Ward G1 is a dementia assessment and treatment ward for individuals with dementia. The people who are referred to our service usually have a diagnosis or a working diagnosis of dementia; and will most like be experiencing distressing behavioural and psychological symptoms associated with dementia. There may be underlying physical health problems, which may exacerbate the level of distress the person is experiencing. Often, there is significant carer distress and usually a crisis occurs at the person’s usual place of residence; and when all other options have been explored and exhausted, this culminates in admission to G1 ward. The way in which people’s unmet needs and causes of their distress are assessed and managed on G1 plays a key part in that person’s road to recovery and the restoration of their wellbeing.
Ward G1 is a dementia assessment and treatment ward for individuals with dementia. The people who are referred to our service usually have a diagnosis or a working diagnosis of dementia; and will most like be experiencing distressing behavioural and psychological symptoms associated with dementia. There may be underlying physical health problems, which may exacerbate the level of distress the person is experiencing. Often, there is significant carer distress and usually a crisis occurs at the person’s usual place of residence; and when all other options have been explored and exhausted, this culminates in admission to G1 ward. The way in which people’s unmet needs and causes of their distress are assessed and managed on G1 plays a key part in that person’s road to recovery and the restoration of their wellbeing.
It is unrealistic to expect recovery from the illness of dementia itself, but with sensitive and skilled intervention from the G1 multi-disciplinary team people can be eased of their emotional, psychological and physical distress up to the point where they may be well enough to return to their usual place of residence, or to an alternative environment which can meet their needs. Families and carers are usually very appreciative of the support and encouragement they receive from the G1 team, and express their gratitude and satisfaction at the service we have provided to their loved ones.
Quotes from compliments we have received are detailed below: “We can’t thank you enough for all the expert care and kindness you’ve shown my Mum over the past months. We will never forget and always appreciate you all.” “Thanks to all for looking after Peter. I hope he settles in his new home as well as he did here. With gratitude.” “We want to thank you for all the care and support you have given Ted during his stay on G1. He has gone through some difficult periods and you have always treated him with patience and respect. In addition, the support you have extended to me and our girls through this difficult time has helped us to cope and we knew you were all there for us if we needed advice. We will miss you all very much and hope the NHS Trust knows what a fantastic team you are. With our sincere thanks.” Helping a person to reach this level of stability and wellbeing, and having been able to support the person and their family through what is often a very stressful and worrying period is hugely satisfying and fulfilling for the ward multi-disciplinary team.
We know that recovery from dementia is not possible, but we can help in so many other ways that impact positively on the person with dementia and their families. It is wonderful to see a person who was distressed and in crisis when they came to G1, some time later, engaging with others and interacting with their environment in a positive and meaningful way. We use technology such as remote bed and door alarms, radio buzzers and intercoms to help to target intensive nursing observations optimally as their overuse is expensive and invasive for patients. Use of (computer) tablets, simulated presence therapy and Paro-seals all demonstrate the most proactive introduction of technology to optimise patient care and quality of life. Each discipline’s input is honed to their skills to heighten efficiency. Clinical outcome data is crucial to demonstrate quality improvement and serious untoward incidents have reduced from an average of 5 per year to 0 so far.
The low use of antipsychotics is accurately targeted and supported by the use of objective rating scales of improved target symptoms versus side effects. We now routinely administer rating scales to objectively quantify clinical outcome including using the neuropsychiatric inventory on all patients after admission and pre-discharge. At G1 we are passionate about caring for people with dementia in a holistic and person centred way. We take pride in our care and also how we care and support the carer/relative. I am proud to say that we offer quality care that we would want either for ourselves or our parents.
What makes your service stand out from others?
At G1 we actively celebrate our patients lives in the here and now and encourage people to live as well as they possibly can with their dementia. We pride ourselves on being an extremely welcoming workforce and environment. The feedback we receive from visitors is always positive and we are told that the ward has a warm and friendly atmosphere. Visiting and new staff receive a thorough induction and often wish to return to us. Students feel thoroughly supported and report that our mentorship and guidance is a hugely positive experience for them. Our relatives and carers provide us with some fantastic feedback and we actually have the largest amount of patient and carer feedback in the Trust.
G1 ward plays a key role in challenging the stigma associated with dementia and mental health. The team are proud to ‘think outside the box’ and explore tools which can reduce distressed behavior and enhance well-being. The team embrace positive risk taking in order to meet the holistic needs of our patients. For example, getting people outside into the open air participating in meaningful activity. Adapting tasks to maximize engagement and stimulate can also help tackle stereotypical attitudes towards ageing. Being outside has huge benefits to physical and mental health.
Our Occupational Therapist recalls: “During a two hour session of horticulture therapy recently observed a man with very poor short term memory function. He retained instruction, maintained focus and enthusiasm. As I thanked him for his efforts he said: “No, thank you, it is so nice to be of use. I know I’m doo lally but I still have my sense of humour, that never leaves.” With Dementia often comes a change in presentation. The shy reserved person is now the extrovert. This can enable self-expression and the opportunity to try the previously unexplored. Using humour can also help people to remember. This gentleman has begun to remember our time spent together in the garden as something positive and now offers his services as soon as he sees me.”
Our ward is a friendly, welcoming environment which plays a big part in educating students of various disciplines. In addition to traditional health care students we have also hosted public health, history and music students. We welcome volunteers and have facilitated placements for a number of service user volunteers. The Sheffield Music Group are good friends who frequently share their musical talents. G1 Ward celebrates the individual. We place emphasis on a persons abilities and tap into what is important to them. This helps empower them and restores their sense of purpose and self-worth. In terms of staff we seek out their skills and interests and then give them permission to incorporate these within their role. The ward team embrace the concept that activity should be everyone’s business regardless of their role, for example creating Singing and Reader champions within our team of Support Workers and involves housekeepers in craft activities.
An outcome measure used frequently on our ward is photography. The camera captures moments of joy and provides concrete evidence of people ‘living’ with Dementia. Images are displayed throughout the ward and shared with carers. They help both to orientate patients and reassure patients and carers that wellbeing is achievable. As the majority of our patients move into 24 hour care it is essential that we work with future care providers in advance and throughout transition. Sharing those personal details about an individual early on and being physically present to educate others about them and make the person feel safe has aided numerous successful discharges. The team run a regular G1’s Got Talent and other regular themed events which offer patients, staff and relatives the opportunity to be creative and express ourselves. Collaborating on these exciting projects results in positive shared experiences between patients and carers and also has a significant impact on staff morale.
Staffing
All G1 we have an excellent record of mandatory training. We also ensure that all staff have regular supervision and that their yearly appraisal is reflective of supervision outcomes. Staff are encouraged to look at their professional development and supported to partake in any development that will enhance personal skills and therefore increase productivity and the quality of our patient care. We treat staff fairly while also meeting the needs of the Ward in a safe and efficient way. G1 is a difficult but rewarding place to work. However, there are times when we are extremely busy or have a particularly unwell patient exhibiting very challenging behaviour. At these times staff morale can drop very quickly and it is important to recognise this and act upon it in a timely manner.
Working collaboratively between our wonderful Occupational Therapist and the Psychology department, G1 provides Reflective Practise sessions for staff. This is an arena in which it is safe for all staff of different areas to express their thoughts, worries, fears etc in a non judgemental manner. The Team Manager actively encourages staff to attend these sessions and works out on the ward to enable them to do so. At G1 we take full advantage of the staff wellbeing services on offer in the Trust and regularly refer staff to the Employee Physiotherapy Service and the Workplace Wellbeing (counselling) service as needed. We are proactive in encouraging staff to access these services early as a preventative measure to support their wellbeing.
Recruitment and retention is a massive national and global issue and G1 is no exception. As a result of the shortage of trained nurses, the Team Manager, alongside senior Management, has looked at other ways to recruit. Ward G1 will actively participate and encourage the Nurse Associate role and the Team Manager is currently looking at the Mental Health Practitioner Occupational Therapist role in a bid to bridge the gap and offer more support to our trained nurses. G1 embraces a culture of valuing all staff and supporting and encouraging them to fulfil their potential, explore new ways of working and learn and develop. As well as corporate training we ensure that regular CPD sessions are held to upskill locally and invite a wide variety of speaker to come and share their best practise with us.
Who is in your team?
1 Ward Manager 2 Deputy Ward Managers 14 Nurses 2 Activity Support Workers 1 Occupational Therapist 21 Support Workers 1 Consultant Psychiatrist 1 Administrative Worker Housekeeping staff who are shared across the site
Working together
G1 ward works in close partnership with the Dementia Rapid Response and Home Treatment Teams, (DRRHTT), and the Mental Health Liaison Service based at the acute general hospital. We take referrals from DRRHTT and from the Liaison Service. If DRRHTT admits a person to G1 they will remain in contact for a period of time and sometimes do in-reach work with individual persons; and they often play a large part in facilitating and supporting the successful discharge of patients back into the community.
The ward team work closely with the local branch of the Alzheimer’s Society and help support their local SHINDIG (Sheffield Involvement Dementia Group) events by attending and sharing best practise with people with dementia and their carers. G1 endeavour to foster good working relationships with Social Workers and Social Services, and work together to ensure timely and appropriate discharge destinations for our patients. We work hard in maintaining our relationships with our colleagues in the acute general Hospital and work collaboratively to achieve the best outcome for our patients. G1 has an excellent relationship with the Chaplaincy Service and have several visits per week from our Chaplain. She loves to spend time with us on G1 and aside from her duties to provide spiritual sustenance to our patients, she loves to get involved in our activities and can often be found sitting round a table with us making collages or being artistic. As well as our ward Chaplain we also work collaboratively with community churches and have displayed G1 art in an exhibition at Penistone Church.
We also work collaboratively with the diocese of Sheffield and other dementia services to hold an annual South Yorkshire Dementia Art Exhibition each July. This year sees the 10th Anniversary of the exhibition. We have strong links with our local Brownies troop who visit us regularly to talk to our patients and to perform for them. This helps to educate the rising generation about dementia and our patients love the connection with the children. Many of the Brownies have grandparents or elderly relatives who have cognitive impairments and the Brown Owl has shared with us that spending time with us on G1 has developed the Brownies’ understanding of dementia and taken some of the ‘fear’ away about the behaviours that their own loved ones may exhibit at times.
The staff team is also fully committed to sharing their skills and knowledge with care homes in Sheffield and South Yorkshire as well as staff in the acute general hospital via training events and presentations to help break down the stigma and misunderstandings around dementia and train people to be able to respond better to the challenging and complex behaviour that people with dementia can exhibit. In recent years we have built strong links with Sheffield’s Universities, Age UK and various people within ‘the arts’ community. This has resulted in a series of reciprocal relationships which benefit these organisations as much as our patients and staff and help address misconceptions and stigma around dementia.
Do you use co-production approaches?
Individuals with dementia and their families and carers are central to the service we provide on G1 ward. We aim to promote person-centred care interventions in all aspects of a person’s individual care needs. We aim to focus on the ‘personhood’ of patients, and learn as much as we can about individual biography, background, family, life and work experiences. G1 uses various means to gather this information, and families are asked to play a large part in this. Patients views, life stories and interests are recorded in care plans and in using “This is me” and “My life story” which is an Application on the Digital & Reminiscence Technology (DRT) that we use. G1 is passionate about providing meaningful occupation and activity and ensuring that this is available to our patients at all times and not just within 9-5 constraint. We also believe that activity and occupation is everybody’s business and ensure that all our staff are trained in how to use our DRT and that resources are always available to provide the activities.
Most recently we have begun to use digital technology to record short clips and photos of relatives visits. This is proving to be of great benefit in reducing patient distress. Patients often don’t recall that their relative has visited recently and this can cause them acute distress. We have found that being able to share the photos or a short video clip of their relative’s most recent visit provides reassurance and support to patients. Relatives and carers have also provided positive feedback about this innovation. We work in partnership with the Alzheimer’s Society to run a monthly support group for patients’ families; which provides an opportunity for education and information sharing about the effects of dementia, and provides a safe and supportive environment for carers to share their views in confidence. This is facilitated by senior staff and the Consultant and has received excellent feedback. A recent survey showed 100% positive feedback from carers about the ward environment. Feedback of outcome data to staff reinforces good practice development.
Do you share your work with others?
The ward team are fully committed to sharing good practice and both learning from others and allowing others to learn from them. The ward team organised and facilitated a ‘Trent Dementia Seminar – Royal College of Psychiatrists’ event entitled ‘How we can make our dementia assessment wards function better’. Every area in the Trent region attended and the evaluation feedback was extremely positive. The ward team also presented at the Annual Royal College of Psychiatrists Old Age national conference and has also presented internally (within the Trust) at the Quality Improvement Group. The Ward Manager is a member of “My Improvement Network” and regularly speaks around the Country to share best practice and network with other Trusts and Practitioners. She also partakes in careers seminars and collaborates with the University of Sheffield in both the interview process of student nurses and in teaching about dementia.
The Team’s Occupational Therapist regularly shares innovative practice from the ward via conferences and visits across the UK and Ireland. We were the first NHS Trust in the country to introduce PARO Seal – an advanced interactive robot with tactile sensors which responds to sounds and can show emotions such as surprise and happiness and this innovation was directly as the result of the Occupational Therapist’s research and commitment to making connections with patients with dementia. The Occupational Therapist went to Denmark to receive training in the PARO Seal technology. She said: “PARO helps calm and relax service users and can distract and reassure them if they are distressed by situations such as having their blood taken or being assisted with self-care. It is helping improve service users’ communication and interaction. One man, whose condition means he is often dealing with high levels of distress, sat in the garden with PARO and, when she visited, his wife couldn’t believe how contented he was.” The ward has hosted many visits from other Trusts and care home across the entire country who were keen to seen PARO Seal in action and now the use of this companion robot has spread widely, benefiting patients greatly.
The Ward Manager also presents at conferences and workshops on the ‘My Life’ reminiscence and communication aid for MyDementia Network. The ward team deliver an ‘Essential skills in dementia care’ course to colleagues across the Trust and staff in partner organisations including local care homes. The most recent course ran in April 2018 and over 50 people attended. Feedback from the course included: • Very interesting and thought-provoking presentations. I have come away with lots of ideas to share with my team. • Excellent day. Very informative. Engaging hands on activities. • Information helpful on how dementia is diagnosed and what is available within Sheffield. Helpful talk on distressed behaviour and tips to help. Useful info given on activities with dementia clients. • Enjoyed the anti-psychotic medication, how the consequences prescribing could have negative effect on their health. • Enjoyable as well as very informative. • Fantastic training day packed with content and good practice to take back, definitely will be contacting speakers for further information especially activities. • My grandad has Alzheimer’s and today has helped me better understand some of his behaviours, and at times has left me feeling very emotional when fondly remembering some of his stories. I don’t specifically work with dementia patients but regularly see them. I find a lack of understanding towards dementia sufferers very frustrating. I look forward to feeding back what I have learnt to my colleagues in a bid to rectify this. •
Very informative and well presented. Good knowledge and understanding of dementia from all of the presenters/speakers. The theatre performance was amazing. Emotional and thought provoking. Top training session. Reduced me to tears. • A very informative, useful and enjoyable day that will have a significant impact on my daily practice. Brilliant. • What an amazing day, very informative, entertaining. Best dementia course I’ve ever attended, loved every minute. • Excellent presentations at a level that is appropriate for all. The enthusiasm from the people who delivered the course was fantastic. Really enjoyed the whole day. Thanks. • After attending this training this will enable me to support my mother pro-actively improving her quality of life. Today will change both my life and my mum. I thank you all for your contribution to change people’s lives. Best training day ever. Really enjoyed it. Learnt loads. • Well I gained knowledge and new skills in this session. I am going to apply in my daily practice how to approach and deal with dementia patients. • Very informative. I have thoroughly enjoyed today. Lots of advice and suggestions provided. Very well organised.
Outcomes and evaluation
We use the Neuropsychiatric Inventory as our PROM. All patients are assessed after one week on the ward, and at discharge. Most patients show an improvement, and research carried out last year, by Junior Doctors on rotation, indicated that the higher the NPI score on admission the more we could expect it to fall. When we achieve only a marginal improvement in NPI score this usually tallies with other indicators that the patient continues to need a high level of on-going care. On ward G1, A lot of thought was taken to find the right tool to measure patient outcome. We use the most valid tool for neuro psychological conditions which is the Neuro Psychiatric Infantry (NPI). Statistics from the NPI on both admission and discharge taken over a period of 2 years show: • The average NPI was 53 on admission and average on discharge was 25 • This is significant that P is less than .001. • This is highly significant and indicates beneficial treatment effect. • The most ill people have the best outcome. • This change correlates and represents improvements in quality of life for index patients.
We are only occasionally able to use CROMs due to the high level of cognitive impairment our patients present with. However, we can and have used CROMs if at all possible. Sometimes this takes a lot of thought regarding the communication method, but it has invariably been worth the effort. The service provided on the ward and the ward team have been reviewed by the Care Quality Commission and the Care Quality Commission Mental Health Act inspections. Regular infection control audits are undertaken as are PEAT inspections and Eliminating Mixed Sex Accommodation (EMSA) audit. A nutritional audit for patients is regularly undertaken as are staff surveys and audits of patients detained under the Mental Health Act. All incidents are reporting in line with Trust guidelines and are fully investigated. Where issues are identified, remedial action is taken and, where appropriate, action plans are put in the place and actively monitored. The team are fully committed to obtaining feedback on the service they provide from patients, relatives, colleagues and external bodies and pride themselves on listening, acting and improving.
Has your service been evaluated (by peer or academic review)?
The service scored 100% in cleanliness, disability and privacy, dignity and wellbeing categories in the most recent Patient Led Assessments of the Care Environment (PLACE) inspection. The service also scored over 90% in all other categories. Well above the national average. The Service was rated as ‘Good’ by the CQC in the most recent inspection. Feedback from the most recent CQC inspection highlighted: “Staff had developed a horticulture group; some of the patients had grown their own tomatoes and strawberries. Patients had access to what staff called a ‘man shed’ and a greenhouse with some basic gardening tools. There was G1’s got talent which took place every two months, which staff and patients could take part in. There had been a Buddy Holly night and an Elvis night. Carers and patients from other services had been invited to attend.
Staff on G1 ward used simulated presence therapy which had been reported to reduce levels of anxiety and challenging behaviour amongst patients with dementia. The intervention consisted of playing a recording or video of patients’ friends, carers or relatives. Staff said playing this to patients often helped to soothe them. There was reader champion whose role it was to read to patients. Staff at G1 had been supported to visit Denmark to be trained on the ethical delivery of ‘paro seal’. The ‘paro seal’ was a therapeutic robot baby harp seal, which was intended to be very cute and to have a calming effect on and elicit emotional responses in patients. Students had visited the ward to see the ‘paro seal’ in action by staff. This meant students learnt about dementia and helped to reduce the stigma. Empathy dolls were used well on the ward. Empathy dolls have been found to reduce the stress in some dementia patients. During our visit, one patient kept an empathy doll in their bedroom and staff said this had helped the patient. We saw technology in the form of a large tablet being used on the ward. There were applications on the tablet to enable karaoke, quizzes and calming images. On the day of our inspection the tablet was displaying a flickering candle with calming music.“
Development and sustainability
The ward team and the senior leadership within the Directorate are fully committed to ensuring that the high-quality service provided on the ward continues and that continuous quality and service improvement is part of the ongoing programme of development. The Directorate has succession plans in place to ensure that the team continues to function should the current management leave.
What aspects of your service would you share with people who want to learn from you?
Dementia in-patient wards assess and treat some of the most distressed patients we see, with severe and challenging behavioural and psychiatric symptoms of dementia. Functioning optimally these wards have great potential to reduce distress and improve quality of life for patients and their families. Staff morale can dip, impacting on patient experience and leading to complaints and poor outcomes.
Several years ago, we introduced a new management structure has been to improve senior clinical leadership of the ward team. This is working very well and is considered a very positive change. Plans have been implemented to offer development opportunities to staff nurses and support workers. Recruitment of staff, and a review of the skill mix has enabled higher ratios of registered staff on the ward. Work continues to maintain and improve the ward internal and external environment to meet the changing needs of our service users.
Some major and extensive building alterations and additions have been implemented. Work continues to be on-going at present. Meaningful activity and engagement for our service users has been maintained and built upon, so that more opportunities are available for therapeutic interventions for service users to access, and greater opportunities created for the staff team and families to become involved. Some major therapy equipment purchases have been made to facilitate this. Training and supervision in dementia care, that is both meaningful and practical for the staff team has been introduced and has been given greater priority. Feedback from the ward team for such ‘in-house’ and external training and development opportunities is favourable. Negative views about dementia in-patient units and poor staff morale can potentially contribute to a sub-optimal quality of care and outcome.
We introduced a robust, forward thinking, compassionate, person centred model of care. All care on the ward is now overseen and co-ordinated by a senior nurse. Frequent staff training focuses on models of dementia care which are reinforced in every multi-disciplinary team meeting and staff handover. Each discipline’s input is considered. Use of technology was proactively introduced and 24/7 Consultant gate-keeping of new admissions was also introduced. This has positively impacted on length of stay, occupancy rates and increased staff morale.
A series of team away days was held last year and the following feedback was received from staff: ‘Brilliant work on G1 which will continue to improve.’ ‘I feel today’s training has been very good and informative. I feel the ward runs excellently and has a very good team.’ ‘I have found today’s session very informative and also very encouraging that developments on the ward are being taken very seriously which will further improve the care that we are able to provide for our patients. It is also pleasing to be given the impression that you are a valued member of staff and that your work is valued and appreciated.’ with patients and carers is now more proactive and is included in care plans as are formal, regular meetings with relatives.
New educational seminars for carers receive excellent feedback. Verbal feedback from a relative on the Carer’s Support group found the meetings to be: ‘A great boon. Very helpful and valuable, especially the verbal and written information given at the meetings. Helps families to learn what is effective and available to help their relative. When choosing a care home, the meetings have helped families to look at care homes, for example, what questions to ask, and to look at staffing levels and training, and turnover of staff in the care home.’ Documented compliments have increased from 0 to 125 per year. Serious untoward incidents have reduced. Low use of antipsychotic is specifically targeted and rating scales of target symptoms versus side effects are administered. Clinical outcome data now shows an average reduction in the neuropsychiatric inventory (NPI) score of 70%. The average of 65 on admission is reduced to an average of 19 pre-discharge. All data indicates we are admitting the most distressed patients and are now providing a high-quality team based intervention of substantial benefit to patients.
Further Information
Population details
City of Sheffield and surrounding South Yorkshire and North Derbyshire area
Size of population and localities covered:
approximately 600,000
Commissioner and providers
Commissioned by (e.g. name of local authority, CCG, NHS England): *
NHS Sheffield Clinical Commissioning Group
Provided by (e.g. name of NHS trust) or your organisation: *
Sheffield Health & Social Care NHS Foundation Trust
