Chapter 20 – Controlling the Confusion


There is now very little room for doubt that care of older people will be a major consumer of health and social services resources in the UK for the foreseeable future. Similar pressures, including effective coordination of care delivery with training, have also been identified in other countries., A perfectly valid desire to have individualized packages of care for people in their own homes contrasts strongly with the need to achieve economies of scale by providing care for more and more older adults with mental health problems in residential and nursing care settings.

Chapter 20 Controlling the Confusion Using Barrier Analysis in the Care Home Sector

Robert Colgate , Alison Turner and Danika Rafferty


There is now very little room for doubt that care of older people will be a major consumer of health and social services resources in the UK for the foreseeable future.1 Similar pressures, including effective coordination of care delivery with training, have also been identified in other countries.2, 3 A perfectly valid desire to have individualized packages of care for people in their own homes contrasts strongly with the need to achieve economies of scale by providing care for more and more older adults with mental health problems in residential and nursing care settings.

There is a clear need for mental health services for older adults to be closely involved in the monitoring of mental health needs in the care home sector. Rates of depressive illness remain consistently high at around 40% in the UK,4, 5 whilst the number of cases of dementia is rising steadily as ageing populations grow. Published reports point to widespread lack of mental health expertise in primary care and increasing societal expectations to manage increasingly complex combinations of mental and physical health needs.6, 7, 8

Over time, these issues have received attention from a wide variety of different sources, from conventional healthcare publications to general interest articles in magazines and mass media. The Royal College of General Practitioners has promoted good practice through a publicly available Mental Health Toolkit ( Some idea of the range of public interest can be shown by just a few examples.

A collaboration with the BBC and the Open University by business expert Sir Gerry Robinson led to the production of a film in 2009 entitled ‘Can Gerry Robinson fix Dementia Care Homes?’, which was originally available as a DVD and promoted for use as a teaching or public education resource.9 An anonymous personal view column in the British Medical Journal (Anonymous 2010) catalogued a damaging sequence of admissions and attempts at treatment involving her father before concluding that the only reliable source of practical help was ‘family, friends and neighbours’.10 The conclusion is all the more striking as the author is a hospital consultant.

Jolley et al. (1998) encouraged mental health services to ‘address the situation [of mental illness in care home settings] actively’ by using a genuine multidisciplinary approach to provide a ‘full competent assessment’.11 The Consumers Association magazine Which? has published a variety of articles, one of which described in some detail the experiences of three actors staying in four care homes in 2011.12 The Which? website ( contains a downloadable checklist of points to consider when choosing a care home and sources for further information.

Bridgend Mental Health Service for Older Adults

In late 2009, the mental health service for older adults in Bridgend was reorganized to create a dedicated multi-professional team with specific responsibility for all residents in care homes in the Bridgend County Borough area. This team also maintained responsibility for providing a mental health liaison service to secondary care health services in Bridgend (based at the Princess of Wales and Maesteg General Hospitals), whilst the team consultant also provided senior psychiatric advice to a shared care ward (rehabilitation medicine and mental healthcare) on the Princess of Wales Hospital site.

The All-Party Parliamentary Group on Dementia has drawn attention to lack of expert input stating:

specialist mental health services that could provide support and training to staff is highlighted as another barrier to workforce development (p. xii).6

In 2014, the Older People’s Commissioner for Wales, Sarah Rochira, published ‘A Place to Call Home’,13 with a follow-up report in 2017 detailing further recommendations and actions required to achieve the necessary impact in a number of areas including medication (especially antipsychotic drugs), falls prevention, befriending and dementia training.14

Published evaluations of care home in-reach teams have recognized the potential value of a more focused approach by nursing staff,15 or nurses working with physiotherapists.16 Commissioners and planners of local services in Bridgend confirmed that suitable training and education of staff was indeed a key priority area. Jolley et al. (1998) concur with this, stating that ‘the need for generous and sensitive attention to the training and support of staff cannot be overestimated’.11 Consequently, a strategic decision was taken deliberately to integrate the new liaison service with an existing educational team.

The educational team collaborated closely with the liaison team in order to identify further potential training or advisory issues within a care home. This might involve referral of a resident for advice around a specific issue or for an individual approach to care or for an intervention. It might also include supportive advice concerning design principles within the care setting, or recommended approaches to meaningful interaction – building upon material taught previously in educational sessions. Other issues that have been considered include concern about mental capacity, pain assessment, and the management, care and support of particular behaviours.

The educational team has consistently emphasized the need actively to consider the role and purpose of antipsychotic medication in dementia and it has been able to coordinate its efforts with members of the care home in-reach team. In addition, attention has been focused upon advance care planning, end-of-life plans and the role of mental health staff in providing advice and support to primary care. In selected cases, this has been undertaken with the intention of avoiding an unnecessary or disruptive hospital admission for people in the terminal stages of dementia.

The Dementia Care Training Team in Bridgend

The number of people with dementia in the UK in 2009 was around 820,000, representing about 1.3 % of the overall population.17 A 2014 report by the Alzheimer’s Society predicted the figure would increase, reaching one million by 2025 and doubling again by 2051 to just over 2 million people.18

Clinical Guideline 42 from NICE made specific reference to staff training, clearly stating that:

all staff working with older people in the Health, Social Care and Voluntary sectors have access to dementia-care training (skill development) that is consistent with their roles and responsibilities.7

This was expanded in updated guidance published in June 2018 with an emphasis upon person-centred care.8 In 2016, the Care Council for Wales published Good Work, the Dementia Learning and Development Framework for Wales, which recommended training standards to facilitate competent dementia care, which in turn underpins the Welsh Government Dementia Care Plan 2018–2022.19

Prior to this, the need for specialist dementia care training and development had been identified locally in Bridgend through routine practice as well as operational and strategic meetings. As a result, a small dementia care training team was established in November 2002 and initially named the Residential Home Advisor team. The team consisted of a full-time registered mental health nurse and two occupational therapists job-sharing the equivalent of one whole-time post. In recognition of the importance of their work the dementia care training team has subsequently increased in size and scope.

Aims of the Team

Originally the aim of the team was to identify and then address the training needs of unqualified care staff working with people with dementia in the Bridgend County Borough area, both in the local authority facilities and throughout the independent care home sector. The team also sought to provide the care home staff with suitable specialist training and education along with an advisory role. The mandate of the team has since widened to provide training for other staff groups including local authority and independent sector domiciliary care and day centre staff, qualified social workers and community care workers, community and ward-based mental health staff and medical, surgical and orthopaedic ward staff (both registered and non-registered).

Training sessions have also been held for the carer education programme of the Alzheimer’s Society, which has covered topics around ‘what is dementia?’, behavioural issues and management of eating and drinking in dementia. Dedicated sessions have been provided for specialist staff in the accident and emergency department, in a renal unit and for palliative care staff. Most recently relevant training has been provided for those working in the field of learning disabilities.

Training Needs

The vision of the team remains that, wherever a person with dementia is being supported and cared for within Bridgend County Borough, those working with them should be appropriately trained and suitably skilled with the expectation that this will lead to enhanced levels of care. This is consistent with recommendations that staff training is universally seen as a key feature in implementing and maintaining a good standard of care in both nursing and residential care homes.20 Recent reports continue to highlight the vast need for training of the staff caring for people living with a diagnosis of dementia.

The All-Party Parliamentary Group on Dementia recommended that:

We need to move towards a situation where the workforce as a whole demonstrates effective knowledge and skills in caring for people with dementia (p. xiv).6

The report also recommended that in order to provide good, high-quality dementia care, the process of working between social care and healthcare must be closely integrated. ‘Standardized training packages would provide quality assurance and consistency’ (p. 33).6 Effective support from specialist mental health teams should also be coordinated with the local education strategy to support training needs within the care home sector.

Training Package

The original dementia care training package was modular in nature and has been refined and developed over many years and in response to local needs and demands. It now consists of five days run over five consecutive weeks. The dementia care team is closely involved in the now mandatory dementia awareness training for all NHS Wales staff.

The first day provides an overview of dementia and the importance of person-centred care. The following days then cover a range of issues including communication, legal and ethical matters, behavioural concerns, hydration and nutrition, as well as hands-on care skills (see Box 20.1).

Box 20.1 Dementia care training package

  • Day 1: An Overview of Dementia

  • Day 2: Communication and Understanding Behaviour

  • Day 3: Physical and Mental Health Well-being

  • Day 4: Legal and Ethical Issues and End-of-Life Care

  • Day 5: Positive Environments and Meaningful Interactions

Professional advice and expert opinion have been sought when developing and redesigning the days to ensure they are evidence-based, relevant and contemporary. The training was originally delivered in both care home settings and central venues, but owing to funding constraints it is now only delivered in central settings. Each day incorporates a wide variety of teaching and learning strategies that enable and facilitate care staff interaction. The package content and form are also influenced by evaluation responses.

The training package has in the past been accredited at certificate level with Swansea University. Specific ‘bespoke’ sessions have been written for certain staff groups – for example, an emphasis upon strategies to manage pain in dementia was required for medical, surgical and orthopaedic nursing staff.

The Dementia Care Training team completed a service evaluation project in 2011 using an action research model to investigate the question ‘How does the dementia care training package impact on person-centred practice? ’ The curriculum underwent a further review by Worcester University in 2016, and at present is undergoing a follow up review by Swansea University.

Barrier Analysis

The title of this chapter (‘Controlling the confusion’) reflects the complexity involved in providing an effective mental health service to the care home sector and at the same time ensuring an integrated approach to training and education. As part of the design process for the service, several different interventions and innovations were deployed. The measures taken were deliberately selected from within the categories of physical and natural barriers, as described in barrier analysis.

Barrier analysis as a technique was developed in the nuclear and chemical industry during the 1990s primarily to reduce error.21 This approach was subsequently transferred to healthcare settings, again with an emphasis on reducing mistakes. Formal teaching and training in barrier analysis was disseminated widely within the NHS in the UK by the National Patient Safety Agency (NPSA) as a component of root cause analysis.

Using the analysis, barriers can be usefully categorized into four main groups:

  • Barriers dependent upon people

  • Administrative or ‘paper’ barriers

  • Physical or geographical barriers

  • Natural barriers related to space or time

Standard teaching suggests that barriers reliant upon paper or upon people are weaker and less effective, while physical or natural barriers are in practice more effective as barriers.

To illustrate this further, it may be helpful to consider the process of maintaining and improving security at international airports. From first principles, it is a relatively simple task to list several measures and interventions that have progressively developed over recent years to prevent the unauthorized carriage of weapons or hazardous material onto commercial flights (see Box 20.2).

Sep 27, 2020 | Posted by in PSYCHIATRY | Comments Off on Chapter 20 – Controlling the Confusion
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