Dignity and Nutrition Inspection (DANI) Programme 2012

1. Dignity and Nutrition Inspection (DANI) Programme 2012

2. Types of inspections • We carry out three types of inspections: • Scheduled: these are unannounced inspections that focus on a minimum of five of the government standards, and they’re also tailored to the type of care that is provided at the service. • Responsive: these are unannounced inspections that are carried out where there are concerns about poor care. • Themed: these inspections focus on specific standards of care or care services.

3. Characteristics of themed inspections Themed Inspection programmes • Targeted to focus on specific standards of care or care services • Check standards for a clearly defined group of people using services, providers and / or regulated activities • Have the potential for influence and leverage of improvement that is wider than the individual providers included in the programme • Are an opportunity to involve key external stakeholders closely in our work via task and finish advisory groups

4. Dignity and nutrition inspections (DANI) March – June 2011 • Three monthinspection programme covering 100 NHS acute hospitals across England • Review how well the dignity, nutrition and hydration needs of older people are met in NHS hospitals • Reviews carried out by CQC inspectors, senior nurses and Experts by Experience • Secretary of State for Health originally requested the programme • Findings collated in a national report

5. DANI results - Number of hospitals by CQC judgement 20 hospitals were not meeting essential standards for dignity and nutrition 80 of the hospitals inspected were compliant with both outcomes To remain compliant we suggested that 35 hospitals need to make improvements Sample of 100 inspections of NHS hospitals

6. Phase 2 DANI - 2012 • Secretary of State requested that CQC undertake a further programme of DANI in the NHS and extend to adult social care settings • Visits to 50 NHS locations and 500 adult social care locations between April and October 2012 • Focus on services provided to older people • NHS locations include mental health services • Five regulations / outcomes inspected

7. DANI 2012 • Inspection teams include CQC inspectors, experts by experience and/or practising professionals either on visits or as part of an expert advisory group • Practising professionals from a wider range of health and social care professional groups e.g. physicians, dieticians, nurses speech and language therapists • National reports due to be published for each sector; Adult social care and the NHS • Will include an evaluation of what worked well

8. Sample - NHS • 37 Acute Trusts • 13 Mental Health Trusts • Includes 9 trusts from DANI 1 8

9. Sample - ASC • 500 locations identified using agreed criteria: • Mix of nursing and non nursing • Dementia • Regional and local authority spread • Size 9

10. The 5 Regulations / Outcomes • Regulation 17 / Outcome 1: Respecting and Involving people who use services • Regulation 14 / Outcome 5 : Meeting nutritional needs • Regulation 11 / Outcome 7: Safeguarding people who use services from abuse • Regulation 22 / Outcome 13: Staffing • Regulation 20 / Outcome 21 : Records • Outcomes 1 and 5 are the key outcomes, 7, 13 and 21 inspected from the perspective of the theme 10

11. Subheadings Outcome 1Respecting and Involving People 1a Is people’s privacy & dignity respected? Do staff treat people with dignity and respect including when they are providing support with eating and drinking? Are arrangements in place to ensure that people’s independence is respected? Does the environment support people’s privacy and dignity? 1b Are people involved in making decisions about care and treatment? Are people’s views and preferences about their care and treatment requested, respected and implemented? Does the care and treatment provided reflect people’s diverse needs related to their age, sex, religious persuasion, sexual orientation, racial origin, cultural and linguistic background and any disability they may have. 11

12. Subheadings Outcome 5Meeting Nutritional Needs 5a Are people given a choice of suitable food and drink to meet nutritional needs? Effective systems in place to protect people from the risk of inadequate nutrition and hydration Choices about the food and drink provided and when and where people can have it Sufficient and suitable nutritious food and drink throughout the day to meet peoples needs 5b Are people’s religious or cultural backgrounds respected? Food and drink which meet individual religious or cultural needs? 5c Are people supported to eat and drink sufficient amounts to meet their needs? Support to have adequate nutrition and hydration Effective systems in place to monitor that people’s nutrition and hydration needs are always met 12

13. Subheadings Outcome 7Safeguarding and Safety 7a Are steps taken to prevent abuse? Do staff understand what constitutes abuse? Is there a recognition that by meeting a person’s individual needs the potential for abuse is reduced? 7b Do people know how to raise concerns? Do staff know how to report abuse? Do people know how to raise concerns? And are they comfortable in doing so? Are there clear procedures to be followed when abuse is suspected or allegations made 7c Are Deprivation of Liberty safeguards used appropriately? Does the service always act in the best interests of a person as required by the MCA when a person is assessed as lacking capacity? 13

14. Subheadings Outcome 13Staffing 13a Are there sufficient numbers of staff on duty? Are there sufficient numbers of staff to provide the required level of support to people who use services at mealtimes? Are there sufficient numbers of staff to ensure the dignity, privacy and independence of people who use services? 13b Do staff have the appropriate skills knowledge and experience? Are nutritional assessments carried out by someone with appropriate skills, knowledge and training? Are staff trained and skilled to provide appropriate nutritional care and support? Do staff know and understand the needs of people who use the service? 14

15. Progress so far and next steps • Publication due March 2013

16. Early findings (NHS) • call bells out of reach, • patients and relatives not involved in decisions about care • lack of appropriate support at mealtimes, • lack of suitable menu choices • patients identified at risk of dehydration and malnutrition not always encouraged and supported to eat and drink • insufficient numbers of staff, not always able to get bank or agency staff at short notice • limited and conflicting information between care plans and risk assessments • inaccurate fluid balance records • lack of integrated records leading to inaccuracies and inconsistencies.

17. Early findings (ASC) - privacy and dignity • Lack of interaction between staff and residents during mealtimes and at other times • Referring to people who need help with their meals as ‘feeders’ • Moving or attending to people without discussion or regard to their wishes • Leaving toilet doors open when in use by residents • Lack of documented preferences for individuals or involvement in how they spend their day • Lack of activities or trips out

18. Early findings (ASC) – meeting nutritional needs • Residents not helped to make choices about what they eat • Residents all served the same food – no choice evident • Failure to provide assistance to people who needed help with their meals • People who had been identified as having lost weight not being monitored • Extended waiting times for meals which meant that some people had finished before others had started. • Use of aprons / bibs without explanation

19. Early findings (ASC) – safeguarding, staffing and records • Lack of response to requests for assistance • Lack of information about how to raise concerns • Residents saying staff too busy to help • Lack of detail in care plans – of particular concern where a risk of poor nutrition has been identified

20. Closing comments • The public puts its faith in those who run and work in care services - but sometimes care fails or presents too much risk • These themes cover the very basics of care • There must be a culture that won’t tolerate poor quality care, neglect or abuse – and encourages people to report it • The regulator can’t do it alone; providers and individuals need to be accountable and focus on quality and safety

21. Contacting CQC • Website: www.cqc.org.uk • Email: enquiries@cqc.org.uk • Telephone our national contact service centre on: 03000 616161