Enhanced GP Support Enhanced GPs began visiting the care homes to complete medical reviews on the residents, some GPs were including family members in the medical reviews from the outset. The Care Home Pilot Scheme has proven to be a great The home have been inviting the family to our planned meetings, this success at Aspray House. We are now in receipt of regular has really helped in completing visits and support, from our GP practice, pharmacist and DNAR form. community matrons, which has resulted in our Service - Pilot GP, Waltham Forest Users receiving medical assistance and support, in a timely manner. We have received positive feedback from some of our family members, as their relatives have not had to wait too long for a visit, and the GP has took time to discuss any concerns they may have into their relatives medical diagnosis. - Sharon Osbourne, Aspray House Manager The pilot has allowed me protected time to completed ‘ward rounds’ in the care home rather than using time over lunch. - Pilot GP, Waltham Forest 22
What is the data telling us? Early results look promising however it is acknowledged that there are quality issues with the source of admission and destination codes which makes analysis difficult. The data is generated using care home post codes to identify non-elective admissions and A&E attendance. Note: A small number of nursing and residential homes have the same post code e.g. Ross Wyld NH and Aston Grange RH and there is the potential to identify non care home related activity – a full audit trail has been maintained. 23
Data – LAS LAS call outs by LAS call outs (8/12 homes) 25 or 10% 50 45 40 35 30 25 20 Apr May Jun Jul Aug Sep 15/16 16/17 LAS records data for 8 of • Albany Nursing Home • Peartree House Care Home the 12 homes; • Aspray House • Ross Wyld Care Home • Waterside Lodge Recovery Centre • Spinney (The) • Parkview House • St Francis Residential Care Home 24
Data – LAS LAS Incidents Care Homes WFCCG trendline 120 100 -1.6 80 +0.3 60 40 20 -2 0 Apr-16 May-16 Jun-16 Jul-16 Aug-16 Sep-16 Linear (All Care Homes) Linear (IC Care Homes) Linear (Non IC care homes) 25
Data – Significant 7 Significant 7 Training – A+E Attendances & Non-elective admissions January – March 15 vs 16 WFCCG Care Homes QIPP 2015 vs. 2016 A+E Attendances £200,000 140 by 35 or 23% £180,000 120 £160,000 Estimated Cost 100 £140,000 £120,000 Non-elective Activity 80 £100,000 60 Admissions by 33 £80,000 £60,000 40 or 35% £40,000 20 £20,000 £0 0 2015 estimated cost 2016 estimated cost 2015 activity 2016 activity Significant 7 training had a positive impact on performance, in both January and February there was a significant reduction in activity. March saw an slight increase in admissions and attendances. (although it is not clear this could be attributed to a change of trainer and a reduced number of training sessions) Sheltered/ Supported Housing Unit benefitted far greater, these Care Homes have little training beyond the mandatory courses where as Nursing and Residential Homes have a much wider portfolio or training programmes on offer and qualified nurses on site. 26
Data – Pilot A+E Attendances WFCCG Care Homes QIPP - FY 2014/15 vs. FY 2015/16 by 84 £250,000 60 50 Non-elective £200,000 Admissions by 69 Estimated Cost 40 £150,000 Activity 30 £100,000 20 £50,000 10 £0 0 2015/16 - estimated cost 2016/17 - estimated cost 2015/16 - activity 2016/17 - activity Combined non-elective admissions and A+E attendances have seen a decrease in activity every month since the pilot began.
What’s going well Lessons Learnt Reduction in A&E attendance and Interoperability – with GPs covering care homes where the residents are not registered with unplanned admission the same GP there have been IT difficulties WF Care Home Market Position – greater Low data number – low numbers has meant understanding of the range of care homes, bed that data cannot be reported from the outset numbers and performance of care homes in the borough LAS – lack of communication, neighbouring CCG’s integrate LAS into their joint care homes Engagement – there has been a significant meetings, WF to adopt this approach. development in the relationships between the CCG and Care Homes. Phlebotomy – 4 month wait for community phlebotomy service. GPs lack skills in taking Newsletter – there will be a monthly newsletter bloods, nursing staff not signed off on shared between GP for best practice competencies, not within rapid response remit. Sharing – Care Homes Managers and GPs have Paperless – Care home use faxing to share been willing to share ideas and templates already information with General Practice, explore use of developed NHS mail. Quality Improvement – it has been reported how happy the residents family are with improve service 28
Next Steps Resulting in a tailored pilot to support the • Continued data • Commission, mobilise needs of WF residents collection and monitor of • Expand significant 7 enhanced support to • Support learning of training to care homes care homes service Care Homes in need • Develop the detail of ‘community GP’ role Resulting in clarity of Resulting in improved data and benefits to quality and financial pilot savings 29
30
A Journey to no delays in Hospital Discharge Moving from Discharge to Care Transition Paul Larrisey
What is a Delayed Transfer of Care (DToC) A delayed transfer of care is defined as a person who is occupying an acute hospital bed that is “medically optimised” i.e. no longer requires the care of an acute hospital care 32
What is the impact? It is more likely that DToC Patients are Older People. We know that Older People decondition by being in hospital both physically & cognitively they longer they stay. By not ensuring that people are discharged when ready, hospital beds are blocked for more acutely unwell patients, which has a knock-on impact across services 33
Local Context Costing WF £1.838m annually 34
Local Context • Helping people to transfer smoothly and appropriately through the health and care system is one of the most complex tasks that the system faces. • Frontline care and health staff have been dealing with this challenge for many years, but the pressure is increasing as our population ages and resources are stretched. And of course many of us have personal experience of the stress that avoidable hospital admissions and delays in transferring to the next level of care can cause. • Last Year in Whipps Cross Hospital Waltham Forest residents used almost 15,000 bed days waiting to be discharged to another setting. This means 41 acute hospital beds are in constant use for people who don’t need to be in hospital. 35
STOP! We Need to Change Our thinking and Approach
Discharge to Assess Right patient, right place, right time! Discharge to Assess • NHSE have identified Discharge to Assess Pathways as part of Eight High Impact Changes that supports patient flow across services; • In essence discharge to assess in Waltham Forest incorporates the ethos that reablement and rehabilitation should not be delivered from a hospital bed, and decisions about long term care needs are not made whilst an individual is in an acute hospital setting. The aims of discharge to assess are to: • Minimise hospital stay; • maximise independence and wherever possible support a return to home for individuals. 37
Discharge to Assess Pathways 38
Patient & System Benefits Anticipated Benefits; • Increasingly joined up care/more seamless for patients/patients in the right place right time; • Reduction in dependency on one part of the system; • Integrated roles and workforce working across the unified system not in organisational silos i.e. have therapists following patients across the system and where most needed; • Aim to improve effective use of pooled resources; 39
Next steps • Evaluate • Identify system changes required • Commission • Monitor • Improve 40
Optimising medicines for people residing in care homes Ada Onyeagwara- Assistant Director, Medicines Optimisation Dr Sabeena Pheerunggee- Named GP for safeguarding Amanda Da Costa- Prescribing Support Pharmacist
National Guidance • NICE Managing medicines in care homes, Social care guideline [SC1] Published date: March 2014 Recommendations for good practices for systems and process for managing medicines in care home • The Royal Pharmaceutical Society “better utilisation of pharmacists’ skills in care homes will bring significant benefits to care home residents, care homes providers and the NHS.” 42
Residents in care homes: • Have the same rights and responsibilities in relation to NHS care as those who do not live in care homes; • More likely to be older and frail • Have multiple health problems • Prescribed many medicines • Increased risk from errors with medicines 43
Patient centred care Helping residents to look after and take their own medicines is important in enabling residents to retain their independence. • When a person moves into a care home, staff should assume that the person can look after and manage their own medicines, unless indicated otherwise. • Each resident should have an individual risk assessment to determine the level of support they need to manage their own medicines. 44
What is Medicines Optimisation? Evidence Based Patient Information •Medicines Policies •Supporting patients to make •Implementation of national informed decisions guidance •Local approved prescribing guidance Safe administration of MDT approach to Medicines providing care •Education and Training •Inclusion of pharmacist •Medicines Policies 45
Principles of safe and appropriate handling of medicines (1) • People who use social care services have freedom of choice in relation to their provider of pharmaceutical care and services including dispensed medicines. • Care staff know which medicines each person has and the social care service keeps a complete account of medicines. • Care staff who help people with their medicines are competent. • Medicines are given safely and correctly, and care staff preserve the dignity and privacy of the individual when they give medicines to them. 46
Principles of safe and appropriate handling of medicines (2) • Medicines are available when the individual needs them and the care provider makes sure that unwanted medicines are disposed of safely. • Medicines are stored safely. • The social care service has access to advice from a pharmacist. • Medicines are used to cure or prevent disease, or to relieve symptoms, and not to punish or control behaviour. 47
Role of the pharmacist Support Medicines Optimisation by: • Medication reviews • Education and Training • Quality assurance visits • Reviewing medication errors • MDT membership • Clinical Advice • Signposting to other services 48
Care Home work in Waltham Forest The Medicines Optimisation team have supported • A local Nursing Home • The CCG commissioned care home service 49
Care Home work in Waltham Forest- The Team Dr Sabeena Pheerunggee Amanda Da Costa 50
Care Home work in Waltham Forest- Case Study The work includes: • Working as a part of the MDT • Review of all medicines related policies • Clinical and safety audits • Joint wards rounds with GPs and other healthcare professionals • Covert administration reviews 51
Outcomes for the local enhanced care home service Total (April to September 2016) 34 No of Visits No of Medication Reviews 305 undertaken 412 No of Medications Changed 1491 No of Medication issues TBC Total Savings 52
Compliance with NICE quality standards Review of Medicines Policies: •Ensure appropriate information is available in the policies •Align it to the NICE guidelines •Review repeat prescribing process NICE Quality Statement Completed Statement 1. People who transfer into a care home have their medicines listed by the care home on the day that they transfer. Statement 2. Providers of health or social care services send a discharge Communication MDT approach to summary, including details of the person's current medicines, with a person who •Patient and carers transfers to or from a care home. reviewing patients: •GP Statement 3. People who live in care homes are supported to self ‑ administer their • Weekly MDT rounds •Pharmacists medicines if they wish to and it does not put them or others at risk. •Ensure prescribing is in •Other healthcare line with local policies and Statement 4. Prescribers responsible for people who live in care homes provide professionals guidelines comprehensive instructions for using and monitoring all newly prescribed •Care Home Staff medicines. Statement 5. People who live in care homes have medication reviews undertaken by a multidisciplinary team. Statement 6. Adults who live in care homes and have been assessed as lacking capacity are only administered medicine covertly if a management plan is agreed after a best interests meeting. Covert Administration Education and Training •Is covert administration necessary •Provided training on •Confirm consent nutritional supplements •Regular review of covert •Support to understand administration medicines and policies 53
Best practice for Medicines Optimisation for Care Homes • Collaborative working between all healthcare professionals • Joint ward rounds • Robust medicines policies • MDT approach to delivering care Difficult Conversations and identifying patients for End of Life Care 54
Useful links • NICE guidance: The NICE Guidance; Management of medicines in care homes (March 2014) clearly states how commissioners, managers of care homes and other healthcare professionals involved in care homes should work in a standardised format with clear consideration for process and safety : https://www.nice.org.uk/guidance/sc1 • Royal Pharmaceutical Society The Handling of Medicines in Social Care sets out principles of good practice and legislation governing the handling of medicines applicable to providers of care services, managers and care workers in many social care settings : https://www.rpharms.com/social-care-settings-pdfs/the-handling-of-medicines-in-social-care.pdf • Care Quality Commission The Care Quality Commission (CQC) regulates the management of medicines in care homes. The Essential Standards guide is designed to help providers of health and adult social care comply with the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009 CQC Essential standards of quality and safety 55
Further queries Medicines Optimisation Team NHS Waltham Forest Clinical Commissioning Group Telephone: 020 3688 2654 E-mail: wfccg.medicinesoptimisation@nhs.net Difficult Conversations and identifying patients for End of Life Care 56
Enhancing support with R&RA’s ‘Keys to Care’ Judy Downey Chair The Relatives & Residents Association With thanks to Comic Relief who financed “ Keys to Care ” 57
R&RA Who we are National charity founded in 1993 We support, inform and campaign on behalf of older people in care We employ the unique perspective of residents and their relatives to help improve services for all those thinking about or living in care homes 58
What we do Helpline Campaigning Resources Publications & Projects 59
R&RA’s Helpline Offers accurate, up-to-date information about the transition to residential care. For example about Who pays? What to pay? Whether to pay? Advocacy and support Concerns about care As well as a sympathetic and compassionate response Our Helpline empowers callers with the information they need 0207 359 8136 open from Monday to Friday 9.30am – 4.30pm 60
R&RA Campaigns To improve the quality of life for older people needing care. We argue for: Higher status for care workers Mandatory training for all care staff Minimum staff ratios Better regulation 61
WHY WE NEED HIGHER STATUS FOR HEALTH AND CARE WORKERS? Because of the increasing needs of those needing care Because people at the end of life deserve the best care Because the workforce deserves better pay and conditions Because this won’t happen without a better career structure All these depend on having a national mandatory, recognised and transferable qualification, which will increase pay and job satisfaction, reduce turnover and promote the status care needs and deserves 62
TRAINING IN THE SECTOR IS SIMPLY INADEQUATE Almost 50% of the adult social care workforce have “no relevant social care qualifications”* Over 90% of care home workers are not working towards any qualification** Fewer than half have any training in medication handling and awareness, mental capacity and deprivation of liberty or dementia care* Only 10% have received training in malnutrition care and assistance with eating** *Skills for Care – State of the Adult Social Care Sector and Workforce in England, 2016 **Skills for Care - National Minimum Data Set for Social Care, November 2016 63
WHY THE CURRENT SITUATION IS JUST NOT GOOD ENOUGH The latest “Safeguarding Adults” Annual Report* showed that people in care homes are more vulnerable than any other group in the adult population. The total number of adults at risk for whom safeguarding concerns were investigated and concluded came to 124,940. This number does not include separate referrals to other agencies. * Safeguarding Adults Annual Report, England 2015-16 64
WHY THE CURRENT SITUATION IS JUST NOT GOOD ENOUGH The vast majority of referrals about a risk of abuse concerned people over 65 i.e. 63% - 6 out of every 10 referrals. The largest group within this were over 85 i.e. 29,760 Adults aged 75-84 were three times more likely, and Those aged 85 and over were more than 10 times more likely to have a Section 42 Enquiry than the England average. 65
WHY THE CURRENT SITUATION IS JUST NOT GOOD ENOUGH The place of risk was most frequently the home of the adult at risk (43%) or the care home (36%). Over 9 million people over 65 live in their own homes. 45,897 were concluded referrals affecting individuals in care homes. Fewer than 400,000 older people live in care homes. 66
R&RA Campaigns We need CQC to be: More efficient and effective More focused on improvement More vigilant with more frequent inspections using trained and experienced inspectors More accessible with signed and readable reports which avoid jargon AND a return to investigating complaints 67
WHY DID WE PRODUCE KEYS TO CARE? Their development was prompted by the worries and distress of residents, relatives and others to our Helpline about poor or rushed care. And the obvious need for more support for staff and those in the front line of caring for frail, elderly people. Our team has produced this practical training resource w ith the benefit of specialist advice and the help of people who live and work in a range of care settings, with charitable funding and the endorsement of Skills for Care and the Department of Health 68
Keys to Care The Keys to Care - 12 little cards on a keyring covering topics, ranging from the practicalities of the Care Plan, Continence Care and Mouth & Teeth Care to the deeply sensitive issues of Dementia and End of Life Care. The key things to Think about Ask Do It is more an aide-memoire, a checklist, a reminder of what matters and yes, a reassurance that you’re doing the right thing. 69
Keys to Care The Keys to Care resource was designed primarily for care workers and healthcare assistants and also found useful for relatives and others. Jargon free, practical, easy to read and use. “A brilliant idea and so well executed.” Sharon Allen, CEO of Skills for Care 70
Keys to Care The Keys to Care resource is unique because it is: Designed for the busy health and care worker Easy to read and use Attractive and durable Flexible in use 71
Keys to Care Evaluation* – Impact on Quality How has Keys to Care resource impacted the quality of care you provide? More than 50% of care workers agreed or strongly agreed with these statements: I seek more advice I am more involved I look for ways to and guidance in deciding how to improve what I do about doing my job care for people I care more about I know better what I am better at my the person and/or I and others should job my job be doing * University of Worcester, Association for Dementia Studies, Evaluation of the Keys to Care Resource, February 2016 72
Keys to Care Evaluation – Association for Dementia Studies 89% of care workers used the ‘Keys’ all the time, frequently or sometimes The flexibility of the ‘Keys’ was reflected in the multiple ways they were used by care workers 73
Feedback from Care Workers “ I like the fact you can “Great prompts and reminders. “It’s all a really look up more good guide for Nice to have the information. I feel that care planning.”* information at hand - the more information saves time.”* you can get, the better. ”* “These should be given to “They are good for “Reminds me everyone who is going to reminding people that it is so work to support people. what they should be important to do You can tell they are doing, particularly my job well.”* written by people who are for new and agency receiving or giving care.”* staff.”* * Quotes from the Royal Hospital Chelsea, The Orders of St John Care Trust and The Extra Mile Care Company 74
Designed for Care Workers by the care sector ‘ They help us focus and remember what is important to caring, as people can become complacent and forget’ ‘It is so easy to slip in to a routine, and they (the Keys to Care) remind you to think about the person and look after people as individuals’ 75
Keynotes Each Key has a complementary Keynote . The Keynotes expand and develop each topic with hints, tips, practical examples and the underpinning Regulations. Each one helps to bring the topic to life. See examples here today. 76
Links across the sector The National Care Keys to Care The Social Care Certificate Com m itm ent Understand Your Role ALL Working co-operatively Continuing to learn Personal Developm ent ALL Duty of Care Listening & Talking Safeguarding Adults The Care Plan Working responsibly Handling Inform ation Em ergencies Daily life Equality & Diversity Fam ily & Friends Treating people fairly Working in a Person Centred way ALL
R&RA Membership Joining The Relatives & Residents Association shows that: YOU care about residents’ quality of life YOU are committed to improving standards YOU care about your workforce www.relres.org info@relres.org 020 7359 8148 78
Workshop 2 – Key issues 1. Personal reflections on key issues (yellow post it notes) 2. Table discussion on Key issues (themes) • Patients • Relatives • Care homes staff • Others 3. What needs to be in place for good quality care? 79
Medicines related care of residents with dysphagia in care homes Heather Eardley, Development Director
The Patients Association • Long established national independent charity • Non-disease specific • Campaigning on patients’ and carers’ issues • National Helpline • Working with NHS trusts, providers and regulators on patient improvement project
Basis for report • Reports to our helpline of swallowing difficulties being a challenge • Telephone survey of 30 care homes based on structured questionnaire • Care homes had between 20 and 90 residents
Major findings • Incidence of swallowing difficulties varied - 1 manager reported that 50% of her residents had some form of difficulty in swallowing. • Over 100 people had profound swallowing difficulties • In over two thirds of homes crushing, melting, dispersing or splitting medication happening daily • In over two thirds of homes mixing medication with food happening daily
Major findings 2 • Many managers referred to advantages of liquid forms of medication but • Over two thirds of homes reported GP concerns about the cost of liquid medication and this was a factor in prescribing practice • Holding off doses due to difficulty in administering medication was an increasing issue
Issues presented • Swallowing problems can lead to residents choking or having coughing fits • Changing structure of medication alters normal arrangement for absorption • Common cause of administration error • Crushing = greater liability to prescriber, dispenser and administer of medication • Risk of residents being covertly treated with medication disguised in food
Training • Most managers had limited detailed understanding of legal position or problems with crushing medication • Significant minority unaware of circumstances under which acceptable to give drugs covertly • Only one fifth of homes had received training in admin of drugs to people with dysphagia in last 5 years
Assessment • Problems with Deprivation of Liberty Assessments for covert administration • Representation of private fee payers • Variable delay for assessments of swallowing by a Speech and Language Therapist
Good practice • No instances of blanket authority for crushing – decision on ‘case by case’ basis • 27 homes had a specific protocol for covert administration • Vast majority of homes taking advice from pharmacists • Local Enhanced Serviced in Sheffield offers useful model for GP involvement in care homes
Recommendations • 21 recommendations in total directed at care homes, CCGs and CQC include: – risks of crushing medication covered in induction + refresher training for all staff – The best form of treatment rather than cost should be primary consideration – DoLS assessments should be prioritised for instances of possible covert medication – CQC should review medication practices for people with dysphagia in targeted inspections
Media New report highlights ‘worrying trends’ in care of the elderly - The • Patients Association • Medication training urged as study shows care home residents struggle swallowing - BT News • New dysphagia recommendations for care homes - Dispensing Doctors’ Association • 50% of care home residents affected by swallowing difficulties - Care Industry News • Concerns over medication crushed into food - QCS New Report Highlights Worrying Trend in Care Homes – Care News Today • • Medication training urged as study shows care home residents struggle swallowing - Care Appointments
Interviews • BBC Radio 5 Live’s Morning Reports • Sky News Radio • BBC1 Breakfast • 5 Live Breakfast • Nine regional BBC radio stations
Next steps • Report from Round table • Commitments from CQC & Waltham Forest CCG • Individual briefings • Dysphagia Advisory group • Resident and Relatives Association conference • Patient safety groups • Look at other aspects of swallowing – e.g. food
Advisory group • Advisory Group met three times since the report – May, September and November 2016 • Martin Vernon, National Clinical Director for Older People and Integrated Person Centred Care, NHS England and Acosia Nyanin, Head of Inspection, Care Quality Commission both attended last meeting to hear from group • Advisory Group developing framework for dysphagia and medicines management in care homes- includes patient expectations and staff information.
In development…. • Protocol/ resource pack for ‘dysphagia and medicines in care homes’. Will include: • Information and advice about swallowing difficulties • Legal implications of covert medication • Importance of decision specific capacity • Charter re use of medication in care homes. • Care home networks to share good practice to help prevent isolation and facilitate collaboration.
Other projects with WFCCG • Reaching for a gold standard • Patients Participation Groups in GP practices • Care academy with Leyton Sixth Form College And with other trusts: • Complaints handling improvement – peer review, patient review panels, staff training , independent investigation • Others
The Patients Association PO BOX 935, Harrow, Middlesex, HA1 3YJ Email: mailbox@patients-association.com Telephone: 020 8423 9111 Fax: 020 8423 9119 Email: helpline@patients-association.com
Reflections of the past Ella Otomewo, Poet and Spoken Artist
What Does Great Care Look Like? How to Measure and Improve Anne Walker - Deputy Nurse Director Quality and Clinical Governance
Good news does not sell newspapers! Nursing Conference WF CCG November 2016 2/1/2017 99
Providing Healthcare That is Great! Often choosing a home happens at pace, families working under pressures and stresses of moving a loved one to a new home. Health care is high credence and intangible, you can not see what great care looks like, so how do you instill confidence in patients and families and help them make the right decision? What one perceives as good is different to another? What can you see? Nursing Conference WF CCG November 2016 2/1/2017 100
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