website

Making a home: Zoe’s Story

Zoe is a woman in her late 40s with moderate learning disabilities and enduring mental health problems. Two-and-a-half years ago she lived in a small dwelling in general needs housing stock, with no personal effects to make it feel like home. The approach adopted by staff was to control what
Zoe could and could not do, and when. She displayed extremely aggressive and challenging behaviour, including destroying windows and furniture. She was frequently incontinent, apparently using incontinence to defy staff.

Staff did not want to work with Zoe and consequently a high level of agency staffing was used. Frequent incidents occurred, many of which were only reported verbally from one staff member to another. There were no plans in place to guide the staff as to how to manage the challenging behaviour, and recording was poor.

Zoe moved to a two-bedroom semi-detached bungalow managed by a specialist provider. Zoe chose the furnishings and there are more personal effects in evidence.

There is now a person-centred plan in place, with policies and procedures to guide staff, accurate recording and staff continuity. Zoe has much greater choice and control over what she does and when she does it.

The improved environment and staff practice has improved Zoe’s sense of well-being and independence. As a consequence, she is no longer incontinent and manifests far fewer, and less extreme aggressive and challenging outbursts. Information taken from the Dignity in Housing LIN Report, 2006 (416kb PDF file).

For further information visit

http://icn.csip.org.uk/housing/

Malnutrition Universal Screening Tool (Caterham Dene Community Hospital)

All patients at Caterham Dene are nutritionally screened on admission as part of the assessment process, using the Malnutrition Universal Screening Tool (MUST) (328kb PDF file). This screening immediately identifies any difficulties a patient may have so that appropriate support can be arranged through the dietitian. All meals are supervised by the nursing staff, and the hospital is due to implement protected mealtimes to ensure that mealtimes are uninterrupted and that those with specific needs are easily identified.

For further information contact

Eileen Clark, Service Manager. Tel 01737 214846. Email eileen.clark@eastsurrey-pct.nhs.uk

Manchester Partnership for Older People Project (Manchester Alliance for Community Care (MACC))

MACC is a campaigning organisation that wants to see an inclusive society that supports and increases the health and social well-being of people in Manchester. It facilitates the Manchester Older People’s Network and encourages older people to contribute to the planning, development and delivery of local services. The following is just one example of how older people, through the support of MACC, have an active influence.

Partnership for Older People Projects (POPPs) are government grants available for innovative approaches which will support older people to live independently, have a better quality of life and avoid the need for hospital and high intensity care. The Department of Health approved the Manchester bid in 2005. This project will develop:

• a team to provide a single point of access with support, advocacy and navigation for older people, their carers and professionals
• a team to strengthen the capacity of the voluntary sector
• a programme of grants for low-level services.

MACC believes older people should be an intrinsic part of delivering the NSF for Older People and related projects of work, and it involves service users and carers from the beginning of a process. Older people are recruited for their particular skills and experience, and have been involved with the POPP from the beginning - they were instrumental in the recruitment of the staff who now work on it, including the project manager, who is based with MACC.

For further information contact

Mary Duncan, Development Worker. Tel 0161 834 9823. Email mary@macc.org.uk

Mealtimes (Hyndburn short break service)

At Hyndburn short break service for people with learning disabilities staff spend time with the person, their family and any other professionals involved at induction to establish the person’s dietary requirements, preferences, usual routines and any individual guidelines. Before the person’s stay, staff refer to their person centred plan and ensure their preferences are included in shopping for that week. A review of information is ongoing and an official meeting with all involved is held every 6 months. All staff have basic food and hygiene training and understand what constitutes to a well balanced diet. Staff support individuals who require assistance during their meals. Main meals are eaten around a table in a 'family’ atmosphere unless a need or preference requires different support.  

For further information contact

Rebecca Toman, Short Breaks Manager, 98/100 Gloucester Avenue, Accrington, BB5 4BG. Tel: 01254 395060

Modesty preserved (Portsmouth Hospital NHS Trust)

It was noted that in the general ward areas hospital gowns were open-backed, with ties. Since the gowns were often used as temporary nightwear, mobile patients would frequently wear two gowns (one on backwards, to cover their back). Pyjamas supplied to patients were also often an undignified mismatch. Replacement gowns and pyjamas were agreed with textile services and endorsed by the Patient Experience Council. A bid for funding was presented to the local Patient Environment Action Group and full funding secured from the League of Friends. The change of bedwear overcame a simple matter the Matron’s Essence of Care Group had identified, and enabled patients to regain a little more dignity at a vulnerable time.

For further information contact

Sarah Balchin, Lead Nurse Clinical Developments. Email sarah.balchin@porthosp.nhs.uk

Nutrition support pack (Surrey and Borders Partnership NHS Trust)

The support pack was developed by the practice development nurse, who worked with a number of professionals, including dietitians, speech and language therapists and medical staff. The guide includes information on:

• promoting good dietary intake (including special needs and gastrointestinal diseases)
• nutritional requirements of older people and those from ethnic minorities
• MUST (Malnutrition Universal Screening Tool) and flow charts
• DETERMINE ABCDEF Tool for assessing nutritional risk in the community
• audit - monitoring and recording of food waste
• care plan for patients who will not eat
• constipation and incontinence in older people
• Diabetes mellitus, including pathways
• bone health.

The nutrition support pack was originally developed for use in one of the trust’s localities working with older people and mental health services. The intention is to expand its use across the trust after evaluation.

For further information contact

Jill Ruhomutally, Practice Development Nurse. Email Jill.Ruhomutally@sabp.nhs.uk

Nutritional Awareness Week (Southampton University Hospitals NHS Trust)

This helped raise the understanding of how important it is for patients to receive good nutritional food. Guidance was also given to all wards on nutritional supplements. The work was carried out through the Essence of Care Group.

For further information contact

Julie Dawes, Associate Director of Nursing. Tel 02380 798435. Email julie.dawes@suht.swest.nhs.uk

Related document

• A guide to nutritional supplements and their uses (64kb PDF file)
• Newsbite: August 2006 (106kb PDF file)

On the road to independence - Betty’s story (Staffordshire County Council)

Betty was diagnosed with glaucoma just before her 70th birthday and, as the disease progressed, her life slowly changed from one full of hobbies and interests to one of ever more limited involvement in activities. When her husband died she realised how dependent she had become on him. A fortuitous appointment with a consultant ophthalmologist resulted in her being certified severely sight impaired, which then put the wheels of social care and healthcare in motion. A rehabilitation officer was assigned to Betty to enable her to open up a new world of independence. He gave her time to discuss her difficulties and support her. He encouraged her to accept a symbol cane to alert others of her limited vision and then to undertake a course of long cane orientation and mobility training. From one small tentative step forward Betty's confidence grew and she found herself navigating around new as well as familiar places.

For further information

• 'Changing Lives' - Vision for Adult Social Care and Health

Over 60s project (Merseyside Fire and Rescue Service)

Merseyside Fire and Rescue has established a schools initiative that plays a key role in bringing older people to the attention of the service, as well as raising awareness of fire safety among children. A fire fighter leads a session on fire safety, after which children are offered prizes in return for signing up older relatives and neighbours for a home safety check. In 2004/2005, 15,000 checks were made as a result of the project, almost one third of the total target number for Merseyside. This project has a strong intergenerational focus, encouraging children to make contact with older people in the community to improve the safety of their homes. From 'Good practice in services for older people' (434kb PDF file) (Healthcare Commission et al., 2006)

Palliative care support (Macmillan Cancer Support/Greenwich Teaching Primary Care Trust)

Greenwich Macmillan Palliative Care Support Service (funded by Macmillan Cancer Support and Greenwich Teaching PCT) aims to maximise choice for patients at the end of their lives, allowing them to die at home, if that is their wish, in maximum comfort and with maximum dignity. It also offers support to carers. The service operates 24 hours a day every day of the year, with a high level of flexibility to meet the needs and wishes of patients and carers, which can vary from day to day. There are three elements: daytime service, overnight sitting service and pop-in service (providing 15-minute checks through the night). The small, dedicated team of support workers from Greenwich Council are specially trained in health-related care and support for terminally ill patients, such as catheter and stoma care, pressure sore management, minor dressings, medication prompting, blood glucose monitoring, urinalysis, mouth care and peg feed care. They get to know the patient and carer very quickly and work at least 30 hours a week, to provide continuity of care. There has been very positive feedback and a formal evaluation is in progress.

Key learning points

• Provide support 24 hours a day, seven days a week to ensure maximum flexibility to patients and carers; this is the key to enabling patients to die at home if this is their wish.
• Set up a specialist training programme before the service/new workers start.
• Training should include topics that cross the health/social care divide, such as care of the dying at home and after-death support, clinical communication skills, medicine management, spiritual diversity support, cultural diversity awareness, OT and physiotherapist support, and diet.
• Spend time in local hospice as healthcare assistants and with district nursing staff visiting patients in their homes.
• Use a small team, all working at least 30 hours a week - this makes continuity of care much easier.
• Establish a cross-agency steering group from the start, to enable good links to develop with the PCT continuing care nursing team, community specialist palliative care team, district nursing service and local carers’ centre.
• Monitor demand - be ready and able to re-allocate hours between service elements if possible.
• Set up a single point of access to service - provided in this case by the PCT continuing care nursing team.
• Support the support workers - this is a very demanding service. Provide intensive line management support (24/7 if necessary), team meetings and external counselling. A rota of four days on three days off allows workers to recharge their batteries.

For further information contact

June Williamson,Macmillan Palliative Care Support Service Co-ordinator, Greenwich Homecare. Tel 020 8921 2349. Email june.williamson@greenwich.gov.uk

Patient Catering Survey (University Hospital of South Manchester NHS Trust)

The Patient Catering Survey (80kb PDF file) was designed to help assess whether service users were satisfied with the standard of food and support during mealtimes. In addition to the survey, nutritional awareness training was made mandatory for all new staff, and a newsletter, Essence of Care News was produced outlining the work and improvements made. The changes were carried out as part of Department of Health Essence of Care benchmarking on Food and Nutrition.

For further information contact

Sheila Wilkinson, Improving the Patient Experience Project Manager. Tel 0161 2912761. Email Sheila.wilkinson@smuht.nwest.nhs.uk

Person-centred care (Birmingham and Solihull Mental Health Trust)

Staff use a person-centred care (PCC) position statement, based on the work of the late Tom Kitwood (a leader in the field of dementia care whose goal was to see widespread practice of person-centred care for people with dementia). This covers:

• value people with mental health needs and those who care for them
• treat people as individuals
• acknowledge life experience
• provide a positive social environment.

Senior staff undertake regular 'quality visits’. They walk the wards, scrutinise the patient environment and, if areas for improvement are noted, ensure an action plan is implemented. Staff are supported with regular person-centred training days, focus groups for carers, patients and staff are listened to and complaints are examined closely to see what themes are emerging. As a consequence, the service can produce a range of evidence-based interventions and evaluations of how their constant search for improvement in person-centred care is benefiting patients.

For further information contact

Linda Playford. Email Linda.Playford@bsmht.nhs.uk

Paul’s story: an Extra Care experience

Paul is a middle-aged man with a physical disability and mental health problems. He has spent most of his adult life living in nursing homes, but just over a year ago moved into a newly built Extra Care scheme. Paul said: 'I suffered a lot of abuse at the nursing homes. I have intelligence which they don’t like.’

Paul described how staff in the last nursing home would sweep into his bedroom without knocking and pull the bed covers off exposing his naked body, his physical condition necessitating his sleeping unclothed. Staff would come straight into the bathroom while he was using the toilet to give him his medication, neither knocking nor waiting till he had finished. 'In a nursing home, you’re a non-entity because of the power and control that the staff have over you…when you can go to the toilet; when you get up or go to bed; when you have your meals.’

Paul says of the move to Extra Care: 'It is 100% different here. Staff knock before entering. They treat me with respect and dignity. Dignity means being able to go to the loo and close the door; dignity means when you have a bath, not having fun poked at your body.’ Paul has no restrictions on him - he can choose when to get up or go to bed. Any concerns that he has raised have received a positive response.

Paul is now a member of the housing association’s board. Paul’s view is that having a tenancy and his own front door gives him choice and control. 'The tenancy is 101 per cent part of it. Staff can come in - it is a choice that I make. Choice is a precious thing in life.’ Paul’s sense of well-being and mental health have improved immeasurably. Moving to Extra Care has given him a new lease of life. 'The reason my mental health is helped here is because I’m treated as a human being. I am respected as Paul. People, staff, respect my views and respect me as a person.’

Information taken from the Dignity in Housing LIN Report, 2006 (416kb PDF file).

See also The Extra Care Housing Toolkit (4.10Mb PDF file) on the ICN website.

For further information visit

http://icn.csip.org.uk/housing/

Peter’s story (Advocacy Partners)

Peter’s story shows how advocacy services were able to help someone with learning disabilities achieve the celebration he wanted.

Peter had recently had his 60th birthday. When asked by members of the self-advocacy group what he had done for his birthday, Peter said that staff where he lived had been busy on the day of his birthday and so he had gone out for a pub lunch with three people he lived with at the weekend. Unfortunately, the pub was not serving food that day so they just got fish and chips to eat at home. When the advocate asked about a party, Peter said he would like one, but that the staff hadn't asked him if he had wanted one. The advocacy group didn't think the staff had supported Peter well for such an important birthday. This was communicated to the service, who acknowledged quickly that they had not treated Peter with dignity and helped him organise the party he wanted, inviting his family and friends, including members of the self-advocacy group.

Peter’s story highlights the importance of effective and timely communication and shows how, through joint working between the staff and the advocacy supporter, Peter was able to express his wishes and make them happen.

For further information contact

David Thompson, Advocacy Partners. Email david.thompson@advocacypartners.org

Providing advocacy support (East Cheshire Advocacy)

The attached document describes how an advocate working for East Cheshire Advocacy supported a client with learning disabilities who was suffering from cancer. The example shows the importance of having someone to act on their behalf when the person is terminally ill. It also demonstrates how services were tailored for an individual with obsessive compulsive disorder when they were receiving emergency care and how instrumental using the Patient Advice and Liaison Service (PALS) can be. The advocate was able to support the person through each stage of treatment, offering advice and helping them to take decisions and also act as an intermediary between clinicians and patient.

For further information contact

Maggie Harwood, Manager, East Cheshire Advocacy, The Moss, 4-6 Congleton Road. Macclesfield SK11 7UE. Website www.ecadvocacy.co.uk.

Related document

• Case Example - Advocacy (36kb PDF file)

Putting therapeutic skills to work (Caterham Dene Community Hospital)

Caterham Dene has a weekly timetable of activities, and all staff have been trained in occupational therapy and physiotherapy skills through an in-house programme developed by the therapists working on the ward. The healthcare assistants, supported by the therapists, are encouraged to take on a range of activities such as recreational therapies - quizzes, craft work and exercise groups, which include chair-based exercises. There is a close working relationship with the nearby local authority residential home, and activity coordinators from there visit to assist with activities.

For further information contact

Eileen Clark, Service Manager. Tel 01737 214846. Email eileen.clark@eastsurrey-pct.nhs.uk