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Wellbeing and Health Rounds and Champion Carers: Evaluation Report of a nine month pilot in four Sutton Residential Homes

Programme: Sutton Homes of Care Vanguard November 2017

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Contents Page number

1.0 Executive Summary……………………………………………………………………………. 3 2.0 Background to pilot…………………………………………………………………………….. 4

2.1 Research evidence ……………………………………………………………………….. 4 2.2 Local population……………………………………………………………………………. 5 2.3 Introduction to the pilot……………………………………………………………………. 5

3.0 The Wellbeing and health Round……………………………………………………………. 6 3.1 Quantitative outcomes and impacts…………………………………………………….. 7 3.2 Qualitative outcomes and impact………………………………………………………... 14 3.3 Discussion…………………………………………………………………………………. 15

4.0 Champions……………………………………………………………………………………… 15 4.1 Qualitative outcomes…………………………………………………………………....... 16 4.2 End of Life care Champions: Quantitative outcomes and impact………………… 18

4.3 Falls Champions: Quantitative outcomes and impact………………………………… 20 5.0 Financial costs of pilot…………………………………………………………………………. 21 6.0 Emerging outcomes from qualitative data…………………………………………………… 23

6.1 Key requirements for effectiveness…………………………………………………... 23 6.2 Key requirements for undertaking a pilot and measuring impact ………………… 24 6.3 Options for development of model……………………………………………………….. 24

7.0 Conclusion………………………………………………………………………………………. 25 8.0 Going forward………………………………………………………………………………...... 25 9.0 References…………………………………………………………………………………...... 26

10.0 Appendices……………………………………………………………………………………… 27

A Template for data collection from Care Home Managers B Template for data collection from Falls Champions C Research tasks D Template for collecting qualitative data E Wellbeing and Health Round framework and FAQ F Framework for Champions roles G Framework for Champion roles falls H Framework for Champion roles EOLC I Qualitative report by Dr Stephanie Fade PhD

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1.0 Executive summary

Residents of care homes are becoming increasingly frail with complex healthcare needs that

require proactive management in order to maximise their quality of life. A pilot of a new model of

care was set up in four residential care homes within Sutton which involved a wellbeing and health

round (WBHR) and a clinical champion model.

The aim of the WBHR pilot was for liaison nurses to deliver weekly proactive care to residents. The

aim of the clinical champion model was to improve the quality of care to residents by preventing

falls and providing end of life care, by adopting agreed shared initiatives and ensuring experiences

were cascaded to other care staff.

The combined initiatives were expected to deliver an improvement in the wellbeing and health of

residents in the pilot residential homes. The improvements expected were:

reduced falls, ambulance incidents, ambulance conveyances, A&E attendances and non-

elective admissions (NELs);

increased number of residents having Advance Care Plans (ACP), having Coordinate My

Care (CMC) records (the local e-PACC system), and achieving their preferred place of

death (PPD);

Increased confidence and competence of care staff.

Following a nine month pilot, the four pilot homes appear to be performing better than the non-pilot

homes on ambulance conveyances and A&E attendances, and are showing signs of sustained

improvement in these two areas. NEL admissions in four pilot homes have not shown an

improvement against non-pilot homes, although the activity levels of both groups of homes are

within their boundary control lines so they are performing as they are expected to, with the ongoing

support of the Vanguard programme. Neither group of homes has demonstrated a sustained

improvement on NEL admissions. One home appears to be responding positively to the pilot as an

impact can be seen with ambulance incidents and conveyances, and there appears to be some

impact on its hospital activity. For the other three homes the pilot appears to have had no impact

on the key ambulance and hospital outcome measures.

These results may be due to a number of factors. A key factor is that all residential homes have

been exposed to a number of initiatives to support them to provide better care over an 18-month

period prior to the pilot. Another factor could be that the length of the pilot was only nine months

which for a new model of care is a short time within which to expect large changes. A further factor

could be that there was a change to the staffing structure within The Royal Marsden Community

Services (RMCS) who were providing support to the homes and champions. Other factors could

include changes in the care homes themselves, such as, changes to care home managers and

other key personnel, which the Vanguard had no influence over.

The introduction of care home staff champions in falls and EOLC has shown positive changes. The

percentage of residents on CMC records has increased in each of the pilot homes. In addition, the

number of care home falls and residents who have fallen have been gradually decreasing,

although results are variable as expected within this cohort of frail elderly residents. Therefore, the

conclusion is that the champion role has been shown to be effective within the care homes. The

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evidence suggests that for sustainability the champion and the staff in the home need to be willing

to make changes and promote new initiatives.

Going forward, the wellbeing and health round model is being progressed by RMCS with Sutton’s

care homes. The champion role is being promoted at an event for care home mangers where the

role will be described and discussed to enable care home managers to understand how to embed

it in to their homes. Following this, a session will be organised for all newly identified champions to

attend. There will be presentations from clinical leads from EOLC, and Care home support team, to

enable swift implementation across the homes. Take up by the care homes of this offer has been

incredibly positive.

2.0 Background to pilot

2.1 Research evidence To ensure care home residents live well and have the best quality of life, proactive and

preventative input is required. Providing routine checks by health care professionals, avoidable

health problems such as falls can be minimised and acute illness detected early to prevent

potentially serious consequences. (National Institute for Health Research Annual report, 2017)

National Institute for Health and Care Excellence, guidelines for Mental Health of Older People in

Care homes (2013) identify one of the problems facing residents is the lack of access to healthcare

services which can impact on their mental wellbeing. The WBHR would identify resident’s needs

earlier, the liaison nurse working closely with the care homes to improve and support the resident’s

access to healthcare services. The liaison nurse will provide guidance to care homes, thus

preventing deterioration in both physical and mental health. Evidence from a project providing

nursing support within residential care homes (University West England, 2008) showed that by

introducing dedicated nursing and physiotherapy, hospital admissions and nursing home transfers

were reduced, care staff education improved and early detection of illness with early intervention

led to improved quality of life with evidence of cost savings.

There is less evidence for promoting champions in care homes however a joint venture between

BUPA and Alzheimer’s Society in 2009, showed that by promoting dementia champions significant

improvements in the lives and daily experiences of people with dementia in care homes was noted.

Nutrition Champions in Scotland reported that by participating in a six month programme provided

them with an excellent grounding in nutrition allowing changes to be made within the care homes

and improved their knowledge and confidence in all aspects of practice. It gave them the

opportunity to challenge and raise awareness of ways to improve nutrition with staff and share

experiences with other Nutrition Champions. (Scottish commission for the regulation of care, 2009)

Further evidence can be seen from a Hydrate in care homes project (Colson.S and O’Callaghan.S

2014) where Hydration Champions in care homes undertook bespoke training to reduce urinary

tract infections (UTI’s), falls and subsequent associated admissions. Feedback from the care staff

included 100% saying they would recommend the project to others, and said staff were more

aware of importance of hydration and all had enjoyed their role. Managers reported a change in

long term practice with a reduction in UTI’s and falls. Although the Sutton pilot did not directly

record the reduction in fracture neck of femurs (#NOF), this project highlighted an actual cost

savings of £86,524 for acute admissions associated with #NOF.

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East and North Hertfordshire Vanguard Programme (2016) have delivered a Complex Care

Premium, developing champions in six areas. The expectation of the champions was to train,

mentor and coach staff in their specialist areas. The goal was to up skill staff to improve confidence

when supporting resident’s wellbeing and health. This has demonstrated lower ambulance call

outs, reduction in falls and confident staff team. The premium has reduced hospital admissions and

improved communications with clinical professionals with one home reporting that “this programme

has enabled all of our staff to gain confidence and knowledge of our client’s needs, improving our

care standards, resulting in a reduction of ambulance call outs, A&E visits and admissions.”

Champions within this model are renumerated and sustainability of this model is not known. In the

Sutton Homes of Care model, it was therefore agreed that there would be no financial

compensation for the champions to allow other care homes the opportunity to adopt champions in

the future.

By introducing Falls and EOLC Champions to Sutton care homes, the pilot was expecting a

reduction in falls in the care homes and an increase in the number of residents with an Advanced

care plan and achieving preferred place of death. The champions would be confident in their

agreed area and cascade information to their peers.

2.2 Local population Sutton is an outer London borough with a population of 198,134 (Joint Strategic Needs

Assessment 2014). Sutton has 81 care homes, of which 18 are nursing, 11 are residential and the

remainder are for those with learning disabilities or mental health needs. There are a total of 1300

beds, of which approximately 30 per cent are funded through statutory provision by health or social

care and the remainder are funded privately. Sutton has been working in partnership with local

care homes since April 2014 and various initiatives have been implemented during the last 2 years

including, sign-posting and education packages, care home manager forums and bespoke training

from in-reach community nursing. Within the first year of this work, Sutton saw a reduction in non-

elective admissions from care homes across the area of between 10-14 per cent. Sutton was

awarded Vanguard status in spring 2015 based on these achievements.

2.3 Introduction to the pilot An initial task and finish group involving stakeholders and representatives from residential care

homes was held in September 2016 where options regarding the pilot were discussed and the

group agreed to pilot wellbeing and health rounds in four residential homes plus champions for falls

and end of life care as it was recognised these were areas where the homes would benefit from

further training and support.

The pilot was launched in November 2016 with an event attended by the four home managers and

their two champions, representatives from the Supportive Care Home Team, formerly known as

the End of Life Care (EOLC) team, falls team, liaison nurse and a GP. At the event outcome

measures, metrics and further dates for evaluation were agreed.

The residential homes agreed to complete a monthly data set and the Falls Champions within the

homes agreed to monitor and submit monthly falls data (Appendix A and B). The liaison nurses

would produce monthly statistics to determine time spent in the homes completing a WBHR and

additional tasks completed. The EOLC team monitored training in the homes and the number of

residents offered an advanced care plan and recorded on CMC.

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Alongside quantitative analysis of data, the evaluation undertook analysis of qualitative data, to

monitor how the residential home managers, champions, liaison nurses and EOLC team thought

the pilot was progressing. This data was gathered through questionnaires completed by care home

managers, champions, liaison nurses, end of life care nurses, and a GP.

Discussion at evaluation events facilitated change using quality improvement (QI) methodology to

both the structure of WBHR and the role of the Champions. The results are highlighted in this

report (see section 4). Attendance at the events was variable due to rota’s, staffing, leave and

change in the number of Champions involved with the pilot (Details are listed in Appendix C and

D).

The pilot was extended from four months to nine due to changes in staffing within teams and

ceased on the 31st July 2017. However, it was agreed with The Royal Marsden Community

Services they would continue the support within the four pilot homes and the Champions agreed to

continue their roles post pilot.

At the start of the pilot it was agreed by all that an established liaison nurse would provide a weekly

WBHR to four pilot residential homes. This aimed to deliver dedicated pro-active nurse input to

residents and to provide support to the care staff champions who would be available to provide

feedback on the rounds.

In the initial stages of the pilot, it became apparent that the champions would not be always be

available for WBHR due to rotas and the added workload with their new role. Using The Plan-Do-

Study-Act (PDSA) cycle, working with the care staff and managers it was agreed a senior carer or

manager would be available for the rounds. Therefore, the pilot was reconfigured into two strands,

one for the Champions and a second the WBHR, which would be working alongside each other.

3.0 The Wellbeing and Health Round (WBHR)

Considering this evidence, the aims of the Wellbeing and Health Round pilot were to:

1. Provide preventative and proactive healthcare including a formal review of the residents’

care plan every six months.

2. Reduce avoidable admissions to secondary care and inappropriate/unnecessary use of

emergency and urgent care services by care home staff

3. Facilitate effective working relationships between the care home, liaison nurses and GP

and to support multidisciplinary decision-making regarding residents’ care

Weekly WBHR commenced with one liaison nurse in four homes, this was increased to two as the

pilot progressed and staffing within care home support team of The Royal Marsden Community

Services evolved. The WBHR involved:

1. Reviews of residents with acute needs not requiring GP

2. Six monthly reviews of residents to identify any changes to health and/or wellbeing

3. Guidance for referrals to other specialities plus referrals if appropriate, working closely

with other departments within RMCS

4. Identification of any bespoke training needs of care staff

5. Identification of residents requiring medication reviews

6. Feedback to the GP following the round

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3.1 Quantitative outcomes and impact The WBHR were expecting to reduce the following key outcome metrics:

A&E attendances

Non-elective admissions (NEL admissions)

Ambulance call outs (incidents)

Ambulance conveyances

A&E attendances Analysis of A&E attendances from the four pilot homes individually and the pilot group versus the

non-pilot group of homes are shown in graphs 1 to 6. For the individual homes, the graphs indicate

that from the start of Vanguard to end of pilot there is not a significant decline except in graph 3,

care home 3. However, when the four pilot homes are compared to the seven non-pilot homes, as

seen in graphs 5 and 6, it is clear that within the pilot homes some improvement is happening. This

is shown by looking at the last nine months the pilot homes are close to or below the mean apart

from in April 2017, whilst in comparison non-pilot homes are above the mean in six out of the last

nine months. The care homes in the non-pilot group and the pilot group are both supported by

Sutton CCG GPs which enables the groups to be compared. Both groups of homes are within the

control lines so they are performing as would be expected due to the ongoing input from Vanguard

initiatives already implemented.

These positive results would appear to indicate that the liaison nurses with the weekly WBHR are

impacting on ambulance conveyances and A&E attendances by promoting proactive care. Training

on the deteriorating resident has ensured that changes to a resident’s wellbeing and health are

detected early, with care staff feeling empowered to refer appropriate residents to either the liaison

nurses or other Health Care Professionals (HCP) in a timely way, to facilitate the development of

care plans to address these needs before a crisis arises.

Falls and EOLC Champions can impact on inappropriate A&E attendances too. Falls Champions

have achieved this by introducing initiatives, reflecting on the reasons for falls and implementing

agreed planned support. EOLC Champions have been working closely with the Supportive Care

Home Team to ensure the residents in the pilot homes are offered an ACP and CMC record. By

residents having these plans secondary care activity could be reduced as residents who have

chosen to remain in their home at the end of their life are not being taken to A&E unnecessarily.

The peaks seen in the graphs could be due to a number of factors. The peaks between October

and December 2016 could be due to the availability and continuity of the liaison nurses and a

member of care home staff being identified at this time for the WBHR. The structure of the WBHR

was still to be finalised and changes were implemented following the midpoint evaluation in

January. Peaks around January to March 2017 saw the introduction of two new liaison nurses

ensuring continuity of WBHR and proactive care. The April 2017 peak maybe due to the

introduction of Telehealth Pods in non-pilot homes as the liaison nurses were required to oversee

their introduction and assist the homes to input data, thus making them less available for WBHR in

pilot homes. In September 2017, which although outside of the pilot timeframe was included to

allow quarterly analysis of few data points, one pilot home had 4 A&E attendances; this home was

awaiting a new manager and had been without one for three months.

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Graphs 1-6 showing A&E Attendances Control lines (green for the lower and upper limits, and red for the mean/average) are set using 2013/14, 2014/15 and 2015/16. The purple vertical line indicates the start of the pilot.

Pilot homes A&E attendances per 100 beds each quarter for four pilot homes

ANONYMOUS DATA Graph 1 Graph 2

Graph 3 Graph 4

Pilot Homes compared with non-pilot homes A&E attendances per 100 beds each month for pilot and non-pilot homes Graph 5 Graph 6

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NEL admissions Analysis of NEL admissions from the four pilot homes individually and the pilot group versus the non-pilot group of homes are shown in graphs 7 to 12. Care Home 3 in graph 9, appears to be the only home of the four homes that is responding to targeted support of a weekly dedicated WBHR and liaison nurse. This conclusion is drawn because for two out of four quarters after the pilot started activity is below the mean, and two quarter are just slightly above the mean, and because prior to the pilot the three previous quarters were much higher than the mean. However, all the charts from the pilot homes show that the number of NEL admissions from the homes are within the expected levels for each home. In graphs 11 and 12 pilot homes are compared with non-pilot homes. The seven care homes in the non-pilot group are ones that are supported by a Sutton CCG GP but did not participate in the residential home pilot. Both groups of homes are within the control lines set using the previous three years of data so are performing as they have done in the past with the ongoing input from Vanguard initiatives. Neither group of homes are showing sustained improvement since the start of the pilot. The reasons for the residential home pilot not reducing NELs admissions are difficult to determine. One reason could be due to the residents living longer and exceeding the national average of 2.3 years in residential care. Generally, care homes residents are becoming frailer with worsening long term conditions (British Geriatric society, 2015) and a number of NEL admissions are appropriate and to be expected.

Graphs showing NEL admissions

Control lines (green for the lower and upper limits, and red for the mean/average) are set using

2013/14, 2014/15 and 2015/16. The purple vertical line indicates the start of the pilot.

Pilot homes NEL admissions per 100 beds each quarter for four pilot homes

This data is anonymised Graph 7 Graph 8

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Graph 9 Graph 10

Pilot Homes compared with Non-Pilot Homes NEL admissions per 100 beds each month for pilot and non-pilot homes Graph 11 Graph 12

LAS Callouts and Conveyances Analysis of LAS call outs and conveyances from the four pilot homes individually and the pilot group versus the non-pilot group of homes are shown in graphs 13 to 22.Graphs 13 to16 show LAS callouts to the four pilot homes. From examining graph 15, it appears that care home 3 has responded to the support provided by WBHR and champions because over the last ten months only two months are above the average activity levels.

Reasons for the variation in the activity in the homes may be attributable to a change in management, with one home being without a manager or clinical lead for two months at the end of the pilot. Leave and recruitment will impact on staffing levels in the care homes with an increased use of agency and bank staff who may not have the confidence or knowledge of the residents. As with NEL admissions the callouts may have been appropriate for this cohort of residents.

When comparing the pilot homes with the non-pilot homes shown by graphs 17 and 18, there is less variation around the mean with the pilot homes than the non-pilot homes. All homes are within their control lines but there is no sustained improvement for the nine months of the pilot.

LAS conveyances in the four pilot homes are shown in graphs 19 to 22. Care Home 3 is showing a similar picture with conveyances as callouts. It appears it is responding to targeted support as over the last ten months only two months are above the average, and one of those is just above average. The other care homes are not showing the same positive response to pilot. The residents in the care homes are frail and the conveyances may have been required to ensure their health

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need is responded to appropriately. Also, the data does not clarify whether the conveyances were for individual residents who may hay have required more than one conveyance.

To understand these results and the full effect of the pilot on the four care homes, a further breakdown may be required.

Comparison of conveyances for the pilot homes and non-pilot homes, as seen in graphs 23 and 24, shows that since the pilot, neither group of homes are showing sustained improvement. However, the conveyances from the pilot homes are on or below the mean for 13 of the 16 months, just not consecutively for seven or more months. System change takes time and a short term pilot may not provide positive sustainable results immediately Graphs showing LAS Callouts and Conveyances Control lines (green for the lower and upper limits, and red for the mean/average) are set using 2013/14, 2014/15 and 2015/16 up to October 2016. The purple vertical line indicates the start of the pilot. Pilot homes LAS Callouts per 100 beds each month for four pilot homes

This data is anonymised Graph 13 Graph 14

Graph 15 Graph 16

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Pilot Homes compared with Non-Pilot Homes LAS Callouts per 100 beds each month for pilot and non-pilot homes

Graph 17 Graph 18

Pilot homes LAS Conveyances per 100 beds each month for four pilot homes

This data is anonymised

Graph 19 Graph 20

Graph 21 Graph 22

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Pilot Homes compared with Non-Pilot Homes LAS Conveyances per 100 beds each month for pilot and non-pilot homes

Graph 23 Graph 24

Conclusions Pilot homes

Care Home 1 – There appears to be no impact on any of the above outcome measures.

Care Home 2 – There appears to be no impact on any of the above outcome measures.

Care Home 3 – It appears that this is the only home responding positively to the pilot as an impact can be seen with ambulance incidents and conveyances, and as there appears to be some impact on A&E attendances and NEL admissions.

Care Home 4 - There appears to be no impact on any of the above outcome measures. Observation by project manager identified that the levels of engagement and active involvement of the care home manager, the champions and the rest of the care home staff were variable across the four sites. In care home 3, the champions, care home manager and whole care home team were actively engaged and driving the initiatives forward which could account for their positive impact on acute activity. Pilot versus non-pilot homes

The pilot homes appear to be performing better than the non-pilot homes on ambulance conveyances and A&E attendances, and are showing signs of sustained improvement

For the remainder of the outcomes, the care home groups are not showing sustained improvement.

Overall Conclusion Care Home 3 has shown some improvement on the key outcome measures, whilst for the other

homes the impact is unclear. The group of pilot homes appear to be performing better than the

non-pilot homes on ambulance conveyances and A&E attendances and are showing signs of

sustained improvement.

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3.2 Qualitative results of WBHR

The benefits and challenges of the WBHR on care staff and care home managers has been

captured in table 1.0. Challenges arising through the pilot were not always within the control of the

RMCS or Vanguard team but would need to be monitored going forward with the model.

As challenges arose through the pilot, steps were put in place to address them: for example, the

liaison nurses within RMCS agreed a framework for WBHR that they could work towards and an

information sheet on FAQ’s was given to the care homes to address the structure of the WBHR

and how they should prepare for the visit. A regular weekly time for the round was agreed between

the four homes and the liaison nurses.

Table 1.0 Learning from evaluation events

Benefits Challenges

Regular nursing input to RH Improves quality of care and working relationships Signposting, Support and guidance with referrals to other departments within community services ensures timely follow up care Positive Impact on GP visits, problems solved by liaison nurse, however where GP visit is required, staff able to provide better, more detailed information as resident has been reviewed. Improved collaborative working, with staff confident to refer residents to other disciplines

Liaison nurse not always available to undertake the WBHRs. Since January permanent nurses have joined the Care home support team.

Different styles of working/teaching

Lack of clarity over individual roles and responsibilities

Liaison nurses requiring support to evolve the role

Initial regular meetings with liaison nurse able to use PDSA to work through concerns, as the team changed it was difficult to maintain level of feedback due to increased workload, hours of work - Resolving issues takes time

Provision of bespoke training as identified by liaison nurse and the care home resulting in improved staff education

Care staff in homes are not always available to attend the WBHR. Change in daily workload within homes plus shift patterns

No defined structure to the WBHR - Timings of the round not established in the beginning

Not clear understanding what was expected from the care homes

Early Identification of deteriorating resident due to regular support and training

Staff turnover/use of agency staff

Care Staff have a point of contact to ask for advise

Duplication of paperwork, homes already have documentation in place

Evaluation after a short duration of time has the potential of giving a negative reflection

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3.3 Discussion

The WBHR is still in development, a new role in community takes time to establish and will vary in

its structure in each home dependent on a number of factors including the current role of GP, the

engagement of the home manager and owner and the size of the home.

Data may be altered if another project is introduced within the same timeframe where staff are

required to be involved in both highlighting issues of demand and capacity.

A decision to alter the title of the round to promote the wellbeing of residents emphasising the

proactive role of the round has been agreed with RMCS. The round will now be known as the

Wellbeing and Health round as opposed to a Health and Wellbeing round.

Guidance and FAQ’s for care homes is in final development and is currently being tested with the

four residential homes in the pilot. (Appendix E). Pending feedback from the pilot homes, the plan

is to share this document more widely.

The role of the liaison nurse in individual homes will vary and the frequency of visits will be

determined by homes needs and a proforma to guide the liaison nurses in their role is being

established with RMCS.

The addition of Occupational Therapist and Physiotherapist to support the liaison nurses and

champions to further enhance the wellbeing and health of the residents has been identified and the

posts have now been filled, their role in the homes is being established and reviewed.

4.0 CHAMPIONS

Considering the evidence highlighted earlier in the report, the aims of the Champions was;

1. To reduce the number of care home falls and fallers by introducing new initiatives

2. To reduce the number of inappropriate ambulance call outs

3. To be able to recognise a deteriorating resident and put in place an action plan

4. To increase the number of residents with an ACP and a CMC record.

5. To improve confidence of care staff to enable them to cascade their learning to their peers

and become an educator

Each of the four homes identified a Falls Champion and an EOLC champion. These were areas

recognised by the residential home staff as where direction was needed and RMCS would be able

to provide support.

.

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4.1 Qualitative results of Champions The benefits and challenges of the champion roles for care staff and care home managers have

been captured in table 2.0. Challenges arising through the pilot were not always within the control

of the RMCS or Vanguard team and may need to be addressed when rolling out the model to other

care homes

Table 2: Learning from Evaluation events

Positives/benefits Challenges

Development of new skills and confidence

leading to better care

Champions are unable to complete extra

information and deliver cascade training due

to time pressures

Better understanding of residents holistic

needs

Staff in the homes are reluctant to participate

in changes implemented by the champions.

Valued as being part of the team and

confidence to liaise with managers

Lines of communication within the four pilot

care homes

Confidence to speak to relatives and

advocate on behalf of residents

Insufficient time allowed for care homes to

be able to select most appropriate person to

develop as champion

More information re services available for

residents

Limited understanding of role and

responsibilities

Any changes to the residents health and wellbeing are identified early and monitored, with confidence to request a review

Ability to reflect on changes and co-produce solutions / initiatives

Standardised paperwork for staff to complete There is limited flexibility for homes that are part of larger chains to adapt paperwork

Access to equipment for residents to improve their wellbeing and health

Homes reluctant to use equipment as not aesthetically pleasing

Named carer to discuss issues and residents Only one champion per home per area, continuity with leave and shifts

The mid evaluation identified a lack of clarity regarding the roles and responsibilities of a champion

so a framework and role description was developed with the champions and relevant teams. This

has progressed further to a framework for Falls Champions and EOLC Champions. (Appendix F,

G, H)

The framework highlights the key roles of the Champions with guidance on how to achieve these

roles and encourages the champions to document examples of good practice.

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The role description of a champion is highlighted in table 3.0 below, devised by the falls and EOLC

clinical leads, care home managers and champions. The benefits of this is to reduce the challenge

of the selection process, ensuring the champion is self-nominated or has been agreed in

discussion with care home manager.

Table 3.0: Champion role description

Characteristics of a Champion

Willing to take on a new role

Enthusiastic and passionate for change

Able to communicate verbally and in writing

Approachable with good communication skills

Reliable

Motivated, and inspiring

Able to support, encourage and lead their peers through change

Committed to promote new initiatives

Good team player

Creative and Open to new ideas

Belief in themselves, with understanding of their strengths and weaknesses

Main duties and responsibilities

To use their skills and knowledge to promote best practice and lead by example

To be an educator, cascading information to peers

To deliver care interventions, and monitor the wellbeing and health of the resident

To be able to identify changes and work in conjunction with Health Care Professionals (HCP) and managers to promote good care

To improve early interventions that will enhance resident quality of life and safety

To encourage staff to empower residents to maintain independence and choice

To support staff, residents and their families

Confidence of Champion’s in falls and end of life care

Graph 29 provides positive evidence of the impact the champions role has had on their confidence

levels. Improving confidence levels has had a positive effect on the champions and on their

colleagues by improving their self-belief and providing them with the ability to challenge and make

changes, whilst remaining focused and motivated.

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Graph 29

Table 4.0 Questions relating to numbers

6a Communicating concerns to the GP

6b. Handover of residents to emergency services

6c Advocating the residents wishes during care discussions

6d Communicating with relatives in critical situations

Further positive qualitative data to reinforce the impact of the champions on themselves and the

care homes can be seen in appendix I.

4.2 End of Life Care Champions

Quantitative outcomes and impact The Supportive Care Home Team began a pilot in 2015 with five residential care homes to improve EOLC by implementing a model of care of education, training and clinical rounds. In August 2016 the pilot was extended to all residential care homes. Of the five homes in the EOLC pilot, three were also in the champion’s pilot. CMC Records Graph 25 shows that once the EOLC pilot extended to all homes, residents with a CMC record in the pilot homes increased from around 13% to 27%, to reach a high of 42% in August 2017. By September 2017, the percentage of residents with a CMC record in the four pilot homes ranged from 17% to 52% (see table 5). Whilst in the non-pilot homes the range was 9% to 37%. This shows that two pilot homes were performing better than all homes, and two pilot homes were below average. Reasons for this variation in the pilot homes maybe due to the availability of champions within the homes, with one on permanent night duty and one home making a joint decision with EOLC team to recruit following training which was undertaken in early 2017.This is on-going and a champion has still to be identified within the home. There appears to be correlation between a motivated, passionate, engaged champion and residents with a CMC record with the EOLC nurses having a point of contact within a care home as demonstrated by care home 1.

1

3

5

7

9

6a 6b 6c 6d

Sc

ore

Question number

Confidence levels of Champions

Before thepilot

After thepilot

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Graph 25

Table 5.0

Percentage of residents with a CMC Record. Rank is in brackets(September 2017)

Pilot homes Non pilot homes

Care Home 1 (1) 52% Care Home A (3) 37%

Care Home 2 (2) 50% Care Home B (4) 35%

Care Home 3 (8) 18% Care Home C (5) 33%

Care Home 4 (9) 17% Care Home D (6) 22% Care Home E (7) 20% Care Home F (10) 15% Care Home G (11) 9%

Preferred Place of Death

Residential Homes

The number of residents who achieve their preferred place of death (PPD) is not available for each

care home. Also, the data for the number of residents dying without an EOLC plan only became

available from April 2017. Graph 26 below shows that residents with an EOLC plan are likely to

die in their PPD. Since not all residents have an EOLC plan (ie, CMC record), then not every

resident has a PPD recorded which can be reviewed against.

Graph 26

20

Conclusion Pilot Homes

Care Home 1 – has the highest percentage of residents with a CMC record at just over half.

Care Home 2 – has half its residents with a CMC record and is ranked second.

Care Home 3 – has about one in five of its residents with a CMC record and is ranked 8th.

Care Home 4 - has about one in five of its residents with a CMC record and is ranked 9th.

4.3 Falls Champions Quantitative outcomes and impact A reduction in the number of falls within the pilot care homes would not have been expected till

January/February 2017 as seen in graph 27. The challenges of working in a care home system

required appreciation and respect before a change to the culture and processes could be

observed. Other possible explanations are listed below

Improved recording of falls – aware of falls risk and champion encouraging forms to be

completed so able to identify trends and frequent fallers

Staffing levels and managers – one home prior to start of pilot had 5 different managers

Definition of fall – changed over pilot, following training and recognition

Deterioration of residents – been in home for over 3 years, ageing frailty with increasing

number of long term conditions

Takes time for changes to occur and for a sustained decrease to be noted, the pilot was

limited to nine months

Staff reluctance to adopt changes

Lines of communication within the home due to shifts and rota changes

It takes time for initiatives to be embedded and for staff to fully commit to change. There has been

a gradual decline in the total number of falls in the pilot homes, the peaks are at times of residents

being acutely unwell requiring appropriate hospital admission as observed by project lead on visits

and care home 2 reported an increase in bank and agency shifts during the period February to

May. However, the number of residents who are falling within the four pilot homes is showing a

gradual decline as can be seen in graph 28, except in care home 3 who have been unable to

recruit a new falls champion following resignation from the home in March. They have now

recruited into the role. This suggests that a residential home with a champion who is engaged and

committed to change is able to make a difference. Champions are starting to have an impact on

the falls rate in the care homes and with the assistance of HCP’s and their managers are able to

implement jointly agreed initiatives into the home and provide important information to their peers.

Recognising changes to resident’s wellbeing and health, allowing an action plan to be developed to

prevent falls and applying positive change is evident with a reduction in the number of residents

falling.

21

Graph 27

Graph 28

5.0 Financial costs of pilot

Table 6 below shows the financial costs of the pilot over the nine months.

The liaison nurse, EOLC nurse and the falls lead are contracted roles and already in post at the

beginning of the pilot. (The falls lead role was completed by the Darzi Fellow, AHP lead for

Vanguard due to reduced capacity in Falls Team) The estimated costs do not include any extra

time the HCP incurred when not visiting the homes. Table 6 illustrates the average time per

week/month spent on pilot activities, which indicates that less than a whole time equivalent for

each HCP role is required for this number of care homes. To sustain and continue to improve the

outcomes in all Sutton care homes, full time HCP’s may need to be employed.

Champions were not paid for their role, the care homes were reimbursed for their attendance at the

events however how much extra time the champions spent in the homes completing their role was

unable to be determined and therefore may have been an added cost to the care home.

0

5

10

15

20

JAN

FE

B

MA

RC

H

AP

RIL

MA

Y

JUN

E

JULY

AU

G

SE

PT

OC

T

NO

V

DE

C

JAN

FE

B

MA

RC

H

AP

RIL

MA

Y

JUN

E

JULY

AU

G

SE

PT

OC

T

NO

V

DE

C

JAN

FE

B

MA

RC

H

AP

RIL

MA

Y

JUN

E

JULY

2015 2016 2017

Number of Falls in Pilot Residential Homes

Care Home 1

Care Home 2

Care Home 3

Care Home 4

0

2

4

6

8

10

12

Number of Residents who fell

Series1

Series2

Series3

Series4

22

Table 6: Costs for nine month pilot in four Residential homes

Liaison nurse Champions EOLC Champions Falls EOLC nurse Falls lead *

Band 7 £19 per hour (mid band 7)

Senior carers £10 per hour (as agreed)

Senior carers £10 per hour (as agreed)

Band 7 £19 per hour (mid band 7)

Band 7 £19 per hour (mid band 7)

Weeks of pilot 44 (37.5 hours per week)

Weeks of pilot 44 Weeks of pilot 44 Weeks of pilot 44 (37.5 hours per week)

Weeks of pilot 44 (37.5 hours per week)

Ave. 0.5 hours per week per home 2 hours per week for 4 pilot homes (clinical) 4 hours per week for 4 pilot homes (non-clinical) Total 6 hours per week for four homes

Attendance at 4 events of 3 hours each = 12 hours total 1 Hours with HCP per month of pilot = 9 Total = 21 hours

Attendance at 4 events of 3 hours each = 12 hours total Hours with HCP per month of pilot = 18 Total = 30 hours

Ave. 1 hour per month for each home = 4 hours per month

Ave. 2 hour per month for each home = 8 hours per month

6 hours x £19 = £114 per week

21 hours x £10 = £210 per champion

30 hours x £10 = £300 per champion

4 x £19 = £76 per month

8 x £19 = £152 per month

£114 x 44 weeks of pilot

Total for 4 = £840 Total for 4 = £1200

£76 x 9 months

£152 x 9 months

Total for pilot £5,016

Total for 2 champions for 4 pilot homes = £2040

Total for pilot £684

Total for pilot £1368

Total for pilot £9,108

(costs exclude venue hire, refreshments etc for events)

Evidence for potential financial savings

The quantitative data for the pilot homes has shown improvement in ambulance call outs, which

represents an approximate saving of £299 for each call out. This initiative supports proactive

resident management by liaison nurses, in addition to the EOLC Champions ensuring residents are

offered an ACP and CMC record. This means that inappropriate callouts are avoided for residents

who wish to die in their care home. Falls Champions are impacting on the number of falls and

residents who have fallen, resulting in reduction in inappropriate callouts and NEL’s at an

estimated saving of £3170 per admission. By preventing further falls, #NOF’s are avoided at a

saving of £9000 per fracture.

23

6.0 Emerging outcomes from qualitative data

6.1 Key requirements for effectiveness are:

WBHR

Care homes and liaison nurses need to work together to promote person centred care, and

consider the long term holistic need of the residents; providing a proactive rather than a

reactive service

Protected time for WBHR as agreed with the care home and liaison nurse/ RMCS

Care home Manager and liaison nurse to agree local process and structure for regular visits

including residents six month review, to ensure needs of individual homes are understood

and met (appendix E)

There should be equal responsibility for preparation for WBHR (appendix E)

Continuity of clinical leads and champions is important to enable the care home to develop

an effective working relationship ensuring clear roles, responsibilities and expectations are

adhered to

Documentation is agreed with Community team and adhered to

Liaison nurse to develop a clear pathway for reporting and feedback with GP on regular

basis at the start of WBH rounds

Champions

Protected time with HCP in area of responsibility

Champions need to volunteer for role, with a clear understanding of roles and

responsibilities agreed with manager at beginning

Clear and concise information regarding roles and how to gain most benefit

Continuity of clinical lead to enable the care home staff to develop an effective working

relationship, ensuring champion is able to undertake their roles within shift pattern.

Provision of two champions if available to ensure continuity of development and feedback

and peer support

Good communication between the manager and champions, to ensure messages and

meetings are passed on in timely fashion

Full engagement of manager and staff from beginning with clear understanding of the role

and responsibility of the named champion

Management support with constructive feedback

24

6.2 Key requirements for undertaking a pilot and measuring impact are:

Identifying early in the pilot a baseline data to demonstrate changes in activity and ensuring

it is easy to complete and agreed by all

The project manager will be required to attend the WBHR and regular feedback/reflection

sessions with champions and care home managers in the first few months. This supports

implementation and ensures the individual needs and cultures of each home can be

respected. The principles of the initiatives are standardised, however the way the initiatives

were implemented in each home was variable according to their own working practices

Whilst recognising competing priorities, ensure a robust process for care homes, liaison

nurses and champions to submit their monitoring data and identify ways to encourage

timely submission

Hold mid evaluation events with all stakeholders to use quality improvement methodology

to make changes as required

When completing a pilot ensure one project has priority to maximise the outcomes

Identify a way to present data visually for staff and care home

Ensure evaluation events are booked sufficiently in advance and confirmation received

from care home managers and champions, understanding that the care staff are clinical

and shifts need to be covered

6.3 Options for development of model

WBHR

Enabling residents documented six month wellbeing and health review to be accessed by

out of hour’s services

Potential for Occupational Therapist (OT)or Physiotherapist (PT)to undertake the six month

wellbeing and health review and participate in or complete the weekly round

Virtual multidisciplinary ward round, to include GP, care home support team and care home

manager and families/residents, timing to be agreed by all team members

Integration of Community nursing teams and liaison nurses

Champions

Potential for champions network

Champion forums or Communities of practice to share information and enhance learning

with sessions from Community teams

Further champions in nutrition and medication

To develop a localised risk falls risk assessment with PT and OT

25

7.0 Conclusion

The WBHR has been effective in integrating health and social care across a wider system. There

has been improved staff knowledge and education with staff able to recognise deteriorating

residents and provide preventative management. It has demonstrated that by implementing a

weekly proactive round alongside Champions, ambulance conveyances and A&E attendances can

be reduced and improvement sustained. The round has undergone quality improvement

throughout the pilot and will be known as Well Being and Health Round (WBHR) as it progresses

forward.

The EOLC Champions have been effective in ensuring residents are offered an ACP and therefore

their wishes will be met in the later stages of life. They have increased their confidence when

speaking with other HCP as well as with families and provide the continuity of care in this process.

The effectiveness of a falls champion is evident with later data. The role requires someone who is

willing and engaged to introduce new initiatives, and have the full support of the care home

manager and their peers, with a robust structure in place, to be effective in reducing falls and

identifying early, any resident who may be at risk of further falls.

8.0 Going Forward

WBHR

A framework has been drafted with RMCS for the liaison nurses to work with and frequently asked

questions have been circulated to pilot homes for review and feedback. Discussions are ongoing

with RMCS for further roll out to residential homes and how it will be structured for the future.

Champions

There is an expectation from the National New Care Model team that the Sutton homes of care

programme will be rolled out by end of December 2017, so plans have been worked on for roll out

the Falls and EOLC Champions and the possibility of introducing Nutrition Champions to all Sutton

Care Homes. An event for care home managers and potential Champions to attend has been

organised to provide information on what the role will involve and how to determine the best person

for the position. A follow up session for identified Champions with the relevant clinical teams is to

be arranged for January 2018. Once champions have been identified and attended training, follow

up within the care homes would be provided by Supportive Care Home team plus the

physiotherapist, occupational therapist and dietitian in Care Home support team

The four pilot homes will continue with EOLC and Falls Champions

26

9.0 References

British Geriatrics Society. 2015. Communications: Hospital admissions from care homes. Available

at https://britishgeriatricssociety.wordpress.com/2015/03/13/hospital-admissions-from-care-homes

Colson. S and O’Callaghan. S (2014) Hydrate in care homes. Available from

http://www.kssahsn.net/what-we-do/our-

news/events/Care%20Homes%20Collaborative/Hydrate%20in%20care%20homes%20S%20OCall

aghan.pdf

National institute for Health and Care Excellence (2015) Older people: independence and mental

wellbeing: Nice guidelines [ng32]. Available from: http://nice.org/guidance/ng32

National Institute for care Research. (2017) NIHR research on living well, ageing well and dying

well in care homes. Available from http://www.dc.nihr.ac.uk/themed-reviews/advancing-care-

themed-review.pdf

Scottish commission for the regulation of care. (2009) Promoting nutrition in care homes for older

people. Available from

https://www.dignityincare.org.uk/_assets/Resources/Dignity/CSIPComment/promotingnutritionincar

e_homes1.pdf

University of the west of England, Bristol and the University of Warwick. (2008) Providing nursing

support within residential care homes. Available from: https://www.jrf.org.uk/report/providing-

nursing-support-within-residential-care-homes

27

10.0 Appendices

Appendix A

Vanguard Pilot in Sutton Residential Care Homes

Monthly submission of information

RECORD OF ACTIVITY

Name of Home:

Month covered:

Report completed by:

Date completed:

Number on registration

Current CQC rating

Number of residents in home on last day of month.

Instructions for submission:

This table must be completed and submitted to sutccg.carehomevanguard@nhs.net no later than five working days after the end of the month.

Thank you

Instructions on how to complete: For each performance indicator please include the total number of occurrences for the month in question in the last column of the table below.

ID Performance Indicator Descriptor Data/Information to be completed

CQC information

1. CQC Visit Has the home been visited by CQC in last month?

Yes / No

2. CQC rating Has there been a change in your CQC rating?

Yes / No

Quality Data

3. Safeguarding Number of new reported safeguarding incidents

4. Pressure sore Number of residents who develop a new pressure sore, grade 3 and above

Referrals

5. Voluntary services

Number of new referrals that resulted in engagement / involvement with a Charity or voluntary sector

6. Silver Letters Number of residents that are participating in Silver Letters

7. Community services: Physiotherapy

Number of new referrals to community physiotherapy

8. Private Physiotherapy Number of new referrals to private physiotherapy

28

ID Performance Indicator Descriptor Data/Information to be completed

9. Community services: Falls Service

Number of new referrals to Falls service

10. Community services: District Nursing

Number of new referrals to district nursing

See separate sheet

11. Community services: District Nursing

Number of residents currently being been by District Nurse

12. Community services: SALT Number of new referrals to SALT

13. Community services: Dietician

Number of new referrals to Dietician

14. Community services: podiatry

Number of new referrals to Podiatry

15. Community services: EOLC Number of new referrals to EOLC

16. Pharmacy Number of residents identified as requiring medication review?

Staffing levels

17. Permanent staff Number of permanent staff

18. Permanent staff (WTE) Number of WTE permanent staff

19. Bank staff Number of bank staff

20. Bank staff (WTE) Number of WTE bank staff

21. Agency staff Number of agency staff

22. Agency staff (WTE) Number of WTE agency staff

Conditions

23. Falls Number of Falls: and reason See separate sheet

24. Urinary Tract Infections (UTI)

Number of residents who develop a new UTI

25. Pressure sores Number of residents who develop a new pressure sore Grade 1or 2?

29

Appendix B

30

Appendix C

31

Appendix D

Sutton Homes of Care

Pilot in Residential Homes

March 2017 Evaluation for Managers

Name of residential Home

Please take a few moments to consider the following questions, they will used as part of the

discussion to be completed with Lisa

What is your understanding of the following roles (describe in less than ten words):

Role of champion carer:

Role of the Link nurse plus Health and Well Being Round

What benefits and outcomes have you seen in your home from introducing these roles:

WBHR and Link Nurse:

Champions; Falls;

End of life care;

32

As the care home manager, have you experienced any challenges from introducing ;

HWBR and link Nurse

Champions;

Falls;

End of life care;

Please indicate your current level of confidence (0= no confidence, 10= very confident) in your 2 Champions

current ability in the following situations:

Communicating concerns to the Manager/Link Nurse:

0 5 10

Handover of residents to emergency services:

0 5 10

Advocating the residents wishes during care discussions:

0 5 10

Communicating with relatives:

0 5 10

33

What makes a good champion?

What further skills do you think your Champions need to develop or enhance to maximise their effectiveness

in this role?

.

How do you think we can take this role forward to ensure it is embedded at end of pilot?

What training has your home been involved with since start of Pilot?

Who provided the training?

Do you have any other concerns or comments re the pilot??

Thank you for completing the mid pilot questionnaire. Your responses will be used to evaluate the

effectiveness of the Champion role and the training and support provided.

Please return completed form via email or on visit.

34

Appendix E

Part A Community Services guidelines (not for Care Homes)

Frame work for WELLBEING AND HEALTH ROUNDs in Care Homes in Sutton

Background

Evidence suggests that;

There is a need for a co-ordinated and managed approach to the health conditions

of Care Home residents.

Care Home residents would benefit from more proactive primary care

There is a need to provide early detection of new or changing health conditions of

residents in Care Homes

There is also a need to demonstrate compliance against Enhanced health in Care Homes

Framework (EHCH)

PURPOSE

A weekly ‘home round’ is a requirement of Enhanced health in Care Home framework.

(2.3b)

“A weekly ‘home round’ should be held in each Care Home. This proactive round is a cross

between a hospital ward round and a home visit, and it is crucial for reviewing and planning

a resident’s care. Members of the team who participate in the ‘home round’ are the

resident’s GP, the Care Home team and other members of the local MDT such as nurse

specialists and pharmacists. If appropriate, this can form part of a virtual ward round, should

this be in place locally.”

Some Nursing and residential Care Homes in Sutton do have contact with a named GP on a

weekly basis, however if this is not in place the liaison nurse will work with the MDT to

ensure a weekly ‘home round’ is undertaken.

The purpose of the Wellbeing and Health (WBH) round is to provide a proactive weekly

review of the residents in Care Homes. To identify with the Care Home staff any active

health concern and proactively manage the residents Wellbeing and Health in order to

maintain independence and quality of life. The liaison nurse will liaise with primary care or

community services regarding any concerns, need for clinical investigations or request a

medical review if required for any of the residents as a result of undertaking the Wellbeing

and Health rounds.

PROCESS

1. The Liaison nurse will visit the Care Home on a weekly basis where the need for a

Care Home visit has been identified, on a day and time that is mutually agreeable to

the Care Home and the nurse. This may be virtual as agreed with Care Home.

2. The Liaison nurse to have contact with the Care Home prior to visit to get a list of

residents to be seen, enabling time to collate information on the resident. E.g. EMIS

report. A template/format for this list is to be agreed with Care Home

35

3. The Liaison nurse will work with the identified staff member at the Care Home to

review the residents with a stratified approach:

Review required actions taken from previous rounds,

Review residents whom the care staff have reported concerns or where there is

an observed change in their medical or functional status, for example altered

sleep pattern, a change in mobility, or reduced appetite,

Review residents who have been discharged from hospital or have had a fall since the

last visit or a recent illness and prompt to have a medication review,

Complete a review of all residents in the Care Homes twice a year identifying

holistic needs.

4. Following the rounds, actions agreed with the Care Home and the Liaison nurse will

be documented on;

an agreed template,

Care Home records as appropriate to clinical complexity and as Care Home

records dictate (e.g. MDT visit record)

RIO

Care Home staff are responsible for updating their Care Home records and care

plans.

5. Communication of actions whether written or verbal should be clear and

communicated to other members of the MDT as clinically appropriate by Liaison

nurse following the round.

• Possible actions following visit: Liaison with GP and if appropriate referrals to

other HCP within Community Services will be completed by Liaison nurse or

Care Home as agreed.

• Liaison with other members of Care Home Support services e.g. Pharmacy,

CHC, CBT, Sensory team, Sutton vision

• Advice for the Care Home staff to support management of the resident

• Direct clinical intervention by the nurse to the resident/s

• Agree a follow up visit if required

• Discussion of the residents needs at the monthly MDT meeting as appropriate.

• Advise the Care Home to call emergency services and how to manage and support the

resident until arrival

7. Outcomes of the WBH rounds will provide information and observed trends within the

Care Homes. These are to be relayed to the Community Services representative attending

the JIG to inform the training and resource requirements for Care Homes.

36

Example Template

Name of Care Home:

Date:

RESIDENT

CONCERN

Eg; changes in

appetite, sleep.

Mobility, medical

status

AGREED ACTION

FOLLOWING

WELLBEING AND

HEALTH REVIEW

PERSON

RESPONSIBLE

FOR ACTION

B.Smith 4 falls 1.Liaise with

community physio

2.Liaise with sensory

team at LBS

3.Fluid chart

4.Check for UTI

5. review falls risk

assessment

Liaison nurse

Care Home

Care home

37

Part B (to be given to Care Homes)

Wellbeing and Health Rounds for Sutton Care Homes

FAQ sheet for the Care Home

What is it?

The purpose of the Wellbeing and Health round (WBH) is to proactively manage a residents

wellbeing and health needs and support the Care Home staff to recognise early change and

to facilitate optimum management of the resident.

A Liaison nurse will visit your Care Home on a regular basis to review any residents that you

have concerns about.

They will ensure that all residents receive a regular pro-active, holistic review twice a year

The Liaison nurse will liaise with primary care or community services regarding any

concerns, need for clinical investigations or request a medical review if required for any of

the residents as a result of undertaking the Wellbeing and Health rounds.

How do I prepare for a Well-being and Health Round?

The Care Home will have contact with the Liaison nurse prior to the visit to provide a list of

residents to be seen to allow time for the Nurse to collate information on the resident. You

may want to use a template - see example over leaf.

A senior carer (who knows the residents) to be ready to work with and support the

Liaison nurse on the Wellbeing and Health round

Know which resident(s) need to be seen and why they are requiring a visit (what has

changed?)

Ensure the resident is aware of the visit and prepared, for example, do they need to be in

their bedroom to maintain privacy and dignity during the consultation?

Have available up to date information and health history, including the history of the

current problem plus MAR chart, relevant care plan and documents. If you are able,

a set of recent observations.

Provide a Record of what interventions have already been tried and what impact did

they have?

For example: Resident feeling a bit unwell, urine has been checked, no

evidence of UTI, additional fluids have been given, resident still doesn’t

feel any better

resident feeling a bit unwell, urine has been checked, no evidence of UTI,

additional fluids have been given, resident still doesn’t feel any better

38

How does it work?

The Liaison nurse or a member of the Care Home Support team (CHST) will visit your Care

Home on a regular basis on a day and time that is mutually agreeable to the Care Home

and the nurse.

They will work with you at the Care Home to review the wellbeing and health needs of the

residents whom you have previously identified using an agreed template or format

High priority residents identified include those whom:

• Have been discharged from hospital since the last round.

• you have concerns or where there is an observed change in their medical or

functional status, examples include

Increasing confusion

Difficulty breathing

Increased pain

Unusual swelling eg.legs

New or increased falls

Changes in skin eg. Redness, bruising

New vomiting or diarrhoea

Altered sleep pattern

New or unusual behaviour changes

Changes to mood

Change in mobility

reduced appetite or significant weight loss

The Liaison nurse or a member of the CHST will also need to:

• Follow up on the outcome of agreed actions from previous rounds

• Complete a review of all residents in the Care Homes twice a year identifying any

holistic needs.

• Schedule a review for any new residents.

What happens after the round?

Actions will depend on the needs of your residents but may include the following;

The liaison nurse will liaise with GP as necessary

Referrals to other Health Care Professionals (HCP) within Community Services or

the wider Care Home Support teams will be completed by yourselves or the Liaison

nurse as agreed. For example Pharmacy, Challenging Behaviour, sensory team or

Sutton vision

Advise Care Home staff how to support short term and long term management of the

resident and who to contact if resident deteriorates using CAAR poster.

Direct clinical intervention by the nurse.

Advise to call emergency services, the Liaison nurse will provide information on

how to manage and support the resident until arrival

39

What Activities do we need to complete following the visit?:

• Ensure you are clear on the outcome for each resident using the example

template if desired.

• Update the residents care notes and plan to reflect their current

needs/management e.g. now walking with a frame, give milk at every mealtime,

monitor blood pressure daily

• Communicate with the care staff to ensure everyone is aware of any changes to

the resident’s care needs, e.g. elevate legs for 2 hours after lunch, weigh every

week, new medication, observe behaviour

• If the care needs have permanently changed update the ‘older person’s

assessment form’ to ensure clear communication with other teams when

required e.g. admission to hospital

• Communicate with the resident’s next of kin to advise of any outcomes

Questions to ask Liaison nurses before they leave:

• Will the individual need to be reviewed again and if so, when?

• Who to contact if there are further questions or concerns

40

Example Template

Name of Care Home:

Date:

RESIDENT

CONCERN

Eg; changes in

appetite, sleep.

Mobility, medical

status

AGREED ACTION

FOLLOWING

WELLBEING AND

HEALTH REVIEW

PERSON

RESPONSIBLE

FOR ACTION

B.Smith 4 falls 1.Liaise with

community physio

2.Liaise with sensory

team at LBS

3.Fluid chart

4.Check for UTI

5.review falls risk

assessment

Liaison nurse

Care Home

Care home

41

Appendix F

Primary roles of champions:

To use their skills and knowledge to promote best practice and lead by example

To deliver care interventions, and monitor the health and wellbeing of the resident

To be able to identify changes and work in conjunction with Health Care Professionals (HCP) and managers to promote good care

To improve early interventions that will enhance resident quality of life and safety

To encourage staff to empower residents to maintain independence and choice

To support staff, residents and their families

KEY ROLES POSSIBLE WAYS TO ACHIEVE EXAMPLES

1. Improve communication and confidence with:

1.1. Staff

Feedback at staff meetings, shift handover, small groups or 1:1 sessions, discuss with manager options suit you and the home

Ensure changes are escalated on timely basis to all staff

Enhance team work by encouraging others to be involved

Promote role of champion

1.2. Champions on other pilot sites Arrange meeting or use social media for exchange of ideas and feedback

Attend launch, mid-point evaluation and end of pilot evaluation events

1.3. Other health care professionals

Where possible attend weekly WBHR with Liaison nurse,

Work in partnership with Health Care Professionals (HCP), on scheduled visits

In liaison with senior carer and manager provide a list of residents to be reviewed by Liaison nurse or HCP clearly outlining concerns discuss any concerns with peers or lead for area of responsibility

1.4. Residents

Escalate residents wishes to HCP and manager, ensure wishes are documented

Provide information to residents on appropriate services available in liaison with manager/HCP

1.5. Managers With the support of manager, be able to identify and report issues

Arrange regular meetings for feedback, provide information about the Champions role and progress

42

KEY ROLES POSSIBLE WAYS TO ACHIEVE EXAMPLES

1.6. Families

Be able to provide a register of what services the homes can access, e.g. low vision service, and ensure any information is documented in care plan

Develop understanding of how to manage difficult situations with support from manager and/or HCP

2. A working knowledge of their area of responsibility

Attend relevant training in their area plus other as applicable

Be able to recognise signs and symptoms of common issues / deteriorating resident, e.g. UTI and how to escalate and to whom (signposting)

Be able to Identify residents at risk and those who would benefit from review by GP/Liaison nurse/other HCP

Attend WBHR with liaison nurse regularly when on shift

Where possible link with health care professionals on arranged visits

Attend regular peer support/network meeting/Vanguard evaluations

Have an awareness of current services that could be beneficial to resident and how they can be accessed

Work towards producing Top Tips for their area to share with colleagues

Understand the importance of positive person centred approach

3. To be an educator

Cascade information to colleagues in area of responsibility in small groups or 1:1 with support from HCP in their area of responsibility

Enhance team work, encourage staff to work towards same goal

Share new information with staff, residents and families if applicable

Be involved in new staff inductions, discuss with manager/senior carers

Empower staff and listen to concerns

Support other staff to implement change

4. With support from Manager and HCP, ensure correct and up-to-date documentation is in place

Encourage Risk Assessments to be completed for all residents on admission and monitor for your area of responsibility, e.g. falls

When residents medical or functional status has changed ensure evidence is documented in care plans or progress notes

Regular discussions with HCP, being aware of any new documentation, e.g. post falls incident form, ACP

Consider homes guidance/policy for area of responsibility to ensure it reflects current best practise, e.g. falls policy

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Appendix G

Primary roles of falls champions:

• To use their skills and knowledge to promote best practice in falls prevention and lead by example

• To deliver care interventions, and monitor the wellbeing of the resident

• To be able to identify residents where functional changes have occurred and work in conjunction with Health Care Professionals (HCP) an

managers to promote good care

• To promote and improve early interventions that will enhance resident quality of life and safety

• To encourage staff to empower residents to maintain independence and choice, ensuring all residents and families are given the opportunity

to be involved in falls prevention strategies

• To empower and support staff, residents and their families to implement falls prevention strategies

KEY ROLES POSSIBLE WAYS TO ACHIEVE EXAMPLES OF GOOD PRACTICE

1. Improve communication and confidence with:

• Support colleagues to comply with local policy and procedure following fall, ensure a post falls incident form is completed

• With manager and HCP ensure all residents have completed a falls risk assessment and those identified at risk have an up to date multifactorial risk assessment/care plan in place,

• Work in partnership with Health Care Professionals (HCP), on scheduled visits, ensuring information obtained is cascaded to the team

• Feedback at staff meetings, shift handover, small groups or 1:1 sessions, discuss with manager options suit you and the home

• Ensure care staff are aware on a daily basis residents with identified functional or medical changes who are at risk of falls

• Provide staff, residents and families information regarding the falls strategies put in place to prevent further falls and ensure documented in care plan and OPARs form are escalated on timely basis to all staff

• Report outcomes of monthly falls at meeting discussed and agreed with manager using safety cross to provide evidence.

• Enhance team work by encouraging others to be involved • Promote role of champion

44

KEY ROLES POSSIBLE WAYS TO ACHIEVE EXAMPLES OF GOOD PRACTICE

2. To have a working knowledge of

falls and be able to maximise

independence and wellbeing of

residents by improving early

intervention to reduce falls

• Attend yearly falls training as agreed with manager • Working with care home support team, be able to recognise signs and

symptoms of common issues / deteriorating resident, e.g. UTI and how to escalate and to whom

• Be able to Identify residents at risk of falls and those who would benefit from review by GP/Liaison nurse/other HCP

• promote independent and safe transfers and mobility, refer to OT or PT when required

• Where possible link with health care professionals on arranged visits (WBH round), providing a list of residents who have fallen or are at risk of falls.

• Attend regular peer support/network meeting/Vanguard evaluations • Have an awareness of current services that could be beneficial to

resident and how they can be accessed • Understand the importance of positive person centred approach

3. To be an educator

• Share falls strategies with colleagues in small groups or 1:1 with support from HCP and as agreed with manager.

• Enhance team work, encourage staff to work towards same residents goal

• Be involved in new staff inductions, discuss with manager/senior carers • Empower staff and listen to concerns on a daily basis and at monthly

review. • Support other staff to implement change

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Appendix H

Primary roles of champions:

To use their skills and knowledge to promote best practice in end of life care and lead by example.

Recognise residents who may be deteriorating and entering last year of life.

To be able to identify changes at the end of life and work in conjunction with other Health Care Professionals (HCP) and managers to

promote and coordinate good care.

Ensure all residents are given the opportunity to discuss their preferences and wishes.

Communication should be sensitive, timely and reflects an understanding of the resident and their needs.

Assess, plan, implement an individual plan of end of life care, incorporating holistic needs and review accordingly.

To support staff, residents and their families before and after death.

Empower and support staff with implementing good end of life care.

KEY ROLES (as recommended by

Ambitions for Palliative and end of

Life Care 2015-2020)

POSSIBLE WAYS TO ACHIEVE EXAMPLES

1. Each person is seen as an individual

Individualised and holistic plans of care e.g. emotional, spiritual, physical, social and cultural needs recognised. To be aware of local documentation and disseminate as appropriate.

Update plans of care as necessary.

Advance care planning – every resident is offered the opportunity to discuss future wishes and preferences. Champion to support staff to engage with residents and families.

2. Each person gets fair access to care

Embedding an end of life care philosophy into the home, which is for all residents.

Multi-disciplinary approach to care. Ensure the Mental Capacity Act is upheld, which may include Best Interest/Multi-Disciplinary meetings.

3. Maximising comfort and wellbeing

Recognition and assessment of symptoms. Liaise with relevant Health Care Professional(s), to help with management of these. E.g. Supportive Care Home Team. St Raphael’s Hospice, Community Nursing Team.

Understand local systems used to address the Five Priorities of Care for the Dying Person e.g. local signposting tool.

46

KEY ROLES (as recommended by

Ambitions for Palliative and end of

Life Care 2015-2020)

POSSIBLE WAYS TO ACHIEVE EXAMPLES

4. Care is coordinated

Feedback to other members of staff e.g. at handover, staff meetings, WBHR, GP round.

Good communication and joint working with Health Care Professionals (HCP), staff and residents/families.

Use of Electronic Patient Records (in Sutton this is Coordinate My Care) to ensure Out Of Hours are aware of plan of care.

5. All staff are prepared to care

Ensure own skills are updated through attendance at end of life care training. Encourage other staff to attend.

Support and empower other staff with end of life care.

Cascade end of life care information and knowledge to other staff members.

Communicate in a sensitive manner.

Work with manager and other staff to help support each other. Consider other resources which can offer support e.g. external support services.

6. Each community is prepared to help

Work with other Health Care Professionals.

Participate in Vanguard led initiatives ensuring best practice is disseminated e.g. Care Home Forums.

Signposting to local organisations e.g. CRUSE, Alzheimer’s Society.

Appendix I (overleaf)