Quality of care in private sector and NHS facilities for people with dementia: cross sectional survey

Residential and nursing homes provide an essential contribution towards the care of people with dementia. It is a challenge to provide good care within tight budgets and often with a workforce that has little formal training. Most people are cared for within the private sector, although a limited number of NHS beds provide continuing care for people with severe dementia and intractable behaviour problems.

Dementia care mapping¹ is a direct, standardised assessment with good interrater reliability.² Activities are coded according to category of behaviour, and they are recorded every five minutes. Wellbeing is measured using the dementia care index, which indicates the overall quality of care within a particular environment extrapolated from dementia care mapping evaluations of half of the residents.¹ We used dementia care mapping to evaluate the quality of care in 10 private sector and seven NHS care facilities.

Participants, methods, and results

People living in care facilities from specific geographical catchment areas in three regions of the United Kingdom received a standardised assessment from which an operationalised diagnosis of dementia was made.³ The facilities in the group included all seven NHS continuing care units and 10 of 12 private sector facilities with more than 35 residents in the designated areas. Dementia care mapping evaluations were completed by researchers from medical, nursing, or psychology backgrounds. All had completed a certified training course and achieved good interrater reliability (κ scores >0.8) in a six hour evaluation with a senior mapper. A dementia care index score was calculated, and an overall category was assigned to the quality of care.

A total of 367 people with dementia were identified; of these, dementia care mapping was used to evaluate 218 (59%) (table).

The dementia care index rated all seven (100%) NHS facilities (dementia care index rating range −1.6 to 4.1) and five (50%) of the private sector facilities as needing radical improvement (dementia care index rating range 4.1-8.8); the remaining five (50%) private sector facilities were rated as needing much improvement (dementia care index rating range 12.3-20.4). Over the six hour daytime period of observation, people spent 61 minutes (17%) asleep and 108 minutes (30%) either socially withdrawn or not actively engaged in any form of basic or constructive activity. Only 50 minutes (14%) were spent talking (or communicating in other ways) with staff or other residents, and less than 12 minutes (3%) were spent engaged in everyday constructive activities other than watching television (11 minutes (3%)). The remaining 33% of the observation period was spent engaged in basic activities such as eating, going to the toilet, etc.

Comment

Quality of care was rated as needing radical improvement or much improvement in all homes, and no home showed even a fair standard of care. Can our results be regarded as representative? The homes were not selected because of perceived poor standards of care— 17/19 (89%) of the large care facilities in the designated area were surveyed, and the characteristics of the residents were consistent with recent reports. Current care provision is inadequate, at least according to dementia care index standards, and urgent action is required. The evaluation methods currently used by joint inspection teams, do not make use of direct observation, so may not be sufficient to fully evaluate the care environment.

Recent reports have highlighted the need for review and improvement of the standards of care in residential and nursing homes.⁴,⁵ Our data emphasise the need for urgency in this process. The proposed national standards for care in residential and nursing homes for elderly people describe interaction and daily activity as one of 11 key domains.⁵ These aspects of care require particular attention, and they merit a greater focus within revised standards. Improved strategies for joint working between the NHS, social services, and private care providers will ensure that integrated specialist teams can deliver high quality care to these vulnerable patients.

Table.

Quality of care in 10 private sector and seven NHS care facilities for people with dementia evaluated by dementia care mapping

Facility	Mean wellbeing score	Dementia care index rating*	Action needed
Private sector (480 patients, 413 with dementia)†
1	1.23	12.3	Much improvement
2	1.22	18.4	Much improvement
3	1.15	17.2	Much improvement
4	1.02	20.4	Much improvement
5	0.85	12.8	Much improvement
6	0.88	8.8	Radical changes
7	0.75	7.5	Radical changes
8	0.54	8.1	Radical changes
9	0.41	4.1	Radical changes
10	0.38	5.7	Radical changes
NHS (71 patients, 71 with dementia)‡
1	0.81	4.1	Radical changes
2	0.65	3.3	Radical changes
3	0.60	3.0	Radical changes
4	0.31	3.1	Radical changes
5	0.25	2.4	Radical changes
6	0.23	3.5	Radical changes
7	−0.32	−1.6	Radical changes

^*Range 0-300; 10=radical changes needed, 10-24=much improvement needed, 25-49=fair, 50-74=good, 75-99=very good, >99=excellent. 

^†Clinical dementia rating scale scores 31% mild, 32% moderate, and 37% severe; median age 83 years; 69% women; and median neuropsychiatric inventory score 12. 

^‡Clinical dementia rating scale scores 0% mild, 0% moderate, and 100% severe; median age 79 years; 60% women; and median neuropsychiatric inventory score 37. 

Editorial by Marshall