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Wednesday, 10 April 2013

Care home residents with dementia sent to A&E alone

Written by The Guardian
Care homes are increasingly leaving residents with dementia on their own in hospital. Why is this happening?

My mother Madge, 90, who has mild vascular dementia – she knows who the prime minister is but can't remember what she had for lunch – has had several health problems since living in care homes. Most have gone undetected until I have noticed and alerted staff, after which a doctor has been called or, more usually, she has gone straight to A&E. Her undetected health problems have ranged from gout to acute urinary infections to a vascular dementia "episode", the equivalent of a small stroke – it was me who noticed her speech was slurred and her motor skills impaired, not her carers.

The four care homes Madge has lived in since 2005 have all sent residents alone in ambulances to hospital, which means those with dementia or severe memory problems – 80% of all care-home residents according to research by the Alzheimer's Society – are confused about why they are there, with no one to advocate for them, get them a cup of tea or take them to the loo. The wait in A&E can be as long as five hours, a very long time for any elderly person to be alone in a stressful environment, never mind for someone with dementia.

In January, my mother was sent on her own to A&E with a painful knee. Her care home rang to tell me an ambulance was on its way, which is code for "It would be good if you could go with her". As always, I abandoned work and went to A&E to find my mum alone and very distressed because the carers had sent her without her glasses. She was diagnosed with gout, and I was able to tell the doctor her history of this painful condition. The next day carers rang to tell me mum was still in acute pain and was going back to A&E, only this time they sent her not only without glasses, but without her hearing aid or her dentures. Sending a 90-year-old with dementia to hospital alone is, in my view, inhuman, but to send them without the things they need to see, hear, speak and eat is neglect bordering on abuse.

The Residents and Relatives Association is also concerned, as are some care home staff. The R&RA was recently contacted by a care home whistleblower, who witnessed an elderly resident with dementia going to hospital alone with a scrap of paper in her hand "explaining" why she needed to see a doctor. It has also received reports of confused elderly residents found wandering in hospital corridors with no idea why they were there. R&RA chair Judy Downey says: "They have no ID to indicate who they are, no list of medication or what they might be allergic to, and being sent off with no glasses, hearing aid or personal effects is very common."

She adds: "People are in care homes because they need personal care, and looking after them when they go to hospital is an intrinsic part of the duty of care. Someone with dementia who is asked if they are in pain may say no, if they have no pain at that precise moment, and then be in agony 10 minutes later – if there is no one to advocate for them, their long wait in A&E is often fruitless."

Des Kelly, executive director of the National Care Forum believes the problem is increasing due to care homes not having enough members of staff to accompany residents to hospital. "It's inappropriate and unsuitable to send an elderly person with dementia to hospital alone, but it's a dilemma that keeps arising. It's a serious problem and ideally, homes would have sufficient staff so that you can lose one carer for a few hours. This should be a minimum requirement."

The health and social care watchdog, the Care Quality Commission (CQC), which last month published research on how care homes are not detecting and treating residents' health problems and are failing people with dementia, but did not pick up on residents being "dumped" at hospital – says the answer is to keep elderly care home residents out of A&E unless it is strictly necessary by routinely calling on GP services in the first instance. Special policy lead Alan Rosenbach says: "The issue is about managing the needs of people in care homes – no one should be going to A&E with a urinary tract infection. A&E is a bad, intimidating place for anyone to be, but four hours alone in A&E for an elderly person with dementia is unsympathetic and it is not acceptable." He adds: "We will be using the recent reviews we have done on the care of care-home residents with dementia as a basis for starting a conversation between care homes and hospitals on this issue".

The Age UK charity says that many older people are being admitted to hospital from care homes purely because there is a lack of access to good community care. "If these services improved and the right care was delivered at the right time, then many older people would not need to be admitted to hospital at all, " says Michelle Mitchell, Age UK's director general. "There needs to be better training and support for care home staff, urgent improvements to medication management, and much closer links with local GP and other primary care services. With better communication between health and care organisations and an adequately funded social care system many of these admissions could be avoided."

In 2012, David Cameron launched "the dementia challenge" to deliver major improvements in dementia care, awareness and research in three years.

"Dementia is one of the biggest challenges we face as a society and we are determined to transform the quality of dementia care for patients and their families," said Cameron. " In England today, there are an estimated 670,000 people living with dementia, a number that is increasing with one in three people set to develop dementia in the future."

The Department of Health says as part of this challenge it is working with the care sector to ensure that high-quality personalised care is delivered. "There are no excuses for failings in standards of care, or for not treating people with kindness, dignity and respect. We expect providers and commissioners to meet high standards at all times and for the CQC to take firm action where services are found to be below standard," says a DH spokeswoman.

Earlier this month, the National Institute for Health and Clinical Excellence (Nice) became the National Institute for Health and Care Excellence and began a major new programme of work to bring high-quality guidance and standards to the social care sector. Part of this programme includes issuing quality standards for social care designed to help support people with dementia to live well. Launching the standards last week, Gillian Leng, director of health and social care at Nice, said: "It will enable individual care practitioners, care homes, and other social services to ensure that people with dementia have an enhanced quality of life, a postitive experience of their care and are protected from avoidable harm."

Yet the standards fail to address the problem of care homes dumping residents with dementia at hospital. After I complained to the chief executive of Madge's care home group, Sanctuary Care, which runs 50 homes in the UK, it, at least, has now got a protocol in place to ensure residents who go to hospital have a checklist of things they need to take with them. But the bigger issue of elderly care home residents being sent alone to A&E remains something that looks unlikely to be resolved any time soon. Sanctuary says it cannot send "escorts" to hospital with residents because it would leave the home short-staffed.

Another large care home provider, Shaw Healthcare, which owns 90 residential homes, says the acuteness of a resident's dementia would determine whether they are escorted on hospital visits, or sent alone.

Martin Green, chief executive of the English Community Care Association, the industry body for independent care services in England, believes the issue deserves greater attention, but he lays the blame firmly at the feet of local authorities which, he claims, are providing inadequate funding for care home. "It's is an issue that hasn't been properly brought to the attention of the authorities," he says. "The problem of residents going to hospital alone stems from the way care home services are commissioned by local authorities, as it doesn't allow for staff to leave the care home."

He says there is a clear message for service commissioners. "Some sort of protocol needs to be introduced, and the care home system has to start planning for hospital visits".

Some of the solutions being mooted include using volunteers, or calling on charitable organisations to accompany care home residents to hospital.

But, at the R&RA, Downey refutes the claim that the problem boils down to lack of funds. "This isn't just about strapped care homes not being able to afford to spare a staff member – this is happening in homes charging £1,200 a week, as well as those charging £400," she says. "It's about a monumental lack of care, the very thing they are supposed to be providing."