A case note audit of carers interventions
in an eating disorder inpatient unit
2012/13 (470)
Dr Thomas Hanly,
Alison Hall (deputy ward manager)
Audit Period: April 2013
Report Date: June 2013
Executive Summary
This audit was undertaken in response to thinking about how we meet the carers of patients on
our inpatient unit. We know that carers are asking for support and want to be of help to their
loved ones. We also know that carers experience high levels of burden and distress associated
with the caring role as well as increased levels of psychiatric morbidity. In addition most eating
disorder patients will be treated for the most part in a community setting where they may be
resident with or heavily supported by their friends families or carers so the support of carers is
imperative to the overall well-being of this patient group (c.f. Zabala et all 2009).
We developed a carer’s care plan on the ward for use by the nursing staff and to be administered
on or soon after admission. The plan was derived from a set of criteria derived principally from the
NICE guidance on the treatment of eating disorders. The case notes of patients over a years period
were sampled to review the carers care plan specifically as a proxy measure of support provided
to carers (no other part of the care record was reviewed).
Key findings
The carers care plan is being recorded for most patients but in 2/20 cases a care plan was not filled
in at all. Unfortunately in a relatively small sample this meant that no criteria would exceed the
90% compliance standard. One of the two patients for whom a care plan was not recorded had a
short admission of 10 days and took an unplanned discharge, the second patient certainly stayed
long enough to expect completion of the form and we concluded that the process was forgotten in
this. The use of the care plan is somewhat patchy (see the table below for the details). It may be
that carers’ interventions happen over several visits and previously unchecked items are not being
filled in even though the intervention may have happened. A limitation of not looking at the whole
case record is that an intervention may be recorded elsewhere. Nonetheless the care plan is
explicit that the service will use the care plan to evidence carers interventions. For the purpose of
this audit in the absence of the recording on the care plan it is assumed that the intervention did
not happen.
A number of results were particularly poor especially those items of signposting to support for the
carer themselves. We hope to explore this in further discussions with the team when the audit
results are fed back. It is disappointing that an intervention as easy as the offer of a textbook is not
scoring higher.
Key actions
The audit and a survey of staff that use the carers care plan were discussed in the LAEDS in-house
CPD session on the 18/09/2013. Following this a number of recommendations were made
1. A few qualifying remarks to some of the questions should be added e.g. “please record any
relevant rational in the notes”
2. A question should be added to indicate that the patient has not identified any carers
3. The signposting section should be scrapped and replaced with a leaflet for the carers
addressing the former signposting questions “Common concerns for those in a caring role
and how to address these.”
2 of 12
Executive Summary| Error! No text of specified style in document.
4. There was discussion about when the care-plan should be filled in. After a considered
discussion with the ward manager after the presentation he prefers that the care plan
remains an admission task and is completed at that time wherever possible.
5. It was agreed to hand the responsibility for further audit actions over to a member of the
ward nursing staff and thus embedding the audit among the group that are routinely using
the care plan.
Re-audit date
March 2014
Error! No text of specified style in document. | Executive Summary
3 of 12
Contents
Page
Executive Summary ............................................... 2
Key findings
2
Key actions
2
Re-audit date
3
Contents ................................................................ 4
Abbreviations
4
Background ............................................................ 5
Aim & Objectives:
7
Criteria & standards............................................... 7
Method .................................................................. 8
Page
Sample & data source
Audit type:
Service areas / teams included:
8
8
8
Results.................................................................... 9
Comments .............................................................. 9
Recommendations ................................................. 9
References ........................................................... 10
Appendix 1 Audit tool ..................................... 11
Appendix 2 Distribution list............................. 12
Appendix 3 Action plan ................................... 12
Abbreviations
LPT
Leicestershire Partnership Trust
LEADS
Leicester Eating Disorder Service
CPA
Care Programme Approach
CPD
Continuing Professional Development
MDT
Multi-Disciplinary Team
NICE
National Institutes of Care & Excellence
4 of 12
Contents | Error! No text of specified style in document.
Background
This audit aims to l improve the recording of carer interventions in an inpatient unit. The process
of introducing a carer’s care plan will prompt staff to consider carers needs in the assessment and
care planning of new inpatients on the Eating Disorders Unit. The recent revision of the
Leicestershire Partnership Trust CPA policy reflects a national drive to “Refocus the Care
programme Approach” and underpins a commitment to carer support which is a driver for this
audit.
NICE guidance (reference 2) also reflects on the needs of carers. It expects that although for most
eating disordered patients treatment will occur on an out-patient basis, a small percentage will
need inpatient care. Typically patients on inpatient units will have failed to progress in treatment
as an out-patient, there may be concerns about physical health including rapid weight loss or
concerns about mental health co-morbidities such as depression or anxiety disorders. Clearly for
patients who have been difficult to treat then the assessment and planning of carer needs and
support is particularly important.
Throughout the NICE review process, the carer perspective was provided through a focus group
held with carers. The main objective of the group discussion was to discuss carers’ views
concerning communication with clinicians and other professionals, including guidance on
responsibility and expectations of clinicians, carers, and people with eating disorders.
The recommendations from the NICE review in respect of carers are
 “That good practice with regard to confidentiality should not be accepted as an excuse for
not listening to or communicating effectively with carers”.
 “Carers should be given sufficient information by medical and mental health services in a
way that they can readily understand, to help them provide care effectively” (Department
of Health, 2003).
 “Carers themselves have expressed a wish for quality information and effective
communication including information about eating disorders and about physical risk”.
 “Carers wish to be included in their relative’s “treatment team” and to be given the
opportunity to learn from and benefit from the support of others who have been in the
same situation”.
 The UK government has recognised the important role and contribution that carers provide
for people with a range of mental health problems and information and guidance is
available through a website (www.carers.gov.uk).
In parallel with NICE guidance there is an increasing recognition of the needs of carers in the
scientific literature. A meta-analysis conducted in 2009 demonstrated the considerable stress and
burden placed on carers as a result of their caring role, emphasising that the carers of individuals
with eating disorders experience high levels of distress, burden and disability on a par with carers
of patients with other major mental illness (reference 3). Several voluntary agencies are
championing the needs of carers e.g. “Beat” who are offering their “quality assured” mark to
agencies that demonstrate that they meet the needs of carers (reference 4). As a result of this
increasing awareness several attempts have been made to address the issue through information,
Error! No text of specified style in document. | Background
5 of 12
self-help and research (e.g. 1)“Skills-based Learning for Caring for a Loved One with an Eating
Disorder: The New Maudsley Method” 2) “The Clinician's Guide to Collaborative Caring in Eating
Disorders” Treasure et al. 3) a self- help DVD based programme and 4) at least one research study
to assess the effectiveness of a carers intervention (CASIS) (reference 5).
In devising this audit we have made our local carers group for eating disorders aware that we are
looking at this area of practise and they agree that this is useful and desirable. We propose to
disseminate the results of the audit to this group.
There is an increasing awareness of the needs of carers in mental health and recognition of the
important and central role that carers play in the support of patients. This needs to be reflected in
the assessment and care planning of carers needs on our inpatient unit.
Context of the audit:
The Beaumanor unit is a 15 bedded unit for the inpatient treatment of anorexia nervosa.
Treatment on the unit is provided individually and in groups consisting of assessment and planning
of care within a frame of clear roles and responsibilities for staff and patients. In brief patients are
supported to restore their weight through support with eating and compensatory behaviours as
well as several interventions looking to address precipitating and maintaining factors for the
eating disorder including the impact of this on social, vocational and other relationships.
Interventions are led through a system of key working patients with processes to review care at
various points in treatment, (CPA reviews and weekly MDT meetings). A key aspect of the care
programme approach (reference 1), the organising principle for care provision in mental health
services, is the recognition of service users’ wider social relationships to their well-being and
recovery. Carers often provide significant care and support to patients both as inpatients but
especially in community settings where they may be offering support on a daily basis. A careful
and comprehensive assessment of the needs of carers in their own right is an important part of
service provision and statutory services should pay attention to meeting these needs. Carers need
to be recognised as important players in the care network of any patient. The care they provide
may involve physical help, emotional support, financial and housing support and indeed a carer
may be compromised because of their caring role in terms of meeting their own needs and
maintaining their own well-being.
A clear and comprehensive approach to meeting the needs of carers is likely to improve the care
and well-being of patients. We hope to improve our practise on the ward. We have identified that
current practise is neither comprehensive nor consistent (in the absence of a shared framework
we might expect that individual practise among team members might be idiosyncratic/ patchy).
6 of 12
Background | Error! No text of specified style in document.
Aim & Objectives:
Our aim in this audit is to review the assessment and care planning of the needs of carers on the
ward as a ward process.
Criteria & standards
In order to do this we have referenced NICE guidance on Eating Disorders and the local CPA trust
policy. We have derived a set of criteria from these and set >95% compliance as our standard for
each criterion. The criteria are as follows:





Patients will be asked to identify those people they see as having a caring role in respect of
their problems
Their permission to contact these carers will be sought as well as to discuss treatment
issues with them
In the absence of such permission a rational for refusing permission and discussion about
the implications of this decision will be explored and recorded.
Carers should be given information about the patient’s condition and the risks associated
with it as well as information on how to manage this
Carers should be asked about issues that might undermine their capacity to provide care
such as help with finances, housing, their own physical and mental health needs and issues
about achieving a caring for /life balance
We looked at NICE guidance and the LPT CPA policy and derived criteria from these.
The following is quoted from the LPT CPA policy (carers section).
 “All staff in mental health and partner agencies have a responsibility to support carers and
signpost them as necessary”.
 “Indeed local authorities have a legal duty to offer carers who provide or intend to provide
“regular and substantial care” an assessment of their own needs where the service user
they care for is eligible for services”.
 “Staff who come into contact with carers should inform them of their right to an
assessment and help them access this”.
 “Carers have a right to their own assessment whether or not the service user consents to
this or not”.
NICE recommendations are stated above.
Thresholds of compliance
Key:
Full compliance
x  95%
Partial compliance
90% x <95%
Error! No text of specified style in document. | Criteria & standards
Minimal compliance
x < 90%
7 of 12
Method
The audit tool will be applied (see appended) and levels of compliance against each criteria
collected. Looking at the care plan can be assumed to be a proxy measure of performance in this
area.
The data will be calculated by hand and presented in bar graph form showing % compliance.
Post audit and action planning:
Dr Thomas Hanly and Alison Hall will compile a report and present this to the inpatient team on
the Langley ward (the base has moved in the course of the audit) as part of the in-house CPD and
also to the service managers through the management team meeting. Presenting the results to
the team will allow us to develop an action plan collaboratively to improve on the processes as
necessary and to explore any problems with compliance (e.g. it may be that staff attitudes/ values
will need to be explored, the importance of the practise may need to be restated etc.)
Any cause for concern raised by this audit will be discussed with the ward manager and the service
lead immediately and a plan devised to address the concern.
Caldicott principles have been considered in devising this audit, we feel it is justified to collect this
information and only necessary information is being gathered. Patient confidentiality is being
guarded by not having any information/data that might identify a patient in the process of the
audit or in the reporting stages.
Sample & data source
In terms of a sample we will apply the tool to a review of ones years case notes (approximately 26
patients based on previous figures) starting from April 2012. We know from a brief case notes
review that the recording of the needs of carers and carer interventions is at best sporadic and
heterogeneous which we are taking as our baseline position. We are using the case record
specifically the carers care plan as the source of evidence of an intervention with carers.
One year’s admissions will be surveyed by looking at carers care plans in the case records (this is
approximately 26 case records based on previous rates of admission). Given that this is a lengthy
period over which to conduct the audit we will informally review the use of current care plans on
the ward every 3 months or so (usually 15 patients in residence at any one time) and if we identify
any dangers of continuing the audit (e.g. clear evidence that practise is not improving or that areas
of practise are being significantly neglected) then we will bring this to the attention of the service
lead and consider stopping the audit prematurely.
Audit type:
Retrospective case note audit.
See Appendix 1 for a copy of the audit tool
Service areas / teams included:
Eating disorders inpatient ward in FYPC.
It is noted the eating disorder unit is now known as Langley (formally Beaumanor ward).
8 of 12
Method | Error! No text of specified style in document.
Results
Criteria
Number
Patient has given (or denied) permission to contact their carer
Patients agree (or disagree) that staff may discuss with carers issues related to
the treatment plan or progress
Rationale for refusing consent has been recorded
Implications of refusing consent have been discussed and the patients
concerns explored
Carers informed of the diagnosis
Carers have been educated on the presentation and risks associated with the
diagnosis
Offered a loan of the “treasure carers book”
Given a copy of the carers pack (or it was declined)
Given the ward contact details
Carers consented to the recording of their contact details
Orientated to the ward
Details regarding visiting times and parking
Signposted to support for themselves-carers groups-local
Signposted to support for themselves-carers groups-out of area
Signposted to support for themselves-financial and housing (or judged to be
not applicable)-local
Signposted to support for themselves-financial and housing (or judged to be
not applicable)-out of area
Signposted to support for themselves-physical and mental health needs (or
judged to be not applicable)-local
Signposted to support for themselves-physical and mental health needs (or
judged to be not applicable)-out of area
Signposted to support for themselves-help achieving a caring for/life balance
(or judged to be not applicable)-local
Signposted to support for themselves-help achieving a caring for/life balance
(or judged to be not applicable)-out of area
18/20
18/20
Compliance
%
90%
90%
2/2
1/2
100%
50%
16/20
15/20
80%
75%
12/20
16/20
17/20
15/20
14/20
17/20
5/10
4/10
5/10
60%
80%
85%
75%
70%
85%
50%
40%
50%
7/10
70%
5/10
50%
6/10
60%
5/10
50%
6/10
60%
Comments
The results of the audit were presented to the team at the in-house CPD slot on the 18/09/13. The
results from a survey conducted to gather staff views on using the care plan were also presented.
Recommendations
Staff reported difficulties with the signposting section and following discussion it was agreed that:

This section would be taken out of the care plan and replaced by a leaflet perhaps titled
“you may be worried about…..” addressing the questions in the current care plan in the
signposting section. A leaflet could cover these questions (to be devised) and provide
practical advice on how to address these issues. Action: Dr Hanly
Error! No text of specified style in document. | Results
9 of 12

It was agreed that it might be useful to discuss with partner agencies in our clinical network
for counties other than Leicester, how they address these carer concerns in their localities
and to identify points of contact that could be contained in the leaflet. Action: Dr Hanly
There was discussion about when the care plan should be filled out and various options explored.
Following a subsequent discussion with the ward manager it is agreed that:

The care plan will be completed on the day of admission as a standard practice and this
should be even more achievable especially with the removal of the signposting section.

The care plan should have a box to identify if “no carer is identified” and this should be
added to the plan. Action: Dr Hanly

It was agreed that the ward manager will identify a member of the ward team to take this
audit on as lead and Dr Hanly has agreed to continue to offer advice as necessary. Alison
Hall has moved to the out-patient team and will not continue to have involvement with
this audit. Action Paul Williams ward manager
References
1. Refocusing the Care Programme Approach: policy and positive practice guidance-department of
health guidance 2008
2. Eating disorders: Core interventions in the treatment and management of anorexia nervosa,
bulimia nervosa and related eating disorders 2004
3. Appraisal of Care giving Burden, Expressed Emotion and Psychological Distress in families of people
with Eating Disorder: A systematic review: Zabala, Treasure et al 2009
4. B-Eat Assured: http://www.b-eat.co.uk/beatassuredQualityMark
5. Collaborative Caring Project: Carers Assessment, Skills and Information Sharing (CASIS): Institute of
Psychiatry, London
10 of 12
References | Error! No text of specified style in document.
Appendix 1 Audit tool
11 of 12
Error! No text of specified style in document. | Audit tool
Appendix 2 Distribution list
Target audience
FYPC Clinical Audit Group
To (for action)Name, designation
For approval
Clinical Audit Standards & Effectiveness Group
LEADS team (at in house CPD)
For Information
For Information
Appendix 3 Action plan
Objective
Improve signposting for carers of patients
Address carer concerns
Improve completion of care plan
Re-audit
12 of 12
Level
of Risk
Agreed Action
By Whom
By
When
Jan
2014
Resources
Required
Action
complete
Dr Hanly
Jan
2014
Action
complete
Dr Hanly
Sep
2013
Action
Complete
Signposting section to be taken out of the care plan and
replaced with leaflet.
To develop leaflet perhaps titled “you may be worried
about…..”
Contact partner agencies in clinical network for counties other
than Leicester; consider how they address these carer
concerns in their localities and to identify points of contact
that could be contained in the leaflet.
a)It was agreed at the CPD session the care plan will be
completed on the day of admission as a standard practice
Dr Hanly
b)Care plan should have a box to identify if “no carer is
identified”
Dr Hanly
The ward manager will identify a member of the ward team to
take this audit on as lead
Paul Williams
ward manager
Action
Complete
March
2014
Error! No text of specified style in document. | Distribution list