Can Yoga benefit people with dementia in care homes?

Introducing physical activity into the routine of those living in residential care homes can be seen to be beneficial to both them and those around them. Many care homes already carry out regular sessions of light, gentle exercise where appropriate, and anecdotal evidence suggests that they see improvements in residents mental as well as physical well-being.

However, the limitations of many elderly people’s physical capabilities mean certain exercises can be unsuitable or even dangerous. It is therefore very important to not only understand the benefits of exercise, but to also know which exercises are suitable for a range of people.

One form of exercise which could be suitable for most people – including the elderly and physically challenged – is yoga. Yoga can be practiced on many different levels, and in its basic form consists of simple breathing and meditation techniques, combined with the adoption of specific body postures of varying degrees of difficulty.

According to Dr Laura Phipps from Alzheimer’s Research UK yoga can be a positive way to maintain health and wellbeing. She says “that we all know that keeping active is important as we age, and evidence increasingly suggests it could be beneficial for people with dementia”.

She goes on to say “While there is a growing body of evidence to suggest that physical activity is beneficial for cognition, it’s still unclear what type and intensity of activity could be most important.”

The Department of Health (2011) recommends that older adults spend at least two and a half hours doing moderate-intensity aerobic activity every week and muscle-strengthening activities on two or more days a week.

However, many residents in residential care settings perform very little physical activity (Benjamin et al., 2014). Regular tailored yoga sessions are potentially a safe and effective way of helping elderly residents work towards these recommendations.

Yoga and mindfulness based exercise has been proven to be an effective intervention for a number of common conditions that are present in residents living with dementia such as: anxiety, depression, co-ordination and balance problems (McCall, 2007).

There are also a number of other studies showing initial positive results of chair-based yoga on people with Alzheimer’s disease. McCaffrey et al. (2014) showed that older adults with severe Alzheimer’s disease who participated in an 8-week tailored yoga programme showed improvements across a range of physical tests (walking, gait, speed and balance).

Hariprasad et al. (2014) show yoga based interventions appear beneficial to improve several domains of cognitive function in older people living in residential care homes. A recent (2016) UCLA study has shown that a three-month course of yoga and meditation was found to be even more effective than memory enhancement exercises for managing mild cognitive impairment.

Yet despite this growing evidence, to date few residential care homes offer yoga as a regular activity. This may be in part due to lack of awareness of, or scepticism about, the benefits of yoga, or practical difficulties in employing and paying for a regular yoga teacher.

A new project has recently seen yoga sessions introduced into care homes in Britain, with resounding success. The 18-month project was carried out by Tania Plahay, a yoga instructor, and was funded by the Foundation for Nursing Studies with the backing of independent care services body Care England.

During the project, Ms Plahay taught basic movement and relaxation techniques to groups of residents in a care home. The yoga instructor had been prompted to offer the service following her experiences as a volunteer at residential care homes and after her disappointment at the lack of social and physical activity in certain residential settings she had visited while looking after her relatives.

Although no scientific study was made of the results of the yoga project, both the residents and the staff involved reported positive effects.

One of the home’s activities co-ordinators said that residents who had taken part were more relaxed and less agitated following the sessions, while another reported increased level of engagement and improvements in cognitive and memory skills in those with dementia.

It is this positive impact on people with dementia which has been attracting most interest, adding as it does to a growing body of evidence which points to the fact physical activity can benefit cognition as well as physical well-being.

Being able to reduce the levels of anxiety and agitation often experienced by those with dementia would be high on most medical professionals’ wish lists.

The director of research at the Alzheimer’s Society, Dr Doug Brown, welcomed the project, saying although there was little research into the specific benefits of yoga to those with dementia, it was certainly an area worth exploring.

The chief executive of Care England, Martin Green, agreed, saying there is a real need to ensure people in care homes do not live sedentary lives.

Summary

There is growing evidence that physical activity can be of benefit to people who live in care homes. The question is can the benefits of physical activity be extended to improving the quality of life of people with dementia? The yoga project carried out by Tania Plahay is to be commended in that it provides some anecdotal evidence that yoga sessions resulted in an increased level of engagement and improvements in cognitive and memory skills in those with dementia. This work should be followed up by further scientific research to explore the positive effects of yoga for those with dementia who live in care homes.

For more information: Yoga for People Living with Dementia in Residential Care Settings

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Do we need a more balanced approach to Care Quality Commission Inspections?

The Care Quality Commission have recently completed the inspections of some 24,000 different locations providing adult social care. It published its State of Adult Social Care report covering 2014 to 2017 and clearly feels empowered and emboldened to draw conclusions from the inspections it has conducted.

Nursing Homes are singled out for particular mention in the report with one in three failing to be rated at least good overall. Across all adult social care providers one in four providers failed to be rated as at least good for the question ‘is the service safe?’ These conclusions are based within the confines of CQC’s inspections of providers, which by their very nature, are subjective opinions on service provision.

Given the continual stream of CQC negative reports about the performance of Adult Social Care and the subjective opinions of inspectors; is it not time that we started to look for a more balanced approach to the results of inspections that takes an objective account of the provider’s position. Is there not a need for a balanced, rounder, picture of care to come into the public domain. This should include fair due process which acknowledges that providers have rights, too.

In practice, we see the rating system being reduced to a binary judgement in the public discourse on care: so, we have ‘good and outstanding’ or ‘failing’ homes. This is simplistic and adds to the negative portrayal of the sector that is making it so hard to recruit the care managers and other care staff that are needed. The sector cannot survive on a diet of blame and criticism while the longstanding structural issues remain unresolved.

Providers who lack confidence to challenge inspectors

There is among some providers of adult social care a natural deference to the CQC inspector. This is in part due to the threat to their business of a damming report. As such findings made within reports, which may be factually inaccurate or misleading, go unchallenged. If a provider demonstrates a reluctance to challenge the findings of an inspector, then the ‘true’ picture of care at a location is inaccurate. This is not a criticism of CQC but a presentation of the other side of the argument which may go unheard. Of course, it is difficult to objectively draw out this information should a provider remain silent on challenging the findings of an inspector’s report, but this should be considered by managers when reading their report.

Challenging findings

If a provider chooses to challenge the findings of an inspector, that same inspector will review the comments provided before dismissing or adopting the information provided. CQC may say that the matter is resolved by a report being reviewed by the inspectors’ manager. That is not independent, the manager should and will support those they manage; but of more importance that review occurs before the provider has put its case. It is a flawed process.

Should the inspector refuse to take into account issues raised by the provider there is little in the way of further challenge that can be made. There is the process of reviewing the ratings of a service but these will only be challenged on the narrowly defined grounds that the incorrect process was followed by the inspector. A provider may challenge by way of judicial review but this is time consuming, high risk and expensive. According to Ridouts Solicitors, the most effective way to challenge CQC is to provide commentary on the report and append relevant evidence which supports the providers’ objections.

Subjectivity of reports

Inspection reports are by their very nature highly focused on the inspection visit, although some underlying background information is used to inform findings. They remain a snapshot of the service in question at the specific point in time when the visit occurs. They are limited by the competence or otherwise of the inspector and by the provider’s presentation during the visit and the provider’s resolve following it. As such, the relevance of ratings and findings drawn from inspection reports can be questioned, especially when those findings are used as the basis for a change in strategy.

There is no evidence of robust challenge by CQC to its inspectors’ findings. Inspectors are, in effect, encouraged to believe that they are always right.

If we have two providers: one confident in its resolve and effective in its communication who successfully challenges CQC’s findings; set alongside the same provider who accepts CQC’s findings without challenge: Both of whom, provide exactly the same level of care, the only difference is the approach of the provider. The pertinent point is that the quality of care between provider one and two is at the same level; but CQC would ultimately rate each provider differently depending on their respective responses to its draft inspection report.

Summary

The latest report on the state of adult social care up to 2017 published by the CQC provides more negative evidence of the performance of the sector to the public. It can be argued that the report is based on the subjective opinions of inspectors, and does not give a balanced independent view of the sector. There is evidence that mangers are reluctant to challenge inspection reports for fear of poor ratings and damage to their business.

This blog article is not meant to be critical of the CQC but a call for a more objective approach to inspection where providers can feel confident that in challenging inspection reports their views will be heard independently. We may then get a more balanced approach to inspections and ratings.

Acknowledgement: Ridouts Solicitors

Albert Cook Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Using technology to support people with dementia

I recently wrote a blog on technology in social care services (early August). Last week I came across a report produced by the Social Care Institute for Excellence into using technology to support people with dementia.

It seems therefor opportune to take time to expand on the theme, especially in the area of dementia where knowledge of any new innovation or report on the use of technology can only be of benefit to some service users and staff.

The SCIE report stresses the importance of staff preparation before engaging the service user in the use of technology.

Making sure the right equipment is available

Whether it’s a desktop computer, tablet, mobile phone or laptop, staff should make sure that they have the equipment you need for a particular activity. The ‘Dementia and digital’ report from the Good Things Foundation (formerly Tinder Foundation) said that tablets are the most effective devices to support digital skills. It’s helpful to use the technology that the person is most familiar with.

Ensuring the right connection

Some activities need an internet connection and others don’t. It is important that staff know if they need to have a reliable broadband connection, as it’s frustrating if the connection is slow or keeps breaking up. Staff can get a broadband connection through cables or wireless. Wireless is more flexible but does not always work well in some larger or older buildings. A ‘dongle’ can be used which connects an individual computer to the internet as and when you need it. These kinds of solutions don’t work so well in areas where mobile phone signals are weak however, and they are usually too slow for downloading videos or films.

If staff are using equipment powered by batteries, they should make sure these are fully charged. Audio speakers might be necessary for those with hearing loss as the volumes on tablets in particular can be quite low.

Taking a person-centred approach

Do:
• Do focus on the person’s abilities, not their impairments.
• Do remember engagement can be at any level, from sensory stimulation from a video, game or piece of music, to writing emails.
• Do pay attention to each individual’s preferences and capabilities. For example, some people may be able to touch type, and others will never have used a keyboard. A person with arthritis may not be able to use a mouse. Past experience and current capacities will affect the person’s level of engagement.
• Do talk out loud about what you are doing as a running commentary keeps people involved. Remember that things that seem obvious to you may not be to people who are unfamiliar with technology.
• Do make sure carers and family are on board particularly if the technology is going to be used to communicate with others.

Don’t:

• Don’t make prior assumptions about what someone can or can’t do.
• Don’t take over. Wherever possible, the person with dementia should lead the activity with the carer’s support. This can be a fine line in technology but the key is to match the activity with the person’s capacity. You might want to initially introduce an iPad by saying ‘Have you seen this?’ Even if people cannot engage directly with the technology, you can still offer them choices about what you are doing and how.
• Don’t force the issue if the person is not interested. Engagement will vary from person to person, from day to day and at different times of day. Be led by the person.
• Don’t go on too long – it is always good to break activities into small steps. As a rule you should limit activities to 20 minutes or less, unless you have a good reason to carry on.
• Don’t set people up to fail. Don’t suggest complicated tasks if people do not have the capacity to engage with them.

Using technology will not suit everyone. Not all staff will feel comfortable and people with dementia may be resistant. It’s important that this is not seen as a failure. Technology is only one way of engaging people and someone’s interest may fluctuate. Be patient. As with all person-centred care, the wishes and preferences of the individual are paramount.

Introducing technology

Decide beforehand on a simple activity that involves people, for example, playing a game such as solitaire (for an individual) or bingo (for a group) or finding some music on the web. Using a desktop computer may have associations with work or bureaucracy for some people. Consider starting with something that looks more commonplace such as a digital camera. Tablets such as iPads can be useful, as many people do not think of them as ‘computers’.

The authors of the report suggest that technology has so much to offer people living with dementia and their carers including: access to information, advice and entertainment as well as reassurance for a carer who does not live near a loved one.

Summary

The use of technology to engage people who live with dementia can be seen as a step forward and something social care services will need to harness now and into the future. It is not a panacea that can replace the comfort and attention to needs of caring staff. However, used sensitively and thoughtfully, technology enhances rather than replaces human relationships and interactions.

The authors of the Social Care Institute for Excellence report ‘Technology supporting people living with dementia and their carers’ is recommended reading for those social care services providing dementia care.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

Transfer delays from hospital to social care impacts on mental health and wellbeing of older people

Delaying transfers from hospitals to social care is having a tragic impact on the mental health and wellbeing of older people

The financial crisis engulfing health and social care risks driving the NHS and local government further apart.

A recent report in the Local Government Chronicle has revealed that ministers have instructed 47 of the 152 councils running social care to reduce delayed transfers of care from hospitals attributable to social services by 60% or more, based on their performance in February.

The accompanying letter from the Department of Health and Department for Communities and Local Government made clear that councils that fail to hit their target risk being penalised in the allocation of the £2bn of additional social care funding announced in the budget. These threats are hardly likely to improve the relationship between the NHS and Local Government.

The Local Government Association has already withdrawn support for the Better Care Fund planning guidance for this year, which compels councils to focus on reducing pressure on the NHS irrespective of their local priorities.

This raises two crucial issues: whether this is a sensible way to tackle delays in transfers of care, and what this increasingly fractious debate says about relations between health and local government.
According to the official statistics, there were 178,400 days lost through delays in May. Around 55% were attributable to the NHS, 37% to social care and the remainder had shared responsibility. Delays started rising sharply in 2014, reaching a peak of more than 200,000 in October 2016.

The human cost is immense, paid in the physical and mental wellbeing of mostly older people deprived of the comfort, security and independence of home.

But the underlying causes of delayed transfers of care are complex, and reducing it to a simplistic blame game makes it more difficult to identify solutions.

For example, could an admission have been avoided? Was the frailty team engaged as soon as the patient arrived to ensure they were kept as active as possible, thereby reducing their eventual care needs? Was discharge planning begun soon after the patient arrived? Have delays in medical care, such as waiting for scans or test results, increased their care needs by reducing muscle strength or increasing confusion? How well are social care teams integrated with hospital operations?

Slapping an arbitrary target on councils contributes nothing to solving these issues; it simply exacerbates underlying tensions between health and local government.

Councils always resent being ordered about by ministers, and are particularly sensitive over anything to do with the NHS. Many councillors are bitter that their ability to implement severe cuts is rewarded with a requirement to do more of the same, while the NHS is rewarded for going into deficit with more cash. Now even the rare good news of the additional social care funding is being made conditional on helping the NHS.

This dispute is undermining the substantial progress made over the last two years in strengthening collaboration between health and local government. Sustainability and transformation partnerships (STPs), whatever their shortcomings, mark a determined effort by NHS England to involve local politicians and officers in key decisions around the future of local services. The Greater Manchester devolution deal, and now the ambitious agreement for integrating health and care in Surrey Heartlands, demonstrate a willingness to take bold steps towards local empowerment.

But in issuing ill-considered orders around the Better Care Fund, ministers are reverting to old habits of command and control, which are wrong in principle and fail in practice. Their behaviour is reminiscent of a manager who has been trying to be a good leader, but can’t help shouting at the staff when things get tough.

Summary

Delays in transferring people from hospital to social care is having a traumatic effect on the lives of people who wish to live more independently. Improvement in the relationship between health and local government is essential if delays in transfers are to be reduced.

The NHS undoubtedly needs local government support to modernise its care and establish something approaching financial stability. The collaborative approach exemplified by STPs is the only way to achieve this; government interference, arbitrary targets and financial penalties will not only inflict long-term harm, it may well continue to deny people who are able to leave hospital when they choose and live their lives in their community.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy

The growing use of technology in the social care sector

The UK is struggling to cope with the demands of a rapidly ageing population with increasingly complex needs. This is exacerbated by a lack of suitable, adapted homes for them to live in. However, by harnessing assistive technology and creating sustainable living environments, care homes will be able to adapt to the ever-changing needs of the UK’s ageing population.

Staff in care homes have traditionally spent time creating endless streams of paperwork, but as they begin to make the transition from using paper-based systems, to centralised, electronic systems, this sight will become a thing of the past.

Specifically, electronic care management applications are becoming a rapid component within many care homes throughout the UK, providing care and nursing staff with the ability to deliver more efficient and effective care.

While many care home providers are already embracing technology, care homes still have a long way to go before they fully embrace digital advances. The CQC are now getting behind the drive to encourage providers to make best use of the technology that is out there. In their latest review of the Key Lines of Enquiry one of the inspector’s prompts will be the use providers are making of technology to the benefit of service users.

In these cash strapped times many providers may feel that they would like to embrace the use of more technology in their services, they will at the same time ask the question “How are we going to pay for it”.

Given the current momentum towards the use of technology, I would suggest that it is more a question of what providers can do now with the resources they have, rather than waiting for better times in the future.

Some of the advantages of increased use of technology in social care settings could include:
• Savings in staff time.
• Help in the retention of staff by providing a more interesting job.
• More independence for service users.
• Better quality of life for service users.

It should go without saying that technology is not a panacea, it will never stand to replace the human interaction that occupies the very heart of adult social care. Nor will it ever replace the compassion, kindness, empathy and understanding between care staff and the people who receive care, who are care dependent and exposed to considerable vulnerabilities.

However, what technology does represent is the potential to enhance the quality of adult care by empowering care providers with ways to:
• improve operational efficiencies;
• reduce errors and risks;
• increase capacity to manage limited resources effectively;
• and most importantly, give care and nursing staff more time and space to deliver personalised care and support.

Some uses of technology

Electronic care management
Specifically, electronic care management applications are becoming a rapid component within many care homes throughout the UK, providing care and nursing staff with the ability to deliver more efficient and effective care.

The simplified electronic collection of information about service users ensures greater accuracy of service user’s records, while rapid access to this information provides care and nursing staff with the ability to be more responsive in their daily care provisions. Illegible documentation is being replaced by electronic care plans that support person-centred care and assist care facilities to more effectively demonstrate and ensure compliance.

Electronic medication administration records (eMAR)
Enables care and nursing staff to more effectively coordinate, monitor and administer medications and provide more accurate and timely medication information for staff, and further improve service user’s safety.

Replacing paper-based records with comprehensive electronic records also facilitates the flow of this information between the wider health care community including hospitals, medical practitioners, pharmacies, specialists and other care professionals. Whether it is transitioning a service user from a care home to a hospital in an emergency, or to an elective appointment with a specialist, electronic service user records play a major role in communicating the most relevant and important information for each service user.

Internet access
Care homes are also extending broadband internet access to their service users, which is a powerful tool in building a sense of belonging, support and connection. Applications that support video, chat, email and other online communications ensure service users can quickly and easily connect with relatives, close friends and the community, which can significantly contribute to a greater quality of life.

Summary

Although funding for social care services remains a major concern, there is evidence that providers are embracing the advancements in technology. The transition from paper based to centralised electronic systems will take time, but ultimately lead to improvement in operational efficiency and savings in staff time. Embracing technology will bring more benefits to service users through the ability to achieve more independence and better quality of life.

Albert Cook BA, MA & Fellow Charted Quality Institute
Managing Director
Bettal Quality Consultancy