on incidental cognitive impairment

Some members are concerned that the designation of some nursing homes as specialist EMI homes limits the choice available for older people looking for nursing home placement, even if their cognitive decline is incidental to their current frailty.

There is some anecdotal evidence that people whose physical health needs far outweigh their mental health needs are being directed to care in EMI specialist homes when mention is made of cognitive failure or dementia, as part of the information sharing with the home or Social Services; often the reason cited by care managers or nursing home managers is that non-specialist homes are not allowed by the new National Care Standards Commission(NCSC) to care for people with a diagnosis of dementia (even when that is not the main management issue).

In order to address this concern, the Policy Committee sought clarification from the NCSC. The following is the content of that body’s reply, written by Heather Wing, Director of Adult Services on 2nd October 2002:

“Firstly, can I reassure you that the NCSC has no policy which requires persons suffering from dementia to be ‘streamed’ as you put it, into specialist dementia accommodation. Such a policy would fall outside the NCSC’s remit.

Decisions about where service uses are placed in care homes are taken by persons outside of the home e.g. families, funding authorities, and wherever possible, with the active involvement of the service use. The NCSC has no such involvement in this process.

However, all registered persons must be cognisant of the relevant legislation which governs the day to day running of care homes, as well as the national minimum standards relating to such services. The legislation and national minimum standards are both produced by government, and are binding on all registered persons and the National Care Standards Commission.

The legislation makes only one reference to dementia sufferers and this is set out in the NCSC (Registration) Regulations 2001, Schedule 7 paragraph 6(c), where dementia is identified as a specific category which must be applied where this is relevant. Thus, if an applicant for registration specifies that they intend to offer care to people with dementia, assessment of the service to be provided, then the service will be registered as such and the category of dementia will be shown on the registration certificate.

There is no requirement for people with dementia to be cared for in specialist dementia accommodation, but if the provider decides that the individual’s needs can be best met in such an environment, then the NCSC has no power to either prevent this or require this.

Additional impetus for decisions to cater for such people may be drawn from the National Minimum Standards – Care Homes for Older People, which states as follows:

Standard 4 – Outcome
Service users and their representatives know that the home they enter will meet their needs

4.1 The registered person is able to demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home

4.2 All specialised services offered (e.g. services for people with dementia or other cognitive impairments, sensory impairment, physical disabilities, learning disabilities, intermediate or respite care) are demonstrably based on current good practice and reflect specialist and clinical guidance

Care Standards 7 – 11
In the introduction to the Health and Professional the document states that:

“the proprietor/manager and relevant professional staff within the home should be party to that full assessment (carried out by others) and only accept a new resident if they feel that the home can adequately meet the needs of the prospective resident as determined through that assessment”

Standard 11.9
states that:
“the changing needs of service users with deteriorating conditions or dementia – for personal support or technical aids – are reviewed and met swiftly to ensure the individual retains maximum control”

Standards 27-30
In the introduction to Staffing Standards 27-30 the document states:
“Residents with dementia also require care from appropriately skilled staff – and so on. In determining appropriate staffing establishments in all care homes and nursing care homes in particular, the regulatory requirement that staffing levels and skills mix are adequate to meet the assessed and recorded needs of the residents at all times in the particular home in question must be met”

Standards 19-26
In the introduction to Standards 19 – 26 Environment the document states:
“People with dementia have particular needs for the layout of communal space and associated signage which aid their remaining capacity. Other older people however could find some of these features patronising”

It is perhaps in view of the above references to the National Minimum Standards, that some registered person have decided not to operate separate facilities for persons suffering from dementia, although I am not aware that the Commission has any evidence to support this at this time.

You state in your letter that there seems to be a view that this specialist accommodation has come about because of some specific NCSC policy, and I trust that the above assists you to understand our position. However, it would be helpful to have further information from you as to who holds the ‘view’ you refer to, so that we might have a dialogue with these person to clarify our position.” - Letter ends

Thus it seems that there is no requirement from the Commission to stream people into diagnostic groups. Rather there is a perfectly appropriate expectation that older people should only move into a home which is able to address their needs adequately.

Care homes will therefore need to demonstrate to the NCSC during inspections, that they have the skills, expertise and time to care appropriately for any individual.

It is important to recognise that because of ignorance or fear, many homes may quote the NCSC excuse as an attempt to refuse admission of a resident. It is still up to the home to decide whom they accept as a resident, so whilst this explanation from the NCSC is helpful, it may not result in any practical local changes.

The Policy Committee would be pleased to hear of members’ experiences regarding this issue or any other apparent difficulty to do with the care standards commission. Dialogue with the NCSC is commencing and it would be nice to have examples to consider.

Please contact Louise Wykes at the BGS office, email: Louise-Wykes@bgs.org.uk if anything in your experience would contribute to this dialogue.

Gill Turner
Policy Committee