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Faecal incontinence

About

What is covered

This interactive flowchart covers the management of faecal incontinence in adults.
Faecal incontinence is a sign or a symptom, not a diagnosis.
Between 1% and 10% of adults are affected with faecal incontinence, with 0.5–1.0% of adults experiencing regular faecal incontinence that affects their quality of life.
For understandable reasons, faecal incontinence has remained a largely hidden problem. Active case-finding will often be required, probably best targeted at high-risk groups.
A detailed initial assessment and structured approach to management are needed, starting with addressing reversible factors and, only if this fails to restore continence, progressing to specialised options and investigations.

Updates

Updates to this interactive flowchart

25 March 2014 Insertion of a magnetic bead band for faecal incontinence (NICE interventional procedures guidance 483) added to surgery for faecal incontinence.
6 February 2014 Faecal incontinence in adults (NICE quality standard 54) added.
12 December 2013 Mental wellbeing of older people in care homes (NICE quality standard 50) added.

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Short Text

Everything NICE has said on managing faecal incontinence in adults in an interactive flowchart

What is covered

This interactive flowchart covers the management of faecal incontinence in adults.
Faecal incontinence is a sign or a symptom, not a diagnosis.
Between 1% and 10% of adults are affected with faecal incontinence, with 0.5–1.0% of adults experiencing regular faecal incontinence that affects their quality of life.
For understandable reasons, faecal incontinence has remained a largely hidden problem. Active case-finding will often be required, probably best targeted at high-risk groups.
A detailed initial assessment and structured approach to management are needed, starting with addressing reversible factors and, only if this fails to restore continence, progressing to specialised options and investigations.

Updates

Updates to this interactive flowchart

25 March 2014 Insertion of a magnetic bead band for faecal incontinence (NICE interventional procedures guidance 483) added to surgery for faecal incontinence.
6 February 2014 Faecal incontinence in adults (NICE quality standard 54) added.
12 December 2013 Mental wellbeing of older people in care homes (NICE quality standard 50) added.

Sources

NICE guidance and other sources used to create this interactive flowchart.
Insertion of a magnetic bead band for faecal incontinence (2014) NICE interventional procedures guidance 483
Percutaneous tibial nerve stimulation for faecal incontinence (2011) NICE interventional procedures guidance 395
Transabdominal artificial bowel sphincter implantation for faecal incontinence (2008) NICE interventional procedures guidance 276
Injectable bulking agents for faecal incontinence (2007) NICE interventional procedures guidance 210
Stimulated graciloplasty for faecal incontinence (2006) NICE interventional procedures guidance 159
Sacral nerve stimulation for faecal incontinence (2004) NICE interventional procedures guidance 99
Artificial anal sphincter implantation (2004) NICE interventional procedures guidance 66
Faecal incontinence in adults (2014) NICE quality standard 54
Mental wellbeing of older people in care homes (2013) NICE quality standard 50
Secca System for faecal incontinence (2016) NICE medtech innovation briefing 66
Acute diarrhoea in adults: racecadotril (2013) NICE evidence summary ESNM11

Quality standards

Faecal incontinence in adults

These quality statements are taken from the faecal incontinence in adults quality standard. The quality standard defines clinical best practice for faecal incontinence in adults and should be read in full.

Mental wellbeing of older people in care homes

These quality statements are taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice for mental wellbeing of older people in care homes and should be read in full.

Quality statements

Identification in high-risk groups

This quality statement is taken from the faecal incontinence in adults quality standard. The quality standard defines clinical best practice for faecal incontinence in adults and should be read in full.

Quality statement

Adults in high-risk groups for faecal incontinence are asked in a sensitive way, at the time the risk factor is identified and then at times according to local care pathways, whether they have bowel control problems.

Rationale

Faecal incontinence is distressing and can have a big effect on everyday life. Many people are embarrassed to talk about faecal incontinence with doctors and nurses, and their family and friends. Others may report symptoms of diarrhoea to avoid talking about the condition directly. Faecal incontinence can have many different causes. However, once identified there are treatments that can help manage or sometimes cure it. There are also strategies to help people discuss the condition openly and to cope with it. To ensure that everyone with faecal incontinence has access to this management, including people who find it difficult to talk about, it is important that enquiry about symptoms is pro-active and sensitive. How often questions should be asked will vary for each person and will depend on the level of risk and individual circumstances. This might happen at annual review for example, but as a minimum, questions should be asked at the time a risk factor is identified.

Quality measures

Structure
a) Evidence of identification of locally relevant groups at high risk of faecal incontinence from those listed in NICE clinical guideline 49 recommendation 1.1.2.
Data source: Local data collection.
b) Evidence of local initiatives for raising awareness of faecal incontinence among staff working with groups at high risk, including training in talking openly and sensitively about the condition.
Data source: Local data collection.
c) Evidence of local arrangements to ensure that when the risk factor for faecal incontinence is identified, staff ask adults in high-risk groups whether they have bowel control problems.
Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on whether organisations ask a screening question(s) relating to bladder and bowel problems as part of initial assessment.
d) Evidence that local care pathways relevant to the groups at high risk of faecal incontinence include prompts to ask about bowel control problems (for example, at annual review).
Data source: Local data collection.
Process
Proportion of adults in locally relevant groups at high risk of faecal incontinence (from those listed in NICE clinical guideline 49 recommendation 1.1.2) who have been asked whether they have bowel control problems.
Numerator – the number of people in the denominator who have been asked whether they have bowel control problems.
Denominator – the number of adults in identified locally relevant groups at high risk of faecal incontinence (from those listed in NICE clinical guideline 49 recommendation 1.1.2).
Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on how faecal incontinence was identified for each person in the audit.
Outcome
a) Feedback from adults who have been asked about whether they have bowel control problems, on whether this was done in a sensitive way.
Data source: Local data collection.
b) Incidence of faecal incontinence.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that systems are in place for the identification of locally relevant groups at high risk of faecal incontinence from those listed in NICE clinical guideline 49 recommendation 1.1.2 and that local pathways for care of adults in these groups include prompts to ask about bowel control problems (for example, at annual review). Providers should also raise awareness of faecal incontinence among staff working with groups at high risk, and provide training on talking openly and sensitively about the condition.
Health and social care practitioners ensure that they ask adults in identified locally relevant groups at high risk of faecal incontinence, in a sensitive way, at the time the risk factor is identified and then at times according to local care pathways, whether they have bowel control problems.
Commissioners ensure that they commission services that identify key people who are responsible for raising awareness of faecal incontinence and promoting continence and commission from providers that can demonstrate they have systems in place for the identification of locally relevant groups at high risk of faecal incontinence from those listed in NICE clinical guideline 49 recommendation 1.1.2 and that local pathways for care of adults in these groups include prompts to ask about bowel control problems (for example, at annual review). Providers should also raise awareness of faecal incontinence among staff working with groups at high risk, and provide training on talking openly and sensitively about the condition.

What the quality statement means for patients, service users and carers

Adults who are at risk of faecal incontinence (certain groups of people are more likely to have this than others) are asked in a sensitive way by health or social care staff whether they have problems controlling their bowels.

Source guidance

  • Faecal incontinence (NICE clinical guideline 49), recommendation 1.1.2 (key priority for implementation).

Definitions of terms used in this quality statement

Faecal incontinence
This is any involuntary loss of faeces that is a social or hygiene problem [NICE clinical guideline 49, scope].
High-risk groups for faecal incontinence
These include:
  • frail older people
  • people with loose stools or diarrhoea from any cause (for example, inflammatory bowel disease)
  • women following childbirth (especially after obstetric anal sphincter injury)
  • people with neurological or spinal disease or injury (for example, spina bifida, stroke, multiple sclerosis, spinal cord injury)
  • people with severe cognitive impairment
  • people with urinary incontinence
  • people with pelvic organ prolapse and/or rectal prolapse
  • people who have had colonic resection or anal surgery
  • people who have undergone pelvic radiotherapy
  • people with perianal soreness, itching or pain
  • people with learning disabilities.
[Adapted from NICE clinical guideline 49, recommendation 1.1.2 (key priority for implementation]
Sensitive
Sensitive enquiry about faecal incontinence includes not asking more often than is appropriate for the person’s level of risk. [Expert opinion]

Equality and diversity considerations

Risk of faecal incontinence relates closely to many of the protected characteristics that are covered by the Equality Act 2010, including age, disability, sex, and pregnancy and maternity. The consequences may also impact on others, including religion and belief. If people at risk are not asked about faecal incontinence, and if the condition is not effectively managed and treated, some people covered by the Act could be adversely affected. These people may have more than one protected characteristic or be affected by socioeconomic factors. Faecal incontinence may itself be counted as a disability if it occurs over the long term and has a substantial adverse effect on day-to-day activities. Sensitively asking people at risk about faecal incontinence promotes dignity and respect and is an important first step in removing any unequal access to care. Any enquiry about faecal incontinence should take into account the person’s religion and belief and be culturally appropriate. People with faecal incontinence may also be unable to work. Providing assessment, effective management and treatment is likely to allow increased participation in society and public life, promoting equality of opportunity. If the person at risk of faecal incontinence lacks capacity, input from carers should be sought.

Baseline assessment

This quality statement is taken from the faecal incontinence in adults quality standard. The quality standard defines clinical best practice for faecal incontinence in adults and should be read in full.

Quality statement

Adults reporting bowel control problems are offered a full baseline assessment, which is carried out by healthcare professionals who do not assume that symptoms are caused by any existing conditions or disabilities.

Rationale

Faecal incontinence may have different underlying causes and contributing factors. There is a risk that healthcare professionals could make assumptions that faecal incontinence is related to a pre-existing condition or disability (such as a neurological condition or cognitive impairment) without carrying out a full assessment. Faecal incontinence may have different contributing factors in people with the same long-term condition. A baseline assessment that takes account of the individual person, rather than assuming incontinence is related to a pre-existing condition, is therefore essential. Correct identification of contributing factors will promote better access to care and ensure that appropriate management can be planned.

Quality measures

Structure
a) Evidence of local pathways for accessing full baseline assessments when adults report bowel control problems.
Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on whether services have a protocol or pathway that is initiated when a patient reports that they have a bladder or bowel problem. The audit also collects data on whether services have a written protocol on providing basic assessments for people who have problems with urinary and/or faecal incontinence. The APPG Continence Care survey includes a question on what pathways are available for people with incontinence within the organisation.
b) Evidence of local initiatives to raise awareness of factors contributing to faecal incontinence so that healthcare professionals carrying out full baseline assessments do not assume that symptoms are caused by existing conditions or disabilities.
Data source: Local data collection.
Process
Proportion of adults reporting bowel control problems who receive a full baseline assessment.
Numerator – the number of people in the denominator receiving a full baseline assessment.
Denominator – the number of adults reporting bowel control problems.
Data source: Local data collection. Also contained in NICE audit support for Faecal incontinence (NICE clinical guideline 49), criterion 2. The National Audit of Continence Care (NACC) collects data on whether an assessment focusing on finding the cause(s) of faecal incontinence was performed, and specifically on cognitive assessments, rectal examination, medication review and impact on quality of life. The 2010 National Audit of Continence Care collected data on documented evidence of a bowel history.
Outcome
Feedback from adults with faecal incontinence (or their carers) that symptoms were properly assessed and not assumed to be caused by any pre-existing conditions or disabilities.
Data source: Local data collection.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure that local pathways are in place for accessing full baseline assessments when adults report bowel control problems. Providers should also raise awareness among healthcare professionals carrying out the assessments of the many forms and causes of faecal incontinence.
Health and social care practitioners to whom adults with bowel control problems report symptoms, but who are not competent to carry out a full baseline assessment themselves, refer the person for assessment according to local pathways.
Healthcare professionals who are competent to carry out a full baseline assessment themselves ensure that they offer adults reporting bowel control problems (or refer for) a full baseline assessment, which they carry out without assuming that symptoms are caused by any existing conditions or disabilities.
Commissioners ensure that they commission services with capacity and expertise to provide full baseline assessments for adults reporting bowel control problems.

What the quality statement means for patients, service users and carers

Adults who report bowel control problems are offered a full assessment, which includes a physical examination and questions about their medical history, medication, diet and how the bowel problems affect their day-to-day life. Healthcare professionals should not assume that the problems are caused by conditions or disabilities that people already have.

Source guidance

  • Faecal incontinence (NICE clinical guideline 49), recommendations 1.1.6, 1.2.1 and 1.2.2 (key priorities for implementation).

Definitions of terms used in this quality statement

Faecal incontinence
This is any involuntary loss of faeces that is a social or hygiene problem [NICE clinical guideline 49, scope].
Baseline assessments
These are ideally carried out when symptoms are reported and include medical history, physical examination (including anorectal examination) and medication review [adapted from NICE clinical guideline 49, recommendation 1.2.2]. Examples of specific questions to ask as part of a baseline assessment are available in table 1 of NICE clinical guideline 49. Coping strategies should also be provided at the time of assessment (see quality statement 3) [NICE clinical guideline 49 recommendation 1.3.11]
Medical history
This includes:
  • history of bowel habit (including warning signs for lower gastrointestinal cancer such as rectal bleeding and change in bowel habit, as defined in section 1.5 of Referral guidelines for suspected cancer [NICE clinical guideline 27])
  • previous medical history
  • medication review (see below)
  • diet and fluid history
  • consequences of faecal incontinence
  • impact of symptoms on quality of life.
Physical examination
This includes:
  • general examination (as indicated)
  • cognitive and behavioural assessment (if indicated)
  • assessment of person’s ability to use the toilet
  • anorectal examination
    • visual inspection of anus
    • assessment of perineal descent
    • digital rectal examination for anal tone and ability to squeeze anal sphincter voluntarily
    • assessment of faecal loading.
Medication review
This considers whether the person with faecal incontinence is taking any drugs that may exacerbate faecal incontinence (see table 4 of NICE clinical guideline 49) and the effectiveness of any alterations already made.
Equality and diversity considerations
Faecal incontinence is associated with many protected characteristics that are covered by the Equality Act 2010, including age, disability, sex, and pregnancy and maternity. The consequences may also impact on others, including religion and belief. If people with faecal incontinence do not have assessments that take account of individual factors, and if healthcare professionals assume that faecal incontinence is caused by an underlying condition, effective management and treatment may not be provided. This may adversely affect people whose condition is associated with a protected characteristic. Undertaking detailed baseline assessments for each person with faecal incontinence is an important step in removing any unequal access to the most effective care. Extra steps may need to be taken to ensure physical access to clinics and allow extra time to meet the needs of all disabled people, including people with learning disabilities. It may sometimes be appropriate for carers to be involved in the assessment process (for example, helping people to answer questionnaires).

Coping with symptoms

This quality statement is taken from the faecal incontinence in adults quality standard. The quality standard defines clinical best practice for faecal incontinence in adults and should be read in full.

Quality statement

Adults with faecal incontinence and their carers are offered practical support, advice and a choice of appropriate products for coping with symptoms during the period of assessment and for as long as they experience episodes of faecal incontinence.

Rationale

Faecal incontinence can be depressing, demoralising and detrimental to everyday life and it is important that people are able to cope with symptoms. Because some interventions may take time to be effective, people have to cope with symptoms while undergoing baseline assessment and sometimes during the period of initial management, while waiting for specialist referral, or while undergoing specialist assessment or management. People for whom specialist management has not been effective and people who do not wish to pursue active treatment also have to cope with symptoms. Access to support, advice and appropriate coping strategies, including a choice of appropriate products, can allow people with faecal incontinence to lead active lives with as much independence as possible.

Quality measures

Structure
a) Evidence of local provision of ongoing practical support and advice on coping with symptoms of faecal incontinence.
Data source: Local data collection.
b) Evidence of local pathways (which are known to healthcare professionals carrying out baseline assessments for adults reporting bowel control problems) for accessing practical support and advice on coping with symptoms of faecal incontinence.
Data source: Local data collection. The APPG Continence Care survey includes a question on what pathways are available for people with incontinence within the organisation.
c) Evidence that a choice of appropriate products for faecal incontinence is available locally.
Data source: Local data collection. The APPG Continence Care survey includes a question on whether a choice of products within a range is offered after assessment.
Process
a) Proportion of adults reporting bowel control problems and their carers who receive support and advice at the time of baseline assessment for coping with symptoms.
Numerator – the number of people in the denominator for whom they and their carers receive support and advice at the time of baseline assessment for coping with symptoms.
Denominator – the number of adults with faecal incontinence.
Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on how faecal incontinence was identified for each person in the audit.
b) Proportion of adults reporting bowel control problems who are given a choice of appropriate products at the time of baseline assessment for coping with symptoms.
Numerator – the number of people in the denominator who are given a choice of appropriate products at the time of baseline assessment for coping with symptoms.
Denominator – the number of adults with faecal incontinence.
Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on the NHS continence products that people can access.
Outcome
Feedback from adults with faecal incontinence that they receive ongoing support and advice and a choice of appropriate products for coping with symptoms.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers have local pathways (which are known to healthcare professionals carrying out baseline assessments) for accessing ongoing practical support, advice and a choice of appropriate products to help adults and their carers cope with symptoms of faecal incontinence.
Health and social care practitioners ensure that they offer adults with faecal incontinence and their carers (or refer for) practical support, advice and a choice of appropriate products to help them cope with symptoms during the period of assessment and for as long as symptoms persist. This includes up-to-date information about product choice and provision.
Commissioners ensure that they commission services with access to ongoing practical support, advice and a choice of appropriate products to help adults and their carers cope with symptoms of faecal incontinence.

What the quality statement means for patients, service users and carers

Adults with faecal incontinence and their carers are offered advice, support and a choice of products (such as pads, plugs, skincare products and disposable gloves) to help them deal with bowel control problems for as long as there are symptoms.

Source guidance

Definitions of terms used in this quality statement

Faecal incontinence
This is any involuntary loss of faeces that is a social or hygiene problem [NICE clinical guideline 49, scope].
Practical support and advice
This includes written information, opportunities for discussion and access to appropriate services covering:
  • where to get emotional and psychological support, including counselling or psychological therapy or support groups, as appropriate, to foster acceptance and positive attitudes
  • how to talk to friends and family about incontinence and its management
  • strategies such as planning routes for travel to facilitate access to public toilets, and carrying a toilet access card (available from Crohn’s and Colitis UK and Bladder and Bowel Foundation) or RADAR key (available from Disability Rights UK) to allow access to ‘disabled’ toilets in the National Key Scheme.
  • skin-care advice
  • advice on odour control and laundry needs.
[Adapted from NICE clinical guideline 49 recommendations 1.1.5 and 1.3.11].
Appropriate products
These are continence or bowel management products that are appropriate to the person’s circumstances, taking into account their preferences. These may include:
  • disposable body-worn pads in a choice of styles and designs, and disposable bed pads if needed
  • pads in quantities sufficient for the person’s continence needs (it is inappropriate to limit the number of pads given)
  • anal plugs (for people who can tolerate them)
  • disposable gloves
  • cleansing and barrier products for skincare.
Information should be given about product choice, supply sources and use. Reusable absorbent products are not generally recommended for managing faecal incontinence.
[Adapted from NICE clinical guideline 49 recommendations 1.3.11, 1.3.12 and 1.3.13].

Equality and diversity considerations

Faecal incontinence is associated with many protected characteristics that are covered by the Equality Act 2010, including age, disability, sex, and pregnancy and maternity. The consequences may also impact on others, including religion and belief. Without access to individually tailored coping strategies (including continence products), some people with faecal incontinence who have protected characteristics under the Act could be adversely affected. Failure to make reasonable adjustment to take account of disabilities is a particular concern. Providing access to individually tailored coping strategies for people with faecal incontinence and their carers enables them to participate more fully in society and is an important step in preventing discrimination and promoting equality of opportunity.

Initial management

This quality statement is taken from the faecal incontinence in adults quality standard. The quality standard defines clinical best practice for faecal incontinence in adults and should be read in full.

Quality statement

Adults with faecal incontinence have an initial management plan that covers any specific conditions causing the incontinence, and diet, bowel habit, toilet access and medication.

Rationale

Most symptoms of faecal incontinence can be improved, and many resolved, with initial management. Considering simple management options that may improve or resolve symptoms, in addition to providing support and advice on coping, should lead to the biggest improvements in quality of life for people with faecal incontinence. Effective initial management may reduce the risk of skin conditions and falls, and reduce the number of referrals to some specialist services. It can also help carers to cope, preventing carer breakdown and potentially delaying the need for domiciliary or residential care. People for who early specialist referral is indicated should also be offered initial management during any period of waiting.

Quality measures

Structure
a) Evidence of local capability to provide interventions for initial management of faecal incontinence.
Data source: Local data collection.
b) Evidence of local pathways (which are known to healthcare professionals carrying out baseline assessments for adults reporting bowel control problems) for accessing interventions for initial management of faecal incontinence.
Data source: Local data collection. The APPG Continence Care survey includes a question on what pathways are available for people with incontinence within the organisation.
Process
Proportion of adults with faecal incontinence who have had a baseline assessment and have an initial management plan that covers any specific conditions causing symptoms, and diet, bowel habit, toilet access and medication.
Numerator – the number of people in the denominator with an initial management plan that covers specific conditions that are causing symptoms, and diet, bowel habit, toilet access and medication.
Denominator – the number of adults with faecal incontinence who have had a baseline assessment.
Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on whether there is a treatment plan, whether condition-specific interventions have been given or planned and whether the person’s own goals and decisions for treatment and care have been documented.

What the quality statement means for service providers, health and social care practitioners, and commissioners

Service providers ensure there are local pathways (which are known to healthcare professionals carrying out baseline assessments) for accessing initial management for adults with faecal incontinence and that staff have the knowledge, skills and attitudes to develop initial management plans that cover specific conditions that are causing symptoms, and diet, bowel habit, toilet access and medication.
Health and social care practitioners offer adults with faecal incontinence (or refer for) an initial management plan that covers specific conditions causing symptoms, and diet, bowel habit, toilet access and medication.
Commissioners ensure they commission services that provide access to interventions for initial management of faecal incontinence.

What the quality statement means for patients, service users and carers

Adults with faecal incontinence have their bowel control problems managed in the first instance as set out in a plan that covers any specific conditions causing the problems, diet, medication and getting to the toilet. The plan should be adapted to individual needs and preferences.

Source guidance

  • Faecal incontinence (NICE clinical guideline 49), recommendation 1.3.1.

Definitions of terms used in this quality statement

Faecal incontinence
This is any involuntary loss of faeces that is a social or hygiene problem [NICE clinical guideline 49, scope].
Initial management plan
This outlines the initial intervention(s) that have been discussed and agreed with the person with faecal incontinence (and carers, as appropriate), tailored to their individual needs and preferences. Interventions may include addressing specific conditions causing the incontinence and addressing diet, bowel habit, toilet access and medication needs [Adapted from NICE clinical guideline 49 recommendations 1.3.1 to 1.3.15].
Specific conditions
Specific conditions that might cause faecal incontinence and require condition-specific interventions include:
  • faecal loading
  • potentially treatable causes of diarrhoea (for example, infective, inflammatory bowel disease and irritable bowel syndrome)
  • warning signs for lower gastrointestinal cancer, such as rectal bleeding and change in bowel habit, as defined in recommendations 1.5.4 to 1.5.10 of Referral guidelines for suspected cancer [NICE clinical guideline 27])
  • rectal prolapse or third-degree haemorrhoids
  • acute anal sphincter injury including obstetric and other trauma
  • acute disc prolapse/cauda equina syndrome.
[NICE clinical guideline 49 recommendation 1.2.3]
The initial management plan will also incorporate coping strategies (statement 3) and the findings of the baseline assessment (statement 2) [Adapted from NICE clinical guideline 49 recommendations 1.3.1 and 1.3.11].
Medication
Managing medication includes reviewing medication and considering alternatives to drugs that are contributing to faecal incontinence (see table 4 of NICE clinical guideline 49), as well as prescribing anti-diarrhoeal drugs for people with loose stools and associated faecal incontinence [Adapted from NICE clinical guideline 49 recommendations 1.3.6 and 1.3.7].

Equality and diversity considerations

Faecal incontinence is associated with many protected characteristics that are covered by the Equality Act 2010, including age, disability, sex, and pregnancy and maternity. The consequences may also impact on others, including religion and belief. Without access to individually tailored initial management plans, appropriate care and treatment could be restricted for some people with faecal incontinence and protected characteristics. Effective management is likely to promote equality of opportunity by allowing increased participation in society and public life. An individually tailored initial management plan for people with faecal incontinence is therefore important for removing any unequal access to the most effective care.

Specialised management

This quality statement is taken from the faecal incontinence in adults quality standard. The quality standard defines clinical best practice for faecal incontinence in adults and should be read in full.

Quality statement

Adults who continue to experience episodes of faecal incontinence after initial management are offered referral for specialised management.

Rationale

Some people will continue to have episodes of faecal incontinence after initial management and may benefit from specialised assessment and management, which can both identify the cause of symptoms and indicate further treatment options. These people should have the opportunity to discuss the possibility of referral and agree a course of action that meets their needs and preferences; some people will choose not to pursue active treatment. There are a number of specialist conservative, medical and surgical interventions that can help, and these are likely to be provided by different specialists. Access to the most appropriate specialist management will improve the quality of life for some people with faecal incontinence.

Quality measures

Structure
Evidence of local referral pathways for all options for specialised management of faecal incontinence.
Data source: Local data collection. The National Audit of Continence Care (NACC) collects data on whether services have clear pathways for referral between providers. The APPG Continence Care survey includes a question on what pathways are available for people with incontinence within the organisation.
Process
Proportion of adults continuing to experience episodes of faecal incontinence after initial management who are offered referral for specialised management.
Numerator – the number of people in the denominator who are offered referral for specialised management.
Denominator – the number of adults continuing to experience episodes of faecal incontinence after initial management.
Data source: Local data collection. Also contained in NICE audit support for Faecal incontinence (NICE clinical guideline 49), criterion 5. The National Audit of Continence Care (NACC) collects data on further investigations and referrals to a specialist or another service for people with a treatment plan.

What the quality statement means for service providers, healthcare professionals, and commissioners

Service providers have local referral pathways for all options for specialised management of faecal incontinence and ensure that staff providing initial management are aware of them.
Healthcare professionals ensure that they are aware of local referral pathways for all options for specialised management of faecal incontinence and offer referrals in accordance with these to adults who continue to experience episodes of faecal incontinence after initial management.
Commissioners ensure that they commission services with expertise and capacity for specialised management of faecal incontinence.

What the quality statement means for patients, service users and carers

Adults who still have symptoms after the first steps in managing faecal incontinence are offered a referral for specialist advice and possible further treatment.

Source guidance

  • Faecal incontinence (NICE clinical guideline 49), recommendations 1.4.1 (key priority for implementation) and 1.4.2.

Definitions of terms used in this quality statement

Faecal incontinence
This is any involuntary loss of faeces that is a social or hygiene problem [NICE clinical guideline 49, scope].
Initial management
This involves adjusting the person’s fluid intake, diet and medication separately and ensuring that they complement each other (see statement 4). [NICE clinical guideline 49, full guideline].
Specialised management
This consists of conservative, medical or surgical interventions provided by a specialist continence service or secondary care specialists and may include:
  • pelvic floor muscle training
  • bowel retraining
  • specialist dietary assessment and management (this is a detailed specialist intervention, separate to the basic dietary advice offered as part of initial management)
  • biofeedback
  • rectal irrigation
  • electrical stimulation
  • anorectal physiology studies
  • endoanal ultrasound (if this is not available, magnetic resonance imaging, endovaginal ultrasound and perineal ultrasound should be considered)
  • other tests, including proctography, as indicated
  • surgery (for example, sphincter repair, sacral nerve stimulation, stoma).
[Adapted from NICE clinical guideline 49, recommendations 1.4.1 and 1.5.1].

Equality and diversity considerations

Faecal incontinence is associated with many protected characteristics that are covered by the Equality Act 2010, including age, disability, sex, and pregnancy and maternity. The consequences may also impact on others, including religion and belief. Not all interventions offered by specialist services will be suited to all people with faecal incontinence. For example, some treatments may not be suitable for people who are unable to understand or adhere to treatment instructions, and interventions such as pelvic floor muscle training may not be suitable for people with neurological or spinal conditions. The key consideration is to ensure that people with protected characteristics covered by the Act can access specialised management if it is appropriate for them, and that assumptions are not made about suitability of the intervention. Adjustment should be made to both specialist assessment and treatment options when possible. This may mean giving extra support and time, especially to disabled people. Improving access to specialist services for all people with faecal incontinence is an important step in removing any unequal access to the most effective care. Effective management is likely to promote equality of opportunity by allowing increased participation in society and public life.  

Participation in meaningful activity

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.

Rationale

It is important that older people in care homes have the opportunity to take part in activity, including activities of daily living, that helps to maintain or improve their health and mental wellbeing. They should be encouraged to take an active role in choosing and defining activities that are meaningful to them. Whenever possible, and if the person wishes, family, friends and carers should be involved in these activities. This will help to ensure that activity is meaningful and that relationships are developed and maintained.

Quality measures

Structure
Evidence of local arrangements to ensure that older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.
Data source: Local data collection.
Outcome
a) Feedback from older people in care homes that they are offered opportunities to take part in activity during their day.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.
b) Feedback from older people in care homes that they have taken part in activity during their day that is meaningful to them.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that opportunities for activity are available and that staff are trained to offer spontaneous and planned opportunities for older people in care homes to participate in activity that is meaningful to them and that promotes their health and mental wellbeing.
Social care, health and public health practitioners ensure that they offer older people in care homes opportunities during their day to participate in spontaneous and planned activity that is meaningful to them and that promotes their health and mental wellbeing.
Local authorities and other commissioning services ensure that they commission services from providers that can produce evidence of activities that are undertaken within the care home and can demonstrate that staff are trained to offer spontaneous and planned opportunities for older people in care homes to participate in activity that is meaningful to them.

What the quality statement means for service users, family, friends and carers

Older people in care homes have opportunities during their day to take part in activities of their choice that help them stay well and feel satisfied with life. Their family, friends and carers have opportunities to be involved in activities with them when the older person wishes.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Meaningful activity
Meaningful activity includes physical, social and leisure activities that are tailored to the person’s needs and preferences. Activity can range from activities of daily living such as dressing, eating and washing, to leisure activities such as reading, gardening, arts and crafts, conversation, and singing. It can be structured or spontaneous, for groups or for individuals, and may involve family, friends and carers, or the wider community. Activity may provide emotional, creative, intellectual and spiritual stimulation. It should take place in an environment that is appropriate to the person’s needs and preferences, which may include using outdoor spaces or making adaptations to the person’s environment. [Adapted from SCIE guide 15, Choice and Control, Living well through activity in care homes: the toolkit (College of Occupational Therapists) and expert consensus]
Mental wellbeing
Mental wellbeing includes areas that are key to optimum functioning and independence, such as life satisfaction, optimism, self-esteem, feeling in control, having a purpose in life, and a sense of belonging and support. [Adapted from the Mental health improvement programme, background and policy context (NHS Health Scotland)]

Equality and diversity considerations

Staff working with older people in care homes should identify and address the specific needs of older people arising from diversity, including gender and gender identity, sexuality, ethnicity, age and religion.
When tailoring activities to the needs and preferences of older people, staff should be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should have the necessary skills to include people with cognitive or communication difficulties in decision-making (from Dignity in care [SCIE guide 15]: Choice and control). Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
When collecting feedback from older people about whether they have been offered opportunities for meaningful activity, staff should consider using alternative methods for older people who find it difficult to provide feedback. For example, tools such as Dementia Care Mapping can be used, and/or feedback from people who are considered suitable to represent the views of the older person, such as family members, carers, or an advocate.

Personal identity

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes are enabled to maintain and develop their personal identity.

Rationale

It is important that staff working with older people in care homes are aware of the personal history of the people they care for and respect their interests, beliefs and the importance of their personal possessions. Older people should be involved in decision-making and supported and enabled to express who they are as an individual and what they want. They should be able to make their own choices whenever possible. Enabling older people to maintain and develop their personal identity during and after their move to a care home promotes dignity and has a positive impact on their sense of identity and mental wellbeing.

Quality measures

Structure
Evidence of local arrangements to ensure that older people in care homes are enabled to maintain and develop their personal identity.
Data source: Local data collection.
Outcome
Feedback from older people in care homes that their personal identity is respected.
Data source: Local data collection. Adult Social Care Outcomes Toolkit. The following documents from the toolkit include questions about choice and control, personal cleanliness and comfort, social participation and involvement, occupation and dignity: CHINT3 care home interview schedule and CHOBS3 care home observation schedule.
The Personal Social Services Adult Social Care Survey (England). This survey collects data on service users’ views and opinions over a range of outcome areas, including satisfaction with social care and support and quality of life. Appendix F of this report provides a link to model questionnaires.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care work to embed a culture built on dignity and choice in care homes and ensure that staff are trained to work in partnership with older people in care homes in order to enable them to maintain and develop their personal identity.
Social care, health and public health practitioners work with older people in care homes to tailor support and opportunities to their needs and preferences, with the aim of maintaining and developing their personal identity.
Local authorities and other commissioning services ensure that they commission services from providers that can produce evidence of the actions they have taken to embed a culture of dignity and choice, and that staff are trained to work in partnership with older people in care homes in order to enable them to maintain and develop their personal identity.

What the quality statement means for service users

Older people in care homes are given support and opportunities to express themselves as individuals and maintain and develop their sense of who they are.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]

Enabled

‘Enabled’ refers to actions taken by staff working with older people in care homes to ensure that older people can maintain and develop their personal identity. This may include using life history to tailor support and opportunities to the needs and preferences of the individual. Staff should ensure that older people are able to choose their own clothes, have their most valued possessions with them and choose where to sit while they are eating. It may be necessary to adapt the older person’s environment and provide access to outdoor spaces. Staff should facilitate social inclusion by promoting and supporting social interactions and access to social networks, involvement with the community, and existing and new relationships. [Adapted from Dignity in care (SCIE guide 15), Choice and control and Social inclusion, and expert consensus]
Personal identity
This refers to a person’s individuality, including their needs and preferences, and involvement in decision-making in all aspects of their life. Maintaining a sense of personal identity can involve using life history to maintain and build a meaningful and satisfying life, as defined by the person themselves. Central to personal identity is the feeling of having a purpose in life, feeling valued, having a sense of belonging and a feeling of worth. Relationships, including those with family, carers and friends, are an important aspect of a person’s identity and can have a significant impact on mental wellbeing. An individual’s personal identity may change as their circumstances alter. [Adapted from Personalisation: a rough guide (SCIE guide 47), My Home Life: Promoting quality of life in care homes, ‘Voice, choice and control’ in care homes (Joseph Rowntree Foundation); and expert consensus]

Equality and diversity considerations

Staff working with older people in care homes should identify the specific needs arising from diversity, including gender and gender identity, sexuality, ethnicity, spirituality, culture, age and religion.
When ensuring that older people are enabled to maintain and develop their personal identity be aware of any learning disabilities, acquired cognitive impairments, communication or language barriers or cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
When collecting feedback from older people about whether they have been enabled to maintain and develop their personal identity staff should consider using alternative methods for older people who find it difficult to provide feedback. For example, tools such as Dementia Care Mapping can be used, and/or feedback from people who are considered suitable to represent the views of the older person such as family members, carers, or an advocate.

Recognition of mental health conditions

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have the symptoms and signs of mental health conditions recognised and recorded as part of their care plan.

Rationale

Mental health conditions are highly prevalent among older people in care homes, but are often not recognised, diagnosed or treated. Ageing with good mental health can make a key difference in ensuring that life is enjoyable and fulfilling. The recognition and recording of symptoms and signs of mental health conditions by staff who are aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise the symptoms and signs of mental health conditions in older people, and record them in their care plan.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to the symptoms and signs of mental health conditions in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners look for symptoms and signs of mental health conditions and record them in the older person’s care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to the symptoms and signs of mental health conditions in older people in care homes and to record them in a care plan.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise the symptoms and signs of mental health conditions (such as depression and anxiety) and record them in their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Mental health conditions
These include common mental health conditions such as depression, generalised anxiety disorder and social anxiety disorder, and may also include dementia and delirium. People may have more than one mental health condition at a given time. (See the NICE guidelines on dementia (NICE clinical guideline 42), depression in adults (NICE clinical guideline 90), depression in adults with a chronic physical health problem (NICE clinical guideline 91), delirium (NICE clinical guideline 103), common mental health disorders (NICE clinical guideline 123) and social anxiety disorder (NICE clinical guideline 159) for more information.)
Recognised
Recognised in this context relates to staff observing and recognising the symptoms and signs of mental health conditions, and sharing information and concerns with healthcare professionals, including GPs. Staff should be continually alert to new or worsening symptoms and signs. Observation of behaviour should happen on an ongoing basis and in response to the presentation of relevant symptoms. [Expert consensus]
Trained staff
This refers to staff who have been trained to recognise and record the symptoms and signs of mental health conditions when caring for older people. Staff should be alert to the presentation of new symptoms and signs and aware of existing conditions. Staff should also be competent in recognising when older people need a referral for assessment and management of the mental health condition. [Expert consensus]

Equality and diversity considerations

When looking for symptoms and signs of mental health conditions, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, sensory impairment and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Recognition of sensory impairment

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes who have specific needs arising from sensory impairment have these recognised and recorded as part of their care plan.

Rationale

Mild but progressive sight and hearing losses are a common feature of ageing and may go unnoticed for some time, but can have a serious effect on a person’s communication, confidence and independence. The recognition and recording of needs arising from sensory impairment by staff who are alert to the symptoms and signs and aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services. For older people in care homes this is essential to improve their quality of life and avoid isolation, which can have a detrimental effect on mental wellbeing.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise specific needs arising from sensory impairment in older people, and record these needs as part of their care plan.
Data source: Local data collection.
Process
Proportion of older people in care homes who have regular sight tests.
Numerator – the number of people in the denominator who have had a sight test within the past 2 years.
Denominator – the number of older people in care homes.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners are alert to and recognise specific needs arising from sensory impairment in older people in care homes and record them in their care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to specific needs arising from sensory impairment in older people in care homes and to record them in a care plan.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise needs that occur because of sight or hearing problems and record these as part of their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Recognised
Recognised in this context relates to the recognition by staff working with older people in care homes of the needs arising from sensory impairment and the sharing of information with healthcare professionals, including GPs. Staff should be continually alert to new and existing needs. This should involve monitoring of existing impairments and recognition of new sensory impairments. This is likely to include ensuring regular sight and hearing checks are arranged, cleaning glasses, and changing hearing aid batteries, or referral to an appropriately trained professional. [SCIE research briefing 21 and expert consensus]
Regular sight test
Adults are normally advised to have a sight test every 2 years. However, in some circumstances, the ophthalmic practitioner may recommend more frequent sight tests, for example in people who:
  • have diabetes
  • are aged 40 or over and have a family history of glaucoma
  • are aged 70 or over. [NHS Choices]
Sensory impairment
Sensory impairment most commonly refers to sight or hearing loss. It includes combined sight and hearing loss, which is frequently referred to as dual sensory impairment or deafblindness. [Adapted from Basic Sensory Impairment Awareness (NHS Education for Scotland) and Social care for deafblind children and adults (Department of Health)]
Trained staff
This refers to staff who have been trained to recognise and record the symptoms and signs of sensory impairment when caring for older people. Staff should be aware that there are many different types of sight and hearing loss, with a large variation in the degree of impairment. Staff should also be competent in recognising when older people need a referral for assessment and management of the sensory impairment. [Expert consensus]

Equality and diversity considerations

Sensory impairment is common in older people. It is frequently perceived as an expected feature of ageing rather than as potentially disabling. It is important that sensory impairment is not considered as acceptable for older people in care homes. This may need to be emphasised during training to increase awareness and recognition of sensory impairments.
When looking for signs or symptoms of sensory impairment, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Recognition of physical problems

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have the symptoms and signs of physical problems recognised and recorded as part of their care plan.

Rationale

Physical problems can cause discomfort and affect activities of daily living, participation in social activities and independence, and therefore mental wellbeing. The recognition and recording of the symptoms and signs of physical problems by trained staff who are aware of the role of the GP in the route to referral can help to ensure early assessment and access to appropriate healthcare services. This is essential to improve the quality of life and mental wellbeing of older people in care homes.

Quality measures

Structure
Evidence of protocols to ensure that staff are trained to recognise the symptoms and signs of physical problems in older people in care homes, and record them as part of their care plan.
Data source: Local data collection.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that staff are trained to be alert to symptoms and signs of physical problems in older people in care homes and to record them in a care plan.
Social care, health and public health practitioners look for symptoms and signs of physical problems in older people in care homes and record them in their care plan.
Local authorities and other commissioning services commission services from providers that can produce evidence of protocols for training staff to be alert to the symptoms and signs of physical problems in older people in care homes and to record them in care plans.

What the quality statement means for service users

Older people in care homes are cared for by staff who recognise the symptoms and signs of physical problems (such as pain, dizziness, problems with walking, constipation and continence problems) and record them in their care plan.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Physical problems
Examples of physical problems that could potentially affect a person’s wellbeing include, but are not limited to:
  • joint and muscular pain
  • undiagnosed pain
  • incontinence
  • dizziness
  • constipation
  • urinary tract infection
  • reduced ability to move without support
  • unsteady gait. [Expert consensus]
Recognised
Recognised in this context relates to the recognition by staff working with older people in care homes of physical problems and the sharing of information with healthcare professionals, including GPs. Staff should be continually alert to new physical problems and should monitor existing physical problems. [Expert consensus]
Trained staff
Trained staff refers to staff who have been trained to recognise and record the symptoms and signs of physical problems when caring for older people. Staff should be alert to the presentation of new symptoms and competent in recognising when older people need a referral for assessment and management of physical problems. [Expert consensus]

Equality and diversity considerations

When identifying an older person’s needs arising from physical problems, be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Access to healthcare services

This quality statement is taken from the mental wellbeing of older people in care homes quality standard. The quality standard defines clinical best practice in mental wellbeing of older people in care homes and should be read in full.

Quality statement

Older people in care homes have access to the full range of healthcare services when they need them.

Rationale

Older people in care homes typically have greater and more complex health needs than those living in the community, and these needs can affect their wellbeing if they are not addressed. Many care home residents experience problems accessing NHS primary and secondary healthcare services, including GPs. It is important that care homes have good links with GPs and referral arrangements, so that services can be accessed easily and without delay when they are needed. This is essential to prevent unmet healthcare needs from having a negative impact on mental wellbeing.

Quality measures

Structure
Evidence of referral arrangements to ensure that older people in care homes are given access to the full range of healthcare services when they need them.
Data source: Local data collection.
Outcome
Feedback from older people in care homes and from their family, friends and/or carers that they are satisfied with the care they have received.

What the quality statement means for organisations providing care, social care, health and public health practitioners, local authorities and other commissioning services

Organisations providing care ensure that they work in partnership with healthcare organisations to implement effective arrangements for access to primary, secondary, specialist and mental health services for older people in care homes.
Social care, health and public health practitioners facilitate access to primary, secondary, specialist and mental health services for older people in care homes by referring the person to the required service when they need it.
Local authorities and other commissioning services commission services from providers that can produce evidence of arrangements with local healthcare organisations which facilitate access to primary, secondary, specialist and mental health services for older people in care homes.

What the quality statement means for service users

Older people in care homes can see their GP and use hospital services when they need them.

Source guidance

Definitions of terms used in this quality statement

Care homes
This refers to all care home settings, including residential and nursing accommodation, and includes people accessing day care and respite care. [Expert consensus]
Healthcare services
These include primary care, and acute and specialist physical and mental health services. [GP services for older people living in residential care: a guide for care home managers. (SCIE guide 52)]

Equality and diversity considerations

When deciding if access to healthcare services is needed, staff working with older people in care homes should be aware of any learning disabilities, acquired cognitive impairments, communication and language barriers, sensory impairment, and cultural differences. Staff should ensure that they are aware of the needs and preferences of older people who are approaching the end of their life.
It is important that staff are aware that older people in care homes have the same right to access healthcare as people living independently in the community. This is stated in the NHS Constitution.

Effective interventions library

Effective interventions library

Successful effective interventions library details

Implementation

Information for the public

NICE produces information for the public that summarises, in plain English, the recommendations that NICE makes to healthcare and other professionals.
NICE has written information for the public explaining its guidance on each of the following topics.

Pathway information

Your responsibility

Guidelines

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this interactive flowchart is not mandatory and does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the interactive flowchart to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, health professionals are expected to take these recommendations fully into account, alongside the individual needs, preferences and values of their patients. The application of the recommendations in this interactive flowchart is at the discretion of health professionals and their individual patients and do not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Commissioners and/or providers have a responsibility to provide the funding required to enable the recommendations to be applied when individual health professionals and their patients wish to use it, in accordance with the NHS Constitution. They should do so in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, healthcare professionals are expected to take these recommendations fully into account. However, the interactive flowchart does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
Commissioners and/or providers have a responsibility to implement the recommendations, in their local context, in light of their duties to have due regard to the need to eliminate unlawful discrimination, advance equality of opportunity, and foster good relations. Nothing in this interactive flowchart should be interpreted in a way that would be inconsistent with compliance with those duties.
Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

Person-centred care

People have the right to be involved in discussions and make informed decisions about their care, as described in your care.
Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting information

Glossary

Paths in this pathway

Pathway created: February 2013 Last updated: March 2017

© NICE 2017

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