Why we are proposing to create separate wards – our clinical model

It is important that all older people diagnosed with dementia and functional mental health needs get the right care in a safe, appropriate and supportive environment. For everyone who uses our older people’s mental health services, we want to:

Enable older people to live a meaningful healthy and independent life in their community
Meet people’s physical health, mental health and social care needs
Give collaborative, integrated and appropriate care in a safe and supportive environment
Promote independence throughout the patient journey, including over admission and discharge
Provide services which are responsive, fit for people and accessible
Put the needs of carers and families at the heart of what we do
Ensure services are tailored, culturally aware and sensitive.

Mixed needs wards for people living with dementia and a functional mental health need are not ideal for either group of patients. Having separate wards also follows best practice guidelines and is common in other older people’s mental health inpatient wards in the NHS.

This section looks in more detail at the reasons why separate older people’s mental health inpatient wards improve care.

What people who use our services say

John, aged 77, has a functional mental health need. He was admitted to one of our older people’s mental health inpatient wards for people with mixed needs.

John has given us permission to share his story, his name has been changed to protect confidentiality.

“My first experience of being with people with dementia was on my very first day on the ward. I was at my most unwell but I got a real surprise and shock at lunchtime when I was sharing the dining area with people who weren’t really aware of what was happening and were struggling to eat. I saw someone trying to pour salt on their dessert.

“Every day was the same, it felt a bit like groundhog day. Other than mealtimes and medication, I didn’t have anyone to talk to and I didn’t have anything to do. For a while there was one chap with who I could chat with but then he was discharged, and I went back to being alone. I couldn’t even go and make myself a cup of tea as everything was locked away.

“The staff were great, I couldn’t really fault them, they were a different level to others I had come across before. When they had time, they would take me for walks and the chats we had really helped, however they didn’t always have time as there were lots of people with dementia who needed help.

“As I started getting better, I also started noticing more of what was happening on the wards. Times when people were being aggressive. I saw somebody being really aggressive to a nurse, and I tried to help but I’m 77.

“If I could have stayed on a ward with people without dementia, people similar to me, it would have been a much better experience.”

Specialist inpatient wards for people with dementia and dedicated wards for people with functional mental health needs can improve care, and give a better experience for our inpatients, carers, families and staff.

On mixed needs wards we know that:

The clinical and personal needs of patients can be very different.
It is challenging to provide activities that are stimulating and appropriate for all patients.
The ward environment and surroundings do not help patients be independent.
There is more risk of incidents.

The information below explains each of these in more detail.

The clinical and personal needs of patients can be very different

Because of this, there can be challenges when sharing a ward space, such as:

Patients living with dementia need more specialist nursing time, and often have more complex needs which means that other patients do not always get the one-to-one support they need.
Providing the best, and most appropriate, types of individual and group therapy is challenging on mixed needs wards.
The type of observation and input needed is different for both types of patients, such as managing the risk of self-harm or injury.

We know from feedback and observation that mixed needs wards do have an impact on the wellbeing of patients, for example patients with a functional mental health need can:

Find the behaviours of people with dementia disruptive or distressing.
Find noisy environments overwhelming, often choosing to stay in rooms, becoming more socially isolated and inactive.
Feel that their clinical needs may be less significant than patients who have severe dementia.

We also know that patients with dementia find it difficult to recognise the personal space of others. For example, they may wander into bedrooms, use other patients’ belongings or act in a way that a person with a functional mental health need may find inappropriate.

It is challenging to provide activities that are stimulating and appropriate for all patients

Having activities on a ward is important to support independence, improve care and provide a positive experience. On mixed needs wards it is hard to run activities for both groups of patients:

Both dementia and functional patients have different concentration levels. This means group sessions can often be disrupted.
Behaviours during group activities can vary which can often be hard to manage.
The ways to coordinate and run sessions for each group is different, which means patients may not get the specialist activities they need.
Physiotherapy and occupational therapists use corridors to support patients with activities, but sessions can be interrupted by disorientated patients.

Making sure the environment and surroundings support independence

It is important that we promote independence for our inpatients. On our mixed needs wards patients:

With a functional mental health need cannot make a hot drink on their own, as hot water and kettles are a risk for patients with dementia.
Sometimes do not want to leave their bedrooms as they may be fearful of the noise on the ward, or other patients being in their personal space.
With dementia do not have access to items which can help better manage their condition, such as memory boxes or sensory rooms. It is not possible to have these on a ward when caring for patients
with a functional mental health need due to safety concerns.
With dementia need a low stimulus environment.
Do not always feel comfortable moving around the ward space on their own. For patients with a functional need this may be due to a lack of personal space, and for patients with dementia this can be because it is difficult to find their way around the ward.

There is an increased risk of incidents

The challenges described in this document so far which look at the clinical and personal needs of patients, activities, and the ward environment, can lead to an increased risk of incidents on mixed needs wards.

Incidents on our mixed needs wards also happen because of falls, or violence and aggression. We know that these incidents are higher for people living with dementia, as this is often part of their condition.

Not all our wards have an extra care area to be able to manage patients who may become aggressive or violent.

Three of our five wards are also mixed gender, where men and women stay on the same ward. This can also become complicated to manage when patients can misunderstand relationships with one another.

What our staff say

Lyndsey Hall-Patch, a consultant clinical psychologist, works on Ward 19, our mixed needs ward at Dewsbury and District Hospital:

“It can be hard for people who are diagnosed with significant depression, or other functional mental health needs, to see and understand the impact that dementia has on some of our inpatients, and it can be very upsetting and challenging. Our functional patients find that they are sometimes reluctant to get out on the ward as much as they would like to.

“We like to support our inpatients with group activities which complements the clinical work we do. But it is hard on a mixed needs ward to find specialist activities which are pitched at the right level for everyone which means neither of our dementia or functional patients fully benefit from these activities.”

Helen Dowd is the ward manager on Beechdale Ward, our mixed needs ward at Calderdale Royal Hospital:

“We give great care to patients and their families, and it feels like we make a difference. Due to the nature of the condition, our patients with dementia do take more time to look after which means that sometimes those with a functional mental health need may miss out on the time they need with staff. For example, at mealtimes, we dedicate more time to patients with dementia as they often need additional support with swallowing food.

“We try and put on a variety of activities on the ward, such as quizzes, but often our dementia patients can struggle to tolerate noise generated by questions and answers and may not be able to focus for this length of time. Planning shared activities to benefit both groups of patients can be hard.”

Moving people between wards

We expect that creating specialist wards for older people diagnosed with dementia and dedicated wards for functional mental health needs will mean that people are not moved between locations and wards as much as they are now.

People diagnosed with dementia move between wards more often. Across Calderdale, Kirklees and Wakefield:

nearly half of inpatients diagnosed with dementia move wards at least once during their stay on our wards.
one in five patients diagnosed with a functional mental health need move wards at least once during their stay on our wards.

Many people who are admitted to Crofton Ward in Wakefield with dementia will move to The Poplars, which is our mixed-sex dementia ward in Hemsworth. This is because Crofton Ward can manage people when they are at their most unwell. People are admitted to Crofton Ward and then assessed to make sure that they are suitable to be moved to The Poplars, which is less able to manage the most unwell patients because it is located away from other services.

We know that when people diagnosed with dementia, or a functional mental health need, are moved between wards it can:

Impact on the continuity of care – patients need time to get used to being cared for by a new team, to build relationships with staff, and be reassessed.
Increase the amount of time a person spends as an inpatient, and therefore can have a negative impact on their wellbeing.
Have a negative impact on the wellbeing of people living with dementia – moving to a new ward can increase confusion and lead to disorientation as patients get used to a new layout and routine.
Delay care and treatment, as patients, staff, and the wider care team get to know one another and rebuild relationships.
Prevent access by carers, family members, friends and loved ones, as they may need to travel further and get used to different visiting arrangements on a new ward

What people who use our services say

One of our patients with a functional mental health need who was admitted to a mixed needs ward has given us permission to share what they told us:

“It was very upsetting and worrying for me coming in to contact with someone with dementia for the first time. I was worried all night hoping the person could not get into my room.”

What our staff say

Marcio Santa Rosa is a physiotherapist who works on Beechdale Ward, our mixed needs ward at Calderdale Royal Hospital:

“Transferring patients between wards can be a trigger which leads to aggressive behaviour. It is also upsetting for families when a patient may need to be moved further away from home.”

Kirsty Brooke is the ward manager at The Poplars, our dementia ward in Hemsworth, Wakefield:

“Because of our isolated location, we can’t accept direct admissions. This has an impact on patients with dementia because it means they get admitted to another ward for the initial part of their assessment, before then transferring to us once it is felt we can safely support someone. People with dementia can become distressed and increasingly confused with several changes of environment. It would be better if people could be admitted directly to a ward where they can be assessed, treated and supported without needing to move until they were ready for discharge.”

The design, layout and location of our wards

We want to make sure that we use the space we have in our buildings in the best possible way. Our wards should be designed well and create an environment which can improve patient care and experience. Most of our ward sizes are in line with best practice guidance for bed numbers.

We know that some of our older people’s mental health inpatient wards do not have the right environment for modern, therapeutic care. For example:

there are narrow, twisting corridors which lead to dead-ends and mean it can be hard for patients to find their way around,
staff do not have a full line of sight of the whole ward,
it is not possible, due to space, to make all bedrooms en-suite,
there is little access to quiet spaces,
patients with a functional mental health need may not feel comfortable or safe in communal areas,
there is no extra care area.

It is important that we can provide our inpatients with the right environment. We know that it can support people’s care and management of their condition. The information below gives a summary of the improvements that could be made to the design and layout of our wards:

A dementia ward and function ward both need the following facilities:

a layout and design that supports therapies
better sound absorbance to support communication
bedrooms with en-suite facilities that can be personalised by inpatients
good lines of sight for staff
access to outside space from communal areas
facilities that help social stimulation, occupation and activity
a safe environment to minimise risk of self-harm and injury

A dementia ward also needs:

corridors which lead to meaningful paces
clear signage using pictures, graphics and landmarks to help people find their way around the ward
a focus on reducing the risk of falls with extra handrails, grab rails and hoists
focus on preventing falls, activity sensors and quiet spaces

A functional ward also needs:

facilities to support patients to do things for themselves such as making a hot drink
facilities that support one-to-one and group therapies
focus on ligature safety and the right environment for therapy and support.

What our staff say

Susan Narowski, an advanced nurse practitioner, works on Ward 19, our mixed needs ward at Dewsbury and District Hospital:

“Patients with dementia and functional mental health needs would benefit from being in an environment which is focused on their needs. A specialist ward for dementia care would mean that staff working on that ward can also be specialists in end-of-life care.

“On Ward 19 we do have the space and room to manage patients with dementia. But there are things we can easily do to make it an ideal therapeutic environment such as adding sensory rooms and memory boxes to help people navigate around the ward. Unfortunately, with mixed wards, we can’t offer these in the ward environment as it could be unsafe for our functional patients.”

Marcio Santa Rosa, a physiotherapist who works on Beechdale Ward, our mixed needs ward at Calderdale Royal Hospital, said:

“Inpatient stays on mixed wards can deskill our patients. For example, in communal areas it is hard for functional patients who do not always like heightened noise or patients with dementia being in their personal space. This means patients can often spend more time isolated in their bedrooms.

“I run groups on the ward to help patients with pain, balance and exercise, which due to space on the ward has to be done in the corridor. Unfortunately, these groups often get unintentionally interrupted by our dementia patients which means our functional patients don’t get the full benefit from this therapeutic activity.

“With specialist ward space I can see us being able to better support people to be independent wherever possible and create the right spaces for therapeutic activities.”

Supporting our staff to give high quality care

People with dementia and functional mental health needs should expect to receive care which is tailored to the unique and often complex nature of their condition. We know that our staff want to give all our patients high quality, personalised care.

Giving patients, carers, families and loved ones a personal experience when working on a mixed needs ward can be difficult. This is because there are some differences in how people with dementia and how people with a functional mental health need are best cared for. These differences include the types of activities, therapies, and the amount of one-to-one care which is needed to best manage and support people.

When working on a mixed needs ward, our staff need to spend more of their time caring for people with dementia, which can mean that patients with a functional mental health need do not always get the right amount of personalised care.

We think that specialist wards will allow staff to:

improve the quality of therapies on each ward,
better tailor activities to meet people’s needs,
give the right amount of support to both patients with dementia and functional mental health needs,
have the right mix of skills for the patients they care for,
develop new skills,
become more fulfilled in their role.

It will also help our service become:

a more attractive place to work, improving staff wellbeing and morale,
somewhere where staff want to work and in turn help us to recruit and retain staff.

Four out of our five older people’s mental health inpatient services are based at a main general hospital or a mental health hospital. This means that patients on these wards:

are likely to be able to access appropriate and timely urgent and emergency support when they need it,
get care from the right mix of health, care and support staff, and from colleagues working in other departments if needed,
are admitted to a ward which has the right support for people more severe/ acute mental health needs.

Our dementia ward, which is based at The Poplars, in Hemsworth, Wakefield is not located alongside any other hospital service.

At The Poplars:

the nearest emergency department, or access to specialist help, is on average a 30 minute car journey away at Pinderfields Hospital, Wakefield or at Barnsley Hospital.
there may be a delay in patients receiving specialist medical input, especially during the night and over weekends.
the team on the ward are away from support which means in the case of an emergency they can’t call on staff from neighbouring wards to help.

The location of The Poplars, away from other hospital sites was also highlighted by the Care Quality Commission (CQC) during their visit to the ward in 2022.

What our staff say

Elaine White, a healthcare assistant for more than 20 years, works on Beechdale Ward which is our mixed needs ward at Calderdale Royal Hospital:

“I have worked on separate dementia and functional mental health needs wards in the past, there was much more time for activities and one-to-one time with patients.

“It was better being able to work on separate wards, it helps prevent staff from feeling overwhelmed, and we are more able to use our skills in the right way to help our patients.”

Tina Metcalfe is an occupational therapist who works on Crofton Ward, our mixed needs ward at Fieldhead Hospital, Wakefield:

“It’s not a good mix, it’s hard to run groups for patients with dementia and functional patients because they need different things. It’s difficult to give patients with dementia things to occupy their time. It would be better if the ward was more designed for people with dementia. We could make some reminiscence areas or some sensory areas.”

What the last CQC inspection said

In June 2019, our Trust was rated ‘Good’ for mental health inpatient care for older people by the Care Quality Commission (CQC). Although they saw evidence of good care for patients with dementia, they also saw the challenges in managing wards where there are patients with dementia and functional mental health needs.

Following their inspection, the CQC gave our Trust an action to ‘ensure that staff are supported to manage the mix of organic (dementia) and functional patients, and that dementia care is appropriate’.

The CQC also visited Ward 19, our mixed needs ward at Dewsbury and District Hospital, and The Poplars, our dementia ward in Hemsworth, Wakefield, in 2022.

Following their visit to The Poplars, they said:

The location of The Poplars meant that staff were isolated for access to urgent support or cover for unplanned staffing issues.
They were concerned that the distance from The Poplars to other trust locations would impact on out of hours medic assessments.

We are committed to improving care for older people on our inpatient wards. We will do this in line with our Trust values to improve and aim to be outstanding, putting the person first and in the centre, knowing that families and carers matter.

You can read the CQC inspection for our Trust in full on the CQC website: https://www.cqc.org.uk/provider/RXG

Older people’s mental health inpatient services in other areas of the country

Most other NHS mental health Trusts in England have separate inpatient wards for people with dementia and those with a functional mental health need. Only 11% of Trusts have only mixed needs wards.

This shows that our proposed changes are in line with what happens in similar services across the rest of the NHS.