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The Healthcare Commission was yesterday (Thursday) calling for NHS trusts to do more to ensure they consistently provide dignity in care to older people, including offering adequate nutrition and privacy.

Publishing a national report on dignity in care, the independent watchdog is warning NHS trusts of further checks, including unannounced visits, where there are clusters of evidence suggesting a problem at a hospital or on a ward. It is asking patients, their carers and the public - and their representative bodies like Age Concern - to come forward and tell the Commission where they have reason for concern.

The Commission says that overall it was encouraged by signs that the trusts were generally getting the right systems in place. But there was work to do to offer dignity in care to all of the people all of the time and evidence showed this was not always the case.

The national report draws on assessments at 23 NHS hospitals, Commission surveys of 80,000 NHS inpatients and nearly 130,000 NHS staff, the Commission's analysis of 10,000 complaints and National Patient Safety Agency information on safety incidents.

The report also highlights eight other trusts identified as providing dignity in care in line with best practice.

Examples of best practice included one trust that had introduced a new gown to protect patient modesty and another where senior nursing staff spent Fridays on the wards to better understand the challenges.

The Commission chose the 23 trusts by screening of performance data and identifying organisations where there was an apparent risk of non-compliance with government standards. The standards cover how well organisations:

• Ensure that older people are treated with dignity when receiving care in hospital (Core standard 13a)
• Assess and meet the nutritional needs of older people and help them to eat if necessary (Core standard 15b)
• Support older people's need for privacy and confidentiality while in hospital (Core standard 20a)

All the 23 trusts declared themselves compliant with the standards in last year's annual health check of NHS trusts. Separately, the Commission is currently working with a further 17 trusts that have already declared non-compliance with these standards in this year's health check, due to be published next month.

Following the 23 inspections, which included interviews with staff and observation of two wards, the Commission said it found no major breaches of national standards but there was still need for improvement.

It said that five of the 23 trusts complied with all dignity in care standards. It issued eight trusts with notification letters, warning of a risk of non-compliance and urging the board to check carefully when making declarations for this year's health check as these would face particular scrutiny. The remaining ten trusts were told to make improvements, ranging from providing adequate training to ensuring meal times were protected from clinical activity.

The Healthcare Commission's Chief Executive, Anna Walker, said: "It is encouraging to see where organisations are taking on board national concern about this issue and getting the right systems in place, but systems are not enough. There is a critical challenge to ensure that all older people are treated with dignity all of the time. Trusts must step up efforts to achieve this. It is absolutely key to providing the kind of personalised care that the Prime Minister was talking about in Bournemouth this week.”

She added: "Trusts should also know that where there is evidence that the right care is not being provided consistently, we will use all our powers of assessment and inspection. Patients and the public do not want us to let this issue go and we have no intention of doing so.

“We will talk to patients and patient groups to ensure we understand their experience of care.”

The report identified the following key areas for improvement. Trusts that performed well on dignity already payed attention to these areas and the Commission recommends that all trusts should do the same.

Strong Leadership
The Commission’s inspections found not all trusts had clear policies relating to dignity issues for older people, including nutrition and privacy. Some of the trusts inspected claimed these were embedded in other policies and the implementation of many policies was left to ward level.

The Commission recommends that boards need to take a close interest in this issue. There should be a clear lead staff member for dignity at all levels, including boards, and policies should be communicated to staff and patients.

Workforce training
The Commission's inspections found most training arrangements were one-off at the time of recruitment and staff reported they were not always able to attend training due to shortages of personnel. This affected staff ability to identify and deal with difficult areas of care such as dementia and end-of-life care.

The Commission recommends that attendance on training courses on equality, diversity and the practical aspects of dignity must be mandatory and be ongoing, not just available to staff at induction. This is crucial in raising and maintaining awareness of this issue.

Involving older people in their care
The report pointed to survey data that found that nationally only 55% of older people said they felt involved in their care as much as they wanted. Ninety four per cent said they were never asked their views on their care while in hospital. 

The inspections found that all trusts inspected had mechanisms for involving older people in their care but they were not always put into practice. Systems for involving older people and their carers from minority ethnic groups were not robust and there was a greater reliance on family members to provide translation in these cases.

The Commission said that involving older people in their care and discussing it with them should be routine and automatic. It recommends trusts should ensure older people and their carers and relatives are encouraged to be involved in their treatment by making processes transparent.

Ward Environment
All patients were appropriately dressed and staff took care to protect their modesty on the day of the Commission’s visit.

But the Commission also found that in some cases, there were inadequate arrangements for providing privacy through curtains and locks on toilet and wash facilities.

The inspections also found that while placing patients in mixed sex bays was generally considered unacceptable, trusts sometimes struggled to achieve this, especially in times of high demand.

The Commission recommends that trusts should ensure that wards have quiet and private space available to patients, particularly for spiritual needs and confidential consultations when required. This should identify and address the barriers that restrict this provision.

Delivering personal care that ensures dignity
The report also found planning and delivery of end-of-life and dementia care for patients needs to improve.

During its visits to the 23 trusts, the Commission found all the trusts had end-of-life care programmes in place, although implementation was at varying stages.

Staff also told the Commission that caring for patients with dementia was challenging due to a shortage of specialist staff, unclear patient pathways and inadequate training in this area.

Looking at nutrition, the report found there was room for improvement. An inpatient survey used in the report showed that of the older people that needed help to eat, less than a fifth (just over 16%) said they received it.

Fifty nine per cent of older people rated their hospital food as "good" or "very good" in the survey, 28% rated it "fair" and 11% rated it "poor", with wide variations found between trusts. And complaints data reviewed by the Commission showed 25% concerns related to poor nutrition in hospitals.

The seriousness of nutrition issues was highlighted by NPSA data that showed there were approximately 1200 reported patient safety incidents over the last eighteen months regarding nutritional and fluid management per year. Twenty five per cent of those either caused harm or had the potential to cause harm to patients. This included patients being given food they were allergic to, choking on food and diabetic food being unavailable out of hours.

More information and access the report about the review of dignity in care

Notes to editors

Information on the Healthcare Commission
The Healthcare Commission is the health watchdog in England. It keeps check on health services to ensure that they are meeting standards in a range of areas. The Commission also promotes improvements in the quality of healthcare and public health in England through independent, authoritative, patient-centred assessments of those who provide services. 

Responsibility for inspection and investigation of NHS bodies and the independent sector in Wales rests with Healthcare Inspectorate Wales (HIW). The Healthcare Commission has certain statutory functions   in Wales which include producing an annual report on the state of healthcare in England and Wales, national improvement reviews in England and Wales, and working with HIW to ensure that relevant cross-border issues are managed effectively.

The Healthcare Commission does not cover Scotland as it has its own body, NHS Quality Improvement Scotland. The Regulation and Quality   Improvement Authority (RQIA) undertakes regular reviews of the quality of services in Northern Ireland.

For further information contact   Janine Maher on 0207 448 9313, or on 0777 999 0845 after hours