South West Dementia Partnership
Discussion paper
Improving care in care homes in the South West
Introduction
In recent months there has been heightened
public interest about the care of people with
dementia living in care homes. Sustaining high
quality support to people with dementia, 24
hours a day, 7 days a week is huge challenge. It
requires relentless enthusiasm and commitment
from staff who are insightful and skilled. It also
requires care homes have good support from
local health and in reach services.
Many Care Quality Commission inspection
reports pay tribute to the dedication and hard
work of front line care home staff. There are
many homes which strive to provide good care
and many examples of people with dementia
being supported to remain active and involved in
daily life. However the quality of life of
experienced by some people living in care
homes can be poor and the media has raised
serious concerns about the attitude, competence
and behaviour of some people working in the
care home industry. Concerns about training in
dementia has been highlighted in a number of
reports and forums, including the All Party
Parliamentary Group report 'Prepared to care:
challenging the dementia skills gap' on the
dementia workforce and at the Public Accounts
Committee hearing ‘Train to Gain: Developing
the skills of the workforce’ 21 January 2010.
www.southwestdementiapartnership.org.uk
April 2010
Enlightened care is possible. It can be uplifting
and enriching and a source of positive energy. It
is made possible when people with dementia are
placed at the centre of the life of a care home
and when they continue to be people living a life,
and are not just passive recipients of services.
The difference between poor and enlightened
care is about vision and values, and the belief
that people with dementia can continue to live
well in care homes. It is based on the principle
that people at any stage of dementia are still
people, and should be valued and recognised as
such. It is founded person centred care, on the
principle and that people with dementia have
both human and legal rights; rights to be treated
with dignity and respect, for their best interests
to be served and the right to enjoy social
relationships.
The difference between poor and enlightened
care is the belief that a care home can be a
happy and fulfilling community, rich in human
experience and rewarding for the people living in
then home, the staff who work there and the
relatives who visit.
Some owners, managers and staff truly
understand and embrace this. Others do not.
This is often the fundamental difference between
excellent and adequate care. All the paperwork
and training in the world will never help those
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Improving care in care homes in the South West Discussion paper

who don’t truly embrace person centred care to
bridge the gap.
This discussion paper aims to draw together a
lot of evidence about care homes in the South
West. It highlights how managers, staff,
commissioners and Care Quality Commission
inspectors can contribute to improving the
quality of care in care homes.
It is intended as a resource to inform, challenge,
prompt and promote ways to improve the
experience of people living with dementia in care
homes.
The discussion paper has six sections looking at
care homes in the South West from a number of
different perspectives, and sets out action
people might take to improve the quality of care.

1. Best and worst: what is the difference

This section compares samples of reports from the best and worst care homes in the South West. It also
includes the conclusions of a focus group which was held in June 2009 to share learning about improving
care homes, and identifies areas of innovative and best practice.

2. Market analysis
This section provides a breakdown of the level and types of provision across the South West comparing
the region with the rest of the country. It then provides a detailed analysis of the quantity and quality of
provision across the 15 council areas.

3. Fees analysis
This section compares the arrangements for calculating fees and the levels paid across the region. It is
based upon a sample of 8 of the 14 combined council and Primary Care Trust areas in the South West.

4. The South West National Dementia Strategy Review

This section considers the findings of a review which was conducted across the South West in 2009 to
determine the readiness of health and social care communities to carry forward the National Dementia
Strategy. It considers the findings in respect of Objective 11 “Improving care in care homes”, and the extent
to which local social and health care communities are responding to the original recommendations in the
Strategy.

5. Future plans
This section explains how the South West Dementia Partnership will be supporting implementation of the
National Dementia Strategy in respect of care homes.

6. Questions to ask yourself

This section provides self assessment tools to help people to reflect on what they should or could do to
improve care for people with dementia. The tools provide sets of “Questions to ask yourself”, designed for
care home managers and providers, health and social care commissioners and Care Quality Commission
inspectors. The questions are drawn directly from the findings in this discussion document.

www.southwestdementiapartnership.org.uk 2
Background April 2010

Fixing dementia care in care homes

In the Autumn of 2009 two television Sir Gerry said, we face a

programmes were broadcast in which
businessman Sir Gerry Robinson was invited to

“
fix dementia care in care homes. [1]
battle against apathy,
The programmes primarily focussed on
examples of poor care in care homes. The complacency and low

”
programmes did not tell the whole story, and
many people felt they were unbalanced and
painted an unnecessarily negative picture of an
expectations
industry where many work hard and strive to do
their best. Undermining the public image of care
homes does not help people with dementia and
That is not the case everywhere. There are
their carers. They need to feel both positive and
many examples of excellent work and willing
confident about the option of using a care home
minds. However we could do better and it is
when life becomes impossible to sustain at
hoped that this contents of this document and
home. Nor does it help with attracting and
the “questions to ask” will help people in the
retaining a good quality workforce where people
South West to respond to Sir Gerry’s challenge.
should feel proud of working in care homes,
supporting people with dementia.

The programmes did however raise some

powerful questions. They also showed that
excellent care is possible, and it is possible to
improve care homes which are failing by a
change of mindset and strong leadership. This
discussion paper includes a number of quotes
from the programmes.

1. Can Gerry Robinson Fix Dementia Care

Homes? broadcast on BBC Two at 2100 GMT
on Tuesday 8th and Tuesday 15th December
2009.

Working together to promote living well with dementia 3

Improving care in care homes in the South West
1. Best and worst: what is the difference
In order to answer this question a small study
was undertaken in May 2009. This provided the
basis for further discussion in a focus group
which included providers, care home managers,
regulators, commissioners and carer
representatives.
The study was based on a simple textual
analysis of dementia care home reports
downloaded from the Care Quality Commission
website www.cqc.org.uk in May 2009. A sample
of reports for 10 homes covering each rating,
‘poor’, ‘adequate’ and ‘excellent’ was analysed,
that is, 30 reports in total. There was an equal
balance between nursing and residential homes.
The analysis did not focus on the traditional
standards and regulations, but sought to identify
recurring themes across reports. Data was also
collected in respect of bed numbers, fees
charged and whether a registered manager was
in post.
www.southwestdementiapartnership.org.uk
Discussion paper
What quickly emerged from this study was that
there was little apparent difference between
themes arising in nursing homes and residential
homes. Indeed there was as much reference
about health related care (for example, diabetes,
pressure area care) in residential care as there
was in nursing care homes.
It was also apparent that the homes were highly
varied with some purpose built, some with wide
mixes of category and specialist wings. Most
were private institutions; the better homes
appeared to be run by not-for-profit trusts. Two
council homes were included in the sample, one
‘poor’, and one ‘excellent’. However detailed
analysis of provider type was not undertaken as
it was not always clear from the report what type
of provider was concerned.
4
1. Best and worst: what is the difference?
Poor homes
“
How have we allowed
our elderly to be treated
”
this way?
The typical poor home failed in a number of
areas, and the combination of these made for an
impoverished experience for those living and
working in the home, with high risks to health
and well being.
Nine out of ten ‘poor’ homes had weak care
planning processes, and staff who were clearly
unaware of the needs of people living in the
home, notably healthcare needs and support
needs, for example to assist people who
became distressed or anxious. Particular
mention was made of staff not being given
guidance on how to respond to anxiety or
challenging behaviours, and examples were
given of how staff responses had escalated
people’s frustration and distress.
Care plans did not reflect the actual needs of the
people, they were not up to date, not clear, not
accessible, and were said to be of little value to
staff. Care plans were described as being not
person centred or based on people’s wishes or
relatives’ views. Significant risks associated with
behaviour were not anticipated or managed.
In six out of ten homes there was poor attention
paid to critical health care needs. A range of
examples of basic neglect were cited, including
pressure area and wound care, dental hygiene,
blood tests not being done, and poor catheter
care. In four out of ten homes there were serious
Working together to promote living well with dementia
April 2010
errors with medication administration.
In six out of ten homes there was little or no
provision of meaningful activity. In some homes
there appeared to be no activities taking place.
People were observed as being bewildered,
bored and disengaged.
In over half the homes low staffing levels and
lack of training were mentioned. Lack of training
in dementia care was particularly evident.
In half the homes, lack of choice and control was
noted as was lack of dignity and respect paid to
people living in the homes. Clear instances were
cited of people being overlooked, ignored or
‘spoken down to’. There were a number of
examples of institutional practice, for example,
everyone being given a plastic beaker with
diluted cordial.
In four out of ten homes nutrition and food were
cited as poor, and lack of any choice was often
noted.
What was particularly striking was that seven out
of ten of these homes had very poor
environments. They were often described as
shabby, in disrepair, ‘smelly’ and lacking in
investment. Reference was made to stained and
ripped sheets, poor decorative order, confusing
layouts, poor signage, lack of assisted bathing,
and homes being cold. In some, extremely
serious health and safety issues were
highlighted including very hot unguarded
radiators and scalding water.
Poor environments are symptomatic of poor
vision and investment by the provider. Its
consequences are dispiriting for the people who
live in, work in and visit the home. Research
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Improving care in care homes in the South West
suggests that the environment can a large
impact on people’s behaviour, and that enabling
environments result in both better outcomes for
people living in care homes, less dependency on
staff intervention and can be more efficient to
run. See for example, Chapman, A., Jackson, G.
and Macdonald, C. (2009) What Behaviour?
Whose Problem? A guide to responding to the
behavour of people with dementia. Dementia
Services Development Centre, Stirling.
In six out of ten homes there were no quality
assurance measures in place. In five of the ten
homes there was no registered manager,
references being made to managers having left,
recruitment activity and temporary cover
arrangements.
‘Adequate’ homes
“
You can get by with
adequate care that it fails
to address the point. That
life could be so much
better
”
There was a wide of range of ‘adequate’ homes.
Some appeared generally quite good but had
one or two significant failings, for example in
relation to health and safety or medication
management which had brought their rating
down. In some homes most people appeared
were well cared for, but the home had failed to in
respect of the care to one or two people with
more complex needs.
www.southwestdementiapartnership.org.uk
Discussion paper
Other homes had a broader range of concerns
but with less serious consequences than those
noted in poor homes.
A number of adequate homes appeared to be
improving with previous requirements (often
care planning) having been addressed since the
last inspection.
In seven out of ten homes care plans were
noted to be a problem. Plans were not person
centred nor did they reflect individual needs. For
example, staff in some homes did not know the
preferred names of people living in the home,
which is particularly significant when
communicating with someone with dementia. As
with ‘poor’ homes, some care plans failed to
provide staff with skills and strategies for
responding to complex behaviours.
Concerns about healthcare needs were less
prominent (as indicated three out of ten homes),
although medication concerns were still noted in
five of the ten homes.
Choice and control featured as an issue in three
care homes, and dignity and respect in one
home.
The need to improve activities was noted in four
‘adequate’ homes.
Little mention was made of concerns about
staffing levels or staff training. Environmental
concerns featured in only two homes, and the
need for quality assurance only featured in one
home.
As with ‘poor’ homes, half appeared to be
without a registered manager.
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1. Best and worst: what is the difference? April 2010

‘Excellent’ homes

“ It requires
passionate relentless
leadership … leadership
is about rising above
the day to day, and
taking people with
you.
”
The reports for ‘excellent’ homes painted a
completely different picture to that of ‘poor’
and ‘adequate’ homes. ‘Excellent’ homes
appeared be lively places where staff were
proactive in meeting needs. They were
homes that had benefited from investment, had
energy and were places where the people living Despite being ‘excellent’, three homes had
in the home came first. They were also generally requirements relating to medication although
well run. these appeared to be refinements and
improvements rather than necessary as a result
In eight out of ten homes there were positive of serious failings.
comments about care planning: “Very clear
guidance”; “Staff know the needs for people”; Communication with and support for relatives
“Staff know what to do”. Plans tended to be was often mentioned in ‘excellent’ homes. Some
person centred (six out of ten mention this) and ‘excellent’ homes provided private areas to meet
holistic. Critical needs were identified and and some encouraging email communication
addressed. One example was a coloured coded with families, for example enabling downloading
system to direct staff to key areas of need. and printing pictures for people living in the
home. There was also mention of engagement
In five homes health care was highlighted as with the local community. These themes were
being excellent. Health care needs were seen to not apparent in ‘poor’ and ‘adequate’ homes.
be protected and references were made to best
clinical practice, for example the Gold Standards ‘Excellent’ homes were very strong on activity
Framework in Care Homes. provision. This was often described as

Working together to promote living well with dementia 7

Improving care in care homes in the South West
innovative, stimulating and individualised with
mention of variety, one-to-one time and
availability of private space. Examples of good
activity provision were cited in seven of the ten
homes.
Nine of the ten homes were commended for the
dignity and respect being shown to people. The
prevailing ambience was significant, with
inspectors noting laughter and banter and staff
supporting people to use their own skills as
much as possible. Six of the ten homes were
commended for promoting choice and control,
and for reflecting people's views and interests in
the running and management of the home.
www.southwestdementiapartnership.org.uk
Discussion paper
It was particularly striking that nine of the ten
homes had excellent environments. Some were
purpose built or had been carefully adapted.
Some clearly enabled people to have access to
safe gardens and communal areas which
encouraged socialisation. Mention was made of
homes providing a calming atmosphere. Words
used included, welcoming, light, comfortable,
airy, fresh, and clean.
Food and nutrition were commended in five of
the ten homes, choice and healthy, balanced
diets being noted.
Staffing arrangements were commended in eight
of the ten ‘excellent’ homes. Staff were
described as enthusiastic, trained and
competent.
All the excellent homes appeared to have
registered managers in place. Strong
leadership was cited in four reports, with
additional mention of good teamwork and
support for staff. Effective quality assurance
was noted in three homes.
8
1. Best and worst: what is the difference? April 2010

Other findings:

Size of home

In the sample, ‘poor’ homes had 36 beds on “ Good care does not
only come down to

”
average, (range 12 to 68), ‘adequate’ homes 35
beds (range 12 -64) and ‘excellent’ homes 50
beds (range 18 – 102). Many of the bigger, money.
excellent homes however had separate
dementia wings or annexes so it is hard to draw
any firm conclusion. However, these figures

“
suggest that with investment larger homes can
be managed in a way which delivers good From a business point
outcomes for people with dementia.
of view, care given to
residents has to be the
Price
priority. There is no
This analysis is simplistic as the rates charged
by homes vary considerably on the basis of downside from any point
rooms and levels of need, and whether people
are privately or publicly funded. However figures of view in running these

”
show that high fees do not guarantee quality.
There were some very poor, expensive homes services brilliantly.
(for example in old stately buildings), two of
these charging the highest non-nursing fees in
the region, one in excess of one thousand The inspections
pounds a week.
The inspection reports were fairly consistent in
their approach. However some were more
Type Range Average Sample
sensitive to assessing whether care was person
centred, especially where Short Observational
£350 – Framework for Inspections (SOFI) or an expert
Poor £620 10
1050 had been included.

Some inspections and reports, particularly in

£381 –
Adequate £540 10 poor homes, emphasised the importance of
766
basic, safe care as this was clearly seen as a
priority for concern.
6
£380 –
Excellent £631 (4 figures
895
missing)

Working together to promote living well with dementia 9

Improving care in care homes in the South West
Driving improvement
The findings of this study were presented to a
small focus group in June 2009. The group
included managers and providers nominated by
inspectors for having improved care homes for
people with dementia, inspectors with an interest
in dementia care, commissioners and two carer
representatives one of whom acts as an expert
by experience for the Care Quality Commission
and assists with inspections. The group was
asked to consider a range of topics.
What does good care look like?
The answer appeared to be quite simple.
Good care is recognising and supporting people
with dementia as individual people, putting them
at the centre of the life and routines of the
home. It is providing whole person care based
on knowing and understanding a person’s
history and their life before dementia.
Good care is about empowering staff, providing
them with skills and encouraging them to think
creatively, and enabling staff to spend time with
people living in the home rather than being
focussed on completing domestic tasks.
Good care is about working with feelings; to
quote one manager
“
Care without feelings
”
becomes cold
www.southwestdementiapartnership.org.uk
Discussion paper
Good care is about using and sharing good
practice and having strong leadership.
Good care is not isolated, but is integrated with
mainstream community services, with strong
links to multidisciplinary teams and pharmacists.
Good care anticipates end of life needs, and
prepares for this in advance and in line with
people's wishes.
Good care supports good quality ongoing
relationships with carers and promotes their
inclusion in the life of the home.
The focus group was then asked to consider a
number of questions. The responses have been
collated and summarised below. They help to
identify both the barriers to delivering good care
in care homes, and potential solutions.
Commissioning practice
Providers said that commissioning
arrangements tended to be inflexible and were
in favour of variable fees. They said that
contracts tended to be based upon “units of
care”, not individual needs and this created a
tension when trying to deliver personalised care.
Funding streams appear to be locked in
separate health and social care silos, which
meant that people with increased care needs
moved into nursing care at increased marginal
cost when a smaller increase in funding and
community nursing support could have enabled
people to stay in their existing residential home.
They felt that the cost benefits of appropriate
funding and support of less intensive care
needed to be understood. For example,
providers felt more end of life care could be
provided in non-nursing care homes.
10
1. Best and worst: what is the difference?
Providers felt commissioners tended to
commission to a price, not to quality, and there
was a need to model funding at a level which
enabled sufficient staff, particularly nursing staff,
to be on duty.
Care home managers felt that unrealistic
expectations were placed upon them, that they
had to cope “because that was what they were
paid to do”. They said care managers
sometimes placed people with particularly
complex needs in homes not equipped to meet
them, and that these placements quickly
destabilised their homes.
Commissioners said that better diagnosis of
cognitive impairment would assist in informing
placement suitability and assist in making
appropriate placements.
Commissioners felt that commissioning was
increasingly reflecting the wishes and
expectations of people using services and
carers. They believed that contract monitoring
was improving and there was a greater
Working together to promote living well with dementia
April 2010
emphasis on quality. They reported increased
flexibility in using health and social care
budgets.
Primary and secondary healthcare
support
Care home managers said they struggled with a
lack of specialist dementia assessments which
means staff are “working in the dark” without an
effective diagnosis prior to placement; “GPs just
guess”.
Some managers reported close, beneficial
working relationships with local community
mental health teams. They noted that effective
communication with community mental health
teams can offer valuable insights into the life of
the resident before their dementia, and assists
homes in appropriate care planning.
In one home the local consultant held regular
clinics in the home and this was said to have
reduced the number of admissions to hospital.
Some residential homes said that the variation in
11
Improving care in care homes in the South West
the availability of community nursing support is a
problem.
Initiatives being pursued in Gloucestershire
attracted interest, for example, the “No Barrier
referral scheme” which gives care homes direct
access to secondary care support like dieticians
without the need to go via a General
Practitioner. Gloucestershire also has a multi-
disciplinary care home support team available to
support those homes where concerns had been
noted.
Pharmacists were seen as having a key role in
ensuring that medication is reviewed regularly,
and specialist audits were commended.
Regulation
“
In every care home I
have been in we lock
residents in as if it's a
foreign country protecting
people with dementia from
life …we have consigned
them to a safe but
stagnant life, locked
”
inside
www.southwestdementiapartnership.org.uk
Discussion paper
“
I don't think safety
should be placed above
the quality of people's
”
lives
Managers and providers said that there was a
genuine fear of the regulator which made
managers defensive and risk averse. There was
a perceived a lack of consistency and mixed
messages from inspectors particularly in respect
of risk assessments and encouraging creativity.
Managers said that some inspectors did not
engage with people living in services, or observe
care practices when undertaking inspections.
“Some inspectors are only interested in the
paperwork”. This meant good care practice went
unrecognised. In general it was felt there was
excessive auditing of factors which were not
outcome related.
Both inspectors and managers suggested that
there was a lack of oversight and quality
assurance of inspections, and an overemphasis
on the numbers of inspections being completed
rather than the quality of the inspections. They
thought that there is also a need to develop
dementia awareness amongst some inspectors.
Inspectors thought that greater emphasis should
be placed on ensuring services had registered
managers, and that greater regulatory pressure
should be applied on providers to ensure timely
replacement of managers.
12
1. Best and worst: what is the difference? April 2010

Staffing plans to ensuring effective communication, both

between staff and people living in care homes

“
and within staff teams. They felt it was an issue
What is relevant is staff which needed to be addressed, but that people
were anxious about raising it for fear of being
morale; it's the secret of labelled racist or discriminatory.

success in business Managers made a number of recommendations

based on their experience:
where staff are so directly
➜ advertising for and recruiting staff who had
responsible for the care of a “heart for the job” rather than expecting
care work experience
residents.I wouldn't risk to ➜ writing job descriptions which included
involving people living in care homes as
staff morale for the sake part of people jobs, (for example gardening)
➜ providing training incentives for staff
of a few pence … it's
➜ reviewing and restructuring shift patterns.
about caring for your staff,
thinking about them,
bringing them “ the main focus of the
day is connecting with
alongside
”
Care home managers said that skilled staff was
people with dementia; it's
so hard to get staff to
a significant factor. The lack of reliable, specific unhook from the task; its

”
training on good dementia care was a major
issue. Training needed to be funded and
accessible.
their security blanket
David Sheard

Managers said that overuse of agency staff in

some care homes was a major problem as this
disrupted continuity of care. They felt there was
over reliance upon staff from different countries
whose spoken or written English may not be
strong enough to ensure reasonable
communication. This caused a range of
problems from following instructions and care

Working together to promote living well with dementia 13

Improving care in care homes in the South West Discussion paper

Care home managers felt that some staff liked to Care planning
remain in a secure ‘comfort zone’ and avoided
spending time with residents by choosing to

“
remain in established routines. They said many
staff have a genuine fear and unease about There's an awful lot still
talking to people with dementia. This often
related to a lack of skill in communicating with going on inside ... you can
people with dementia, or simply not knowing
anything about them, their lives, preferences or get to it by stepping back
communication needs.
and look at the world
Carers’ and relatives’ issues

Managers felt that in general care homes did not

through their reality; forget
understand the experience or support needs of
carers when their relatives moved into
logic and reason and
residential care. Managers stressed the need for
listen to what the person

”
carers to receive information, and the
importance of carers’ induction and “education”.
The relationship between carers and relatives
is experiencing
and the care home can be very complex and
Alzheimers’ Society trainer
challenging. There are potential relationship
problems with most families, including problems
with carers letting go, jealousy, grief, projection
and underlying denial about the diagnosis of
Managers said the lack of any information about
dementia.
a person’s background or life history was a real
issue, and that despite efforts this was often
Addressing and clarifying expectations of carers
hard to fathom. Obtaining reliable information
is an important part of establishing an effective
from the person with dementia was a challenge,
relationship and responding to carers’ emotional
and families often regarded their family life as
needs.
“private”. One manager remarked that often they
only really found out about a resident’s life when
they attended their funeral. They were left
feeling that the person’s life in the care home
had been a lost opportunity; so much more
could have been done to enrich the person’s life
if the information had been available before the
person died.

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1. Best and worst: what is the difference? April 2010

Managers recognised that establishing people’s

wishes, choices and feelings was not easy. It
was therefore important to use observation to
find out “what works”, what people respond to,
and ways of engaging people. Using life story
books had proved helpful in some homes in
researching people’s needs and discovering
which activities were likely to be enriching and
which should be avoided.

Managers said care planning systems tended to

be clinically based and that there was a
tendency to use stock phrases. This meant the
“individual” didn’t come over.
Managers recommended person-
centred care planning systems
which focussed on ability.

Working together to promote living well with dementia 15

Improving care in care homes in the South West Discussion paper

Activities versus living a life

happened in their lives

“ How can we stand by

and watch our elderly die
that mattered any more,
they are just sitting in this
room like broken vessels
of boredom? … helping to
keep people alive rather
than helping them to
doing nothing
”
live
” “ At 4 pm…the residents

“ We are just stagnant

… we expect to get
were more getting restless
but after six hours of
staring at a wall, is that
ignored, it kills your
spirit
” surprising?
”
“ Quarter of a million
people living in care
homes, … and what
struck me straightaway
was that people were just
sitting there and not doing
anything ... nothing

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1. Best and worst: what is the difference? April 2010

Managers felt that whilst programmed activities
had their place, there was a danger that on their
own they only reinforced an institutional
approach to daily life in the home. The felt a
broader view should be taken and that people
with dementia should be enabled to be
purposeful and contribute to the life of the home.
Many routine tasks provided opportunities for
staff and people living in the home to work
together, including cooking, growing vegetables,
cleaning, gardening, caring for pets and
shopping. In one home people with dementia
living in the home had undertaken NVQ1 in
Food Hygiene alongside staff.
Managers felt homes should be “opened up”,
and that there were mutual benefits in actively
recruiting relatives as a resource to support
one–to-one and small group activities. They
noted the benefits of actively involving the local
community and the importance of bringing the
local community into the home. There were
several examples of things which had proved
successful including people in the community
bringing their pets into the home, and local
people running a gardening club at a home.

“ People (in care

homes) are living in
their home…. we
should be helping them
to run it, making every
resident an activity
worker
” David Sheard

Working together to promote living well with dementia 17

Improving care in care homes in the South West
Environment
Managers felt that homes did not always have to
be purpose built but that investing in buildings
made a real difference to people’s wellbeing and
behaviour. In one home, a simple low cost
extension which joined up the communal space
between two buildings had transformed the lives
of people living in the home. People were more
able to move around freely and as a result had
more exercise. This had meant the use of night
time sedation had significantly reduced. Other
managers had noted similar outcomes by
enabling people to have access to gardens.
One manager believed in creating an
environment which had opportunities for
discovery, and had found that routinely
swapping things around his home had increased
people’s interest and encouraged exploration.
Managers were insistent that architects should
never be allowed to “go it alone”, and
recommended that people with experience of
running homes needed to be actively engaged
throughout the design process.
Management
Care home managers believed that risk
management was often the most significant
issue in determining the culture of care homes.
Risk averse homes tended to be institutionalised
homes. They said managers needed to have the
confidence and ability to take on and manage
risks and have support and understanding from
regulators. They also said managers needed
confidence in challenging barriers to change and
skills in changing staff attitudes.
www.southwestdementiapartnership.org.uk
Discussion paper
Managers felt that poor management practice
was primarily due to ignorance, complacency
and lack of support. This was reinforced by
working in isolation, sometimes spending many
years working in just one home; “you only know
what you know”. Managers said they had
benefited from a range of opportunities including
sharing good practice between services,
external consultancy, cross-service audits, being
a member of a provider association and
accessing best practice through conferences
and publications.
Providing structured peer support to failing
homes was proving to be a particularly
successful strategy which had been developed
by Gloucestershire Care Providers Association
and the County Council.
Care home managers felt there was a lack of
appropriate training and development
opportunities for managing care homes for
dementia. There were unique demands;
“dementia sense is not common sense”.
One provider emphasised the need for long-term
succession planning to avoid reactive
appointments, stressing the importance of
developing strength and depth in leadership so
that if a manager moves on there are people
who can step into their shoes.
18
2. Market analysis April 2010

2. Market analysis homes are those that provide high-quality

care which is person centred.
This analysis is based upon the information
available on the Care Quality Commission
It is generally accepted that the quality of care in
website www.cqc.org.uk as of 6 December
poor and adequate homes should not be seen
2009. It is based on the number of homes rather
as acceptable, and that care services and that
than the number of placements. The tables in
commissioners should seek to ensure people
the Appendix provide a detailed breakdown.
only receive care in homes rated as either good
or excellent.
There are just under 1500 care homes across
the South West providing care to older people
In December 2009, 17.6% of care homes in the
and people with dementia. Of these, 57% of the
South West were graded as poor or adequate.
homes are registered to provide care to older
This is in line with national average (17.5%) and
people, 10% are specifically registered to
is a drop from the regional figure obtained in
provide care to people with dementia, and 33%
May 2009 (22%).
are registered for both older people and
dementia.
3.1 % of homes were judged to be poor.

34% of homes are registered to provide nursing

There is little apparent variance between nursing
care.
homes (17.4%) and non-nursing homes
(17.7%).
The vast majority (84%) of homes are run by
private providers. 11% of homes are run by
16.4% of homes registered only for older people
voluntary organisations and charities, and 5% by
were judged as poor or adequate, however this
local authorities.
increases slightly to 18.5% of homes providing
care to both older people and people with
50% of the region's homes are small to medium
dementia, and 21.2% for homes specifically
size having less than 30 beds. 85% have less
registered for dementia care.
than 50 beds.
Looking at this breakdown more closely, whilst
The Care Quality Commission rates the quality
there is little variance across the types of home
of care homes as either ‘poor’, ‘adequate’,
for non-nursing care, but there is marked
‘good’ or ‘excellent’. These judgements are
variance for nursing homes.
made against published criteria.
➜ Poor homes are those where there are
Only 14.4% of nursing homes registered to older
serious risks and significant concerns about
people only were rated as poor or adequate,
the well-being of the people living in the
however this figure increases to 20.0% of those
home.
registered to provide care to older people and
➜ Adequate homes are those where there people with dementia and 28.6% for nursing
may be risks and concerns but these are homes exclusively registered to provide
being managed. dementia care.
➜ Good homes are those where people are
safe and well cared for, and excellent

Working together to promote living well with dementia 19

Improving care in care homes in the South West
Although the number of dementia specialist
nursing homes is relatively small, these figures
indicate that nursing homes looking after people
with dementia and deserve particular attention.
This appears to be supported by anecdotal
evidence about the prevalence and nature of
safeguarding concerns in nursing homes. There
does appear to be a particular difficulty in
providing effective physical and mental health
nursing care and support to people with
dementia.
Extending the analysis to individual Council
areas highlights a number of variations in terms
of quantity and quality of provision.
www.southwestdementiapartnership.org.uk
Discussion paper
Some Councils have a high number of older
people and dementia care homes in their
locality, the highest being Devon (289) others
have comparatively few (Swindon, 25). The
scale of the commissioning and contracting
challenge therefore varies enormously.
When considering the current estimates for the
over-65 populations, the rate of care home
provision per thousand also varies across
communities. This analysis is based on care
homes rather than bed numbers in so it cannot
be used to assess capacity. However it does
indicate that in some communities there is a
greater relative choice than in others, and it
highlights the density of care homes in some of
the traditional seaside resorts.
20
2. Market analysis April 2010

Comparing areas with small geographic spread, in Swindon there are 25 homes for an older
population of 27,200, this in Torbay there are 80 for a population of 31,600, and in Bournemouth 77
homes for 31,900.

Comparing areas with large rural geographic spread, in Devon there are 289 homes for for an older
population of 164,000 whilst in nearby Dorset there are 128 homes for an older population of
101,700.

Working together to promote living well with dementia 21

Improving care in care homes in the South West
It is difficult to assess the level of dementia-
specific provision across the region as some
homes are jointly registered for older people and
dementia, and in some of these homes there are
specific wings or annexes providing dedicated
care in other jointly registered homes the needs
are not separated.
However the level of dedicated dementia care
home provision does appear to vary across
Council areas. In Poole 9 (24.3%) of the 37 care
homes are specifically registered for dementia,
whilst in Devon 16 (5.5%) of the 289 care homes
have a specific dementia registration.
www.southwestdementiapartnership.org.uk
Discussion paper
There are significant variations in the quality
rating profiles across Council areas. Some have
a low rate of ‘poor’ and ‘adequate’ care home
provision, as in North Somerset (7%), South
Gloucestershire (8%); whilst others have
significantly higher proportion, as in Dorset
(26.5%), Gloucestershire (23%). The tables in
the Appendix provide an opportunity to identify
areas of concerns, for example whether there is
a higher proportion of homes specifically
registered for dementia which all rated as ‘poor’ /
‘adequate’. For example 6 out of the 11 homes
registered specifically for dementia care in
Gloucestershire are rated ‘poor’ or ‘adequate’,
similarly 5 out of 16 in Devon and Cornwall are
rated ‘poor’ or ‘adequate’.
22
3. Fees analysis April 2010

To support adequate matching of capacity and demand commissioners could consider

➜ Is there an over or under supply of care home capacity in your area taking into account your
geography? What are the reasons for this, and the implications of this? Is the range of
specialist dementia provision sufficient?
➜ Are there underlying reasons or specific care home groups which account for the levels of
‘poor’ and ‘adequate’ care provision? How might these be addressed?
➜ Compared with other Councils, do you have sufficient capacity in your commissioning and
purchasing teams to oversee the number of services in your area?

Working together to promote living well with dementia 23

Improving care in care homes in the South West
3. Fees analysis
An analysis of care home rates charged in the
South West
This analysis aimed to find out what rates were
being paid by different areas in respect of older
people (OP) and dementia care (DE).
A simple questionnaire was sent out to 14
localities, and 8 replied. The questionnaire
asked for rates of fees for different placements,
OP and DE, nursing and non-nursing, and
whether recognition was given to different levels
of need and different quality ratings.
Responses were received from Poole and
Bournemouth, Bristol, Dorset, Gloucester, North
Somerset, Swindon, Torbay, Devon.
From the responses received and some of the
discussion which took place, it emerged that:
➜ commissioning practice is highly varied and
it is difficult to make comparisons or
generalisations. Some commissioning
arrangements could not easy be translated
into answers to these questions;
➜ a number of Local Authorities are currently
restructuring their pricing tariffs and are
seeking guidance on yardsticks;
➜ providers have enormous difficulty in
drawing up business plans if they are near
boundaries and delivering to Local
Authorities with very different pricing
arrangements;
➜ pricing is sometimes based on a calculated
“fair price for care”, but it is also often
driven by historical arrangements or market
factors, particularly demand and supply,
and importantly the local ratio of
private/Local Authority placements.
www.southwestdementiapartnership.org.uk
Discussion paper
Given the wide range of variables at play and
the very different approaches it is difficult to
produce a simple analysis.
However, the following results do provide a
context for considering different approaches.
1) The basic price of care homes
These figures exclude any additional payments
which might be made for quality.
Personal care
The price for a placement of an older person
with personal care needs only ranges from £307
to £500. The average when taking lower needs
banded fees into account is £367, with higher it
is £402.
For people with dementia the range is £329 -
£500. The average based on lower needs is
£418 and higher £441.
Six of the areas paid an enhanced rate for
dementia care, two did not. This ranged
between £22 and £112 per week across both
personal and nursing care, on average being
£52 per week.
Nursing homes
The price for a placement of an older person
with nursing needs ranges from £438 to £650.
The average when taking lower needs banded
fees into account is £508, with higher it is £534.
For people with dementia the range is £477 -
£680. The average based on lower needs is
£534 and higher £569.
The £680 rate is an exceptional rate for people
with dementia who require nursing care and
have challenging needs.
24
Section April 2010

2) Paying for increased levels of need Other factors

Two Councils did not have a system for paying
for different levels of needs. One other paid an
additional 3% exceptional needs increment.
Of the remaining five, four Councils had a three
banded needs based system and one a two
banded system which was only applied to their
older person, non-nursing homes.
Banded payments ranged from an additional
premium of £34 - £88, the average being £62
and were similar across nursing and non-nursing
care.
In one area a geographic weighting was applied
ranging from £16.70 - £33.40 which was
primarily a reflection of significant differentials in
land and property prices across the area, and
the need to ensure people who were publicly
funded could remain living within their local town
where care home prices were higher.
There were also some additional complexities
due to historic block placement purchases and
the use of “declared” beds which were held
available for Council use.

3) Paying for increased quality

Only three Councils paid increments for

improved quality.

For homes rated good the additional premium

ranges from £4 to £15 a week, the average
being £8.

For homes rated ‘excellent’ the addition was

£6.20 - £20, the average being £13.

Working together to promote living well with dementia 25

Improving care in care homes in the South West Discussion paper

4. The South West National Dementia

Strategy Review

Between May and July 2009 a review was
undertaken across the South West, looking
indepth at the progress being made in taking
forward the individual objectives of the National
Dementia Strategy.
The table below shows the number of
communities adopting National Dementia
Strategy recommendations identifed in objective
11 and those adopting other strategies.

Number of communities adopting National Dementia Strategy recommendations identifed in

objective 11 (out of 14 communities)

Commissioning specialist in reach support from mental health teams 8

Promoting the identification of senior leads for improving dementia care 6

Promoting the appropriate use of antipsychotic medication 4

Provision of guidance to care home staff on best practice 4

Number of communities adopting other strategies

Targeting Care Quality Commission ratings 8

Supporting care homes staff training 6

Specialist Care home GAP analysis 5

Improving General Practitioner support to care homes 4

Establishing pathways pre- and post- care homes 3

Developing care homes quality metrics 2

Introducing person centred planning 2

Developing dementia service specifications 1

Use of quality / specialist fee incentive 1

Establishing a specialist dementia provider forum 1

Making link to Deprivation of Liberty Safeguards and safeguarding 1

Promoting dignity in care 1

Improving care home environments 1

www.southwestdementiapartnership.org.uk 26
4. The South West National Dementia Strategy Review
In respect of objective 11 “Improving care in care
homes”, the review found that Councils and
Primary Care Trusts place heavy reliance on
Care Quality Commission ratings. A number of
Councils and Primary Care Trusts were noted to
be targeting ‘poor’ care homes, offering support
particularly with staff training. A number of
Councils were strengthening their contracts with
care homes and increasing their contract
monitoring. The review found that systems for
reviewing people living in care homes and
funded by Councils varied across the South
West, some people being regularly reviewed,
others not so.
The review found that whilst there were some
good examples of efforts being made to raise
standards, this was often a reaction to crises
rather than a proactive approach to improving
care across the care home sector. The review
found that the amount of training available and
the level of NHS in-reach support services
including mental health, nutrition and continence
care varied considerably across the South West.
The reviewers also noted that good nursing
homes tended to have strong links with primary
health care team nurses.
The review included feedback from people with
dementia and carers. Their comments
suggested that their experiences of the quality of
care in care homes were much less positive
than that reported by inspectors. Carers were
particularly concerned about the lack of
meaningful activity and stimulation provided in
care homes.
Working together to promote living well with dementia
April 2010
National Dementia Strategy
recommendations
Clearly much emphasis is being placed on
developing in-reach mental health services, and
the benefit of such support was noted by
managers who attended the focus group. They
indicated that there would be some value in
assessing the effectiveness of the various
models of providing such support.
Less than half the communities seem to be
supporting the development of lead dementia
specialists in care homes. Although the objective
is aimed at providers, it is an area where
commissioners can exert a lot of influence and
which could have very significant impact in the
delivery of care and in changing care home
cultures.
Gloucestershire has put substantial effort into
developing a certified training programme for
lead care workers and developed support
networks for dementia care home leads.
Anecdotally this is already showing very
substantial benefits.
There is potential conflict between schemes run
by Councils and those by larger care homes
corporate providers. This will need to be
anticipated and managed.
Placing clear contractual expectations on care
homes in respect of having dementia leads who
receive best practice training and updates is an
achievable opportunity for commissioners. It
could also form part of the quality assurance
analysis and rating assessment undertaken by
Care Quality Commission.
Four communities identified the need to focus on
medication practice within care homes with an
emphasis on the reduction of antipsychotic
27
Improving care in care homes in the South West
medication. Gloucestershire demonstrated in the
Partnership for Older People Projects (POPP)
that considerable savings can be made by
undertaking pharmacy reviews and reducing
medication levels where appropriate.
The reduction of antipsychotic medication has
recently been adopted as the eighteenth
objective of the National Dementia Strategy. A
specific action plan has commenced in the
South West to address this, with the roll out of
an audit commissioned by the Strategic Health
Authority. It is an area that all health
communities will need to consider.
Four communities have work streams which will
focus on improving care home staff awareness.
It is important to note some of the valuable
resources now becoming available for example
of Social Care Institute for Excellence Dementia
Gateway
www.scie.org.uk/publications/dementia/. There
will also be a regional initiative with a letter and
survey being sent to all care homes in the
region.
Other initiatives
The majority of communities are focusing on
improving weaker care homes as identified by
the Care Quality Commission. Whilst
understandable, this is a reactive strategy which
places a high degree of trust in the currency and
validity of the Care Quality Commission rating.
With the changing framework in regulation and
extended frequencies for inspection, this
approach needs to be kept under review. There
will be regional work with the Care Quality
Commission, care home provider associations
and the Alzheimer's Society to consider how
quality assurance systems might be validated
www.southwestdementiapartnership.org.uk
Discussion paper
against the new compliance criteria and
outcomes for people living in services. Future
assurance must place emphasis on owners
taking responsibility for effective quality control
but many providers are looking for support,
direction and encouragement to achieve this.
Two Councils are giving consideration to quality
assurance metrics.
A number of communities placed emphasis on
training for care home staff. The Qualification
Credit Framework for care staff is changing as
NVQs are superseded by the new diploma. A
vast array of training in dementia of variable
quality is available. The South West Dementia
Partnership will offer advice about training
courses people have found useful on the
website during spring 2010. However current
thinking is that for training to be of value, good
dementia practice must be reinforced by the
prevailing leadership and ethos within the care
service, and robust supervision, otherwise the
training is of little value.
Two communities are promoting person centred
planning. This would appear to be a key area for
consideration given the findings of the regional
focus group and study. A common complaint is
that there is too much paperwork in care homes,
but the reality is paperwork systems are often
found to be incomplete or out of date. There
appears to be a real tension between developing
easily accessible plans which simply reflect a
person's identity, wishes and feelings and yet
provide sufficient information to guide staff in
supporting people to have the necessary day-to-
day psychological support and physical care to
enable them to be happy, safe and healthy.
In some services there has been a fundamental
lack of understanding and confidence in
28
4. The South West National Dementia Strategy Review April 2010

supporting risk-taking and choice. There are an
increasing number of sophisticated care
planning systems being developed which will
find danger of overcomplicating and over-
bureaucratising the care planning process. The
South West Dementia Partnership will provide
best practice regional guidance and models on
the website.
Enabling people with dementia living in care
homes to have an active, fulfilling, interesting
and varied experience was not an issue
identified in the action plans. However, it is an
area that some communities have and are
investing in. Traditionally has been thought of as
providing activities within care homes, although
positive practice today aims to promote an
inclusive living experience, with people actively
involved in help in running the home along with
a broad engagement with relatives and the wider
community.

Working together to promote living well with dementia 29

Improving care in care homes in the South West
5 Future plans
In the South West key public agencies and the
Alzheimer’s Society have formed a partnership
to support the implementation of the National
Dementia Strategy.
Details of its activities can be found on the South
West Dementia Partnership website at
www.southwestdementiapartnership.org.uk
www.southwestdementiapartnership.org.uk
Discussion paper
Representatives of this group will be visiting
each health and social care community over the
coming six months to provide support and
advice in respect of delivering their local action
plan, and will be discussing their plans to
improve care homes.
30
5. Future plans April 2010

There will also be a range of activity across the

region including:

➜ Self assessment questionnaires based on

the findings of this review sent to all care
homes, commissioners and Care Quality
Commission. This will encourage people to
think about the part they might play in
improving the experience of people living in
care homes.
➜ Promotion of link dementia workers in all
care homes for older people and dementia
and the development of a social networking
site for this group to receive support.
➜ Letters to all care homes including the
Social Care Institute for Excellence
postcard which explains how to access the
excellent on line training materials it has
developed for care home staff.
➜ Collection of care home positive practice
examples which will the featured in the
South West Dementia Partnership website
and bulletin.
➜ Further work with provider organisations
and commissioners on developing an
agreed quality assurance framework and
person centred care planning.
➜ Presentations and training at care home
provider events across the region.

The South West Dementia Partnership is very

keen to receive feedback, suggestions,
concerns and examples of good practice.

If you would like to give us feedback, send us

examples of good practice or ask a question
please contact us via
David.Francis@dh.gsi.gov.uk.

Working together to promote living well with dementia 31

Improving care in care homes in the South West Discussion paper

6. Questions to ask yourself

The task of improving care in care homes rests with a wide range of people, all of whom have a
responsibility to achieve improvements. To help people to reflect on what they should or could do to
improve care for people with dementia there are sets of “Questions to ask yourself”, designed for
care home managers and providers, commissioners and Care Quality Commission inspectors. The
questions are drawn directly from the findings in this discussion document.

Yes; I know this because No; But I am planning

Care home managers and providers
.. to..

Our care home has a member of staff

who is identified as our dementia
1
champion. They know about best
practice and are an inspiration to others.

Our care home keeps up to date, uses

2 other people’s ideas and is aware of
best dementia practice.

Our staff are well trained and motivated

and understand the importance working
3
from the perspective of the person with
dementia.

All our staff know the preferred name of

each person living in our home. They
4 know about their wishes, background,
their critical care needs and how to
support them if they become distressed.

We positively support relatives and

5 involve them in the life of the home and
in helping support family members.

www.southwestdementiapartnership.org.uk 32
6. Questions to ask yourself April 2010

Yes; I know this because No; But I am planning

Care home managers and providers
.. to..

In our home people with dementia are

supported to do things which they find
6
rewarding. Our home buzzes with
activity.

Our care home has a quality assurance

system which is includes careful
7
assessment of the experience of
people living in the home

We are confident in taking managed

8 risks. We believe in supporting people
to remain active.

We have the right ethos; We enjoy the

challenge of looking after people with
9
dementia, we like problem solving and
being creative.

Our care home is cheerful, safe and

interesting. It enables people to move
10
freely inside and outside and provides
cues to help people find their way.

Our home’s manager is well supported,

11 and has a clear vision about how good
dementia care should be delivered.

We have a strength and depth in the

12 leadership in our home and others who
can step into the manager’s shoes

Working together to promote living well with dementia 33

Improving care in care homes in the South West Discussion paper

Health and social care Yes; I know this because No; But I am planning
commissioners .. to..

Our contracting arrangements require

that care homes have an identified
1
member of staff who is recognised as
the dementia lead / champion.

Our contracting arrangements require

2 that care homes keep up to date about
best dementia practice.

Our contracting arrangements place

minimum expectations on staff training.
They ensure that staff know what
3 dementia is, how it is experienced, and
the importance working from the
perspective of the person with
dementia.
Our contracting arrangements require
that care homes have a robust quality
4 assurance system, which includes an
assessment of the experience of
people living in the home.

Our contracting arrangements require

5 that care homes have effective
management arrangements in place.

People requiring placement are

properly assessed and placed in care
6
homes which are able to meet their
needs.

We have commissioned effective

specialist mental health in reach
7
support, available to all our care
homes.

www.southwestdementiapartnership.org.uk 34
6. Questions to ask yourself April 2010

Health and social care Yes; I know this because No; But I am planning
commissioners .. to..

We have commissioned effective GP

8 and primary health care support to our
care homes.

We have the right range and balance

9 of care homes to meet needs of people
with a range of dementia conditions.

We have sufficient commissioning

10 capacity to manage and oversee our
care home market.

Our contract specifications, monitoring

arrangements and quality assurance
11
systems are based upon person
centred outcomes.

Our workforce development plan

recognises the need to provide
12 effective dementia training to care
home staff across council run and
independent sectors.

We have an effective joint health and

13 social care strategy to provide support
to failing homes.

Our funding arrangements provide

some flexibility across health and
14
social care and can respond to
changing levels of need.

Working together to promote living well with dementia 35

Improving care in care homes in the South West Discussion paper

Yes; I know this because No; But I am planning

Care inspectors
.. to..

I am not risk averse. I give priority to

people in care homes being able to live
1
a life and accept that as a consequence
there will be potential risks.

I have a good understanding of the

needs and experience of people with
2 dementia. My judgements are based on
the perspective of people with
dementia.

During inspection site visits I spend at

least a third of my time directly with or
3
observing the people who live in the
home.

I am confident in judging the quality and

4 effectiveness of staff competence and
training.

I approach inspections with positive

5 expectations and ambitions for people
with dementia.

I am up to date about good dementia

6
practice in care homes.

www.southwestdementiapartnership.org.uk 36
6. Questions to ask yourself April 2010

Yes; I know this because No; But I am planning

Care inspectors
.. to..

My inspection practice is quality

7
assured by others.

When judging care homes I give weight

8 to the importance of appropriate
activity and stimulation.

I have a good understanding of the

National Dementia Strategy, its
9
expectations and its implications for me
as an inspector.

I am confident that the overall ratings I

10 award are a fair reflection of the quality
of life of people living in the home.

I am know which homes do not have

registered managers and am able to
11 apply effective pressure to ensure a
registered manager is identified without
undue delay.

In my inspection practice I am particularly pleased with….

Working together to promote living well with dementia 37

Improving care in care homes in the South West Discussion paper

Appendix

Overview of older peoples and dementia care homes across the South West

Total homes Adeq

POPPI >65 / 000

OP Adeq /Poor

OP Adeq /Poor

DE Adeq /Poor

% Adeq / poor
Homes / 000
Total homes

% DE only
DE only
Council

OP DE

/Poor
OP

Bath and North

37 28 7 2 5.4 4 4 0 0 31.2 1.19 11%
East Somerset

Bournemouth 77 48 10 19 13.0 15 9 3 3 31.9 2.41 19.5%

Bristol 67 44 13 10 14.9 13 7 4 2 55.2 1.21 19.5%

Cornwall and Isles

168 60 82 16 9.5 35 14 16 5 114.2 1.47 21%
of Scilly

Devon 289 139 134 16 5.5 47 22 20 5 164.3 1.76 16%

Dorset 128 96 24 8 6.2 34 23 8 3 101.7 1.27 26.5%

Gloucestershire 132 99 22 11 8.3 30 20 4 6 109.4 1.21 23%

North Somerset 86 64 9 13 10.5 6 4 2 0 41.7 2.10 7%

Plymouth 69 28 35 6 8.7 14 5 9 0 40.7 1.69 20%

Poole 37 19 9 9 24.3 5 2 1 2 29.3 1.26 13.5%

Somerset 150 103 37 10 6.7 28 15 10 3 110.2 1.36 19%

South
49 34 9 6 12.2 4 3 0 1 42.3 1.15 8%
Gloucestershire

Swindon 25 13 10 2 8.0 3 2 0 1 27.2 0.91 12%

Torbay 80 29 46 5 6.2 10 5 5 0 31.6 2.53 12.5%

Wiltshire 100 38 49 13 13.0 19 5 10 4 82.7 1.21 19%

1013 1.46 17.8%

www.southwestdementiapartnership.org.uk 38
Appendix April 2010

Comparison of older peoples and dementia care homes in the South West with national figures

Totals OP only DE+ OP DE only

Number 10,544 4702 4676 1166
National
% - 45% 46% 11%
Number 1842 753 874 216
Adequate / poor
% 17.5% 16% 18.7% 18.5%
Number 1494 852 496 146
South West region
% - 57% 33% 10%
Number 263 140 92 31
Adequate / poor
% 17.6% 16.4% 18.5% 21.2%

Breakdown between nursing and non-nursing care homes in the South West
Totals OP only DE+ OP DE only
Number 512 326 130 56
Nursing
% 34% 64% 25% 11%
Number 89 47 26 16
Adequate / poor
% 17.4% 14.4% 20.0% 28.6%
Number 982 526 366 90
Non Nursing
% 66% 54% 37% 9%
Number 174 93 66 15
Adequate / poor
% 17.7% 17.7% 18.0% 16.7%

Breakdown by size of care home

Size OP+DE OP only DE only Total ~%

<10 8 34 4 46 3
10-29 218 445 68 731 49
30-49 170 281 55 506 34
50-69 63 80 16 159 11
70-89 26 11 3 40 3
>90 10 1 0 11 1

Breakdown by provider of care home

Type OP+DE OP only DE only Total ~%

LA 25 33 11 69 5
Private 413 704 121 1238 84
Voluntary 56 102 13 171 11
Total 494 869 145
~% 33 57 10

Working together to promote living well with dementia 39

Improving care in care homes in the South West
More information
If you would like to give us feedback, send us
examples of good practice or ask a question please
contact us via David.Francis@dh.gsi.gov.uk.
South West Dementia Partnership website
www.southwestdementiapartnership.org.uk provides
further information about the review along with
examples of innovative practice. For example,
Devon have made their action plan to implement
the National Dementia Strategy available for other
communities to refer to
www.southwestdementiapartnership.org.uk/impleme
ntation/devon/
SCIE’s Dementia Gateway
www.scie.org.uk/publications/dementia/ produced
by the Social Care Institute for Excellence (SCIE)
offers high quality information, video and training
programmes. There is in depth advice about
establishing communication and managing difficult
situations. You can also use materials on the site to
update your learning portfolio!
The Alzheimer’s Society www.alzheimers.org.uk
offers a wide range of fact sheets, studies,
discussion forums, advice and sources of support.
There are also some valuable “tips for nurses”
A partnership to promote living well with dementia
Discussion paper
which are suitable for a wide range of professionals
www.alzheimers.org.uk/countingthecost
Dementia Information Portal is a Department of
Health website, which follows the implementation of
the National Dementia Strategy. It offers information
to anyone with an interest in improving services for
people with dementia.
www.dementia.dh.gov.uk
Dementia Services Development Centre (DSDC)
ia an internationally recognised centre for
excellence in dementia research and training for
health and social care professionals working with
people with dementia.
www.dementia.stir.ac.uk
Innovations in Dementia supports people with
dementia to become more involved and have a say
in anything that affects them.
www.innovationsindementia.org.uk
Dementia Voice is a dementia centre of excellence
whose work challenges traditional thinking about the
way dementia services are designed and delivered.
www.dementia-voice.org.uk
40