IT was with some dismay I read Healthcare Improvement Scotland's audit of care of older people in acute hospitals.

While there was some good ­practice which identified 25 areas of strength across eight inspections, there were 87 areas identified for improvement, including issues such as staff not always using appropriate and respectful language when referring to older people in hospital.

In three hospitals, inspection staff found a lack of meaningful stimulation and activity for patients and, across all hospitals inspected, staff were not completing food and fluid balance charts accurately or consistently.

This audit comes some five years after the Scottish Parliament cross-party group on Alzheimer's, which I chaired, produced a report with recommendations on how to improve the hospital experience of older people with dementia.

The report recognised that, by taking simple measures, we can save lives: minimising hospital moves, ensuring good hydration and nutrition and understanding the importance of exercise and stimulation.

We know that increased mortality rates, higher re admission rates and functional decline are associated with this vulnerable patient group.

The report should be operational in every health board. So why do we still read of so many system failures?

Previous inspection reports from the Care and Mental Welfare Commissions make for distressing reading. Despite a highly developed policy structure, reports containing damning information about the care and treatment of older people across all care settings are still being published.

The Dementia Carer Voices project regularly receives reports of less than satisfactory care that falls far short of what would be expected.

The central problem is that the gap between policy and implementation is widening to become a gulf.

The role, paid and unpaid, of caring for older people is undervalued. We pay the lowest wages with the worst conditions of service for those who look after our most vulnerable. We need to raise the profile and status of caring and pay appropriate wages. Besdies being the right thing to do, the economic argument around keeping people well in their own home supported by carers who receive proper allowances is incontrovertible.

As to institutional failures, it is time to get tough.

Frail older people are at risk but people with Alzheimer's and dementia are at particular risk due to their difficulties articulating how they are being treated. We rightly accept the importance of protecting children in our society. We have an independent Commissioner for Children and Young People to protect their rights and give them a voice. We have yet to place the same value on those with dementia and frail older people.

Sarah Rochira, the Independent Older Person's Commissioner in Wales, challenged the Health and Social Care Alliance annual conference to ask the question what constitutes abuse - lack of nutrition, hydration, inappropriate restraint, no outdoor activity, waiting for a bedpan -- and why there are so few prosecutions for elder abuse.

If we are not completing nutrition and hydration charts, how do we know how well someone has eaten across changes in staff shifts? When staff tell patients they'll be there in five minutes with a bedpan - and this becomes 20, is this acceptable?

There needs to be what might feel like an uncomfortable discussion about sanctions and prosecutions. It is a language many politicians and professionals don't like. Interestingly, it's a language with which the Welsh Commissioner seems comfortable .

A clear message about the ­parameters of inappropriate and inadequate care and treatment of older people in Scotland is overdue. When does inadequate become criminal? How many prosecutions have taken place for elder abuse? We have no qualms about discussing these matters in regard to children so why are we so reticent to act on behalf of our older people?

There has to be independent accountability in the system to ensure that change happens. Maybe it is time for Scotland to look to the Welsh Commissioner's Office for a solution.