Improving quality of care in residential care and nursing homes

One of Healthwatch Isle of Wight’s main purposes is to ensure that we listen to the voice of the public and ensure that this voice is heard by commissioners and providers of health and social care services. This will then lead to continual service improvement and to a direct improvement of people’s experiences of services.

Within this project, our main aim was to improve the quality of care in local residential care and nursing homes by highlighting NICE guidance and educating members of the public, service providers and commissioners about good standards of care which all vulnerable people should be able to expect. Prior to starting the project, we looked back at feedback relating to nursing and care homes that we had received from the public. We identified several themes and trends relating to the feedback and this enabled us to focus the project. The themes included, poor personalised care, poor range and access to activities and poor nutrition and fluids.

NICE has produced guidance for commissioners and providers (older people with social care needs and multiple long-term conditions - NG22) which emphasises the need for care plans to include ordinary activities outside the home (whether that is the care home or the person’s own home), for example, shopping or visiting public spaces. It stresses the need for activities to reduce isolation and to build people’s confidence by involving them in their wider community. It goes on to specify that ‘person centred care should ensure that the person is supported in a way that is respectful and promotes dignity and trust’.

These are the standards we wanted implemented in nursing and care homes on the Isle of Wight to ensure that people`s expectations were raised with regards to the care of older people. We know that many people on the Island are very tolerant and have low expectations of the care they can expect to receive. We wanted to support service providers, council members and members of the public to know ‘what good is’ and to embrace NICE guidance and standards as a benchmark of good practice.

Throughout the course of 2015, Healthwatch Isle of Wight received increasing amounts of feedback from members of the public, expressing concerns around the quality of care provided within a significant number of residential and nursing homes on the Island. Towards the end of 2015, Healthwatch found that of the 92 Isle of Wight residential and nursing homes registered with the Care Quality Commission, only 17 had been inspected under their new inspection model and had their reports published. Of those 17, only 3 (18%) were rated as good, 8 (47%) as requiring improvement and 6 (35%) were rated as inadequate.

We benchmarked very unfavourably with ratings from other areas in England and put quite simply, we felt that this was not good enough. This compared to a ratio of 58% of homes on the mainland who have been inspected under the new CQC inspection model and are rated as good, with only 8% rated as inadequate (as of July 2015). We were aware that at the time, the IOW Council were not completing quality monitoring visits to care homes.

There was no quality framework for the Island and most Island nursing and care homes were owned by single providers, some of whom did not engage with other providers or indeed with their wider community. Several homes had closed (one of them suddenly) and this put the IOW Council, primary care services and the IOW Clinical Commissioning Group under great pressure to support the home before finding urgent care placements for all residents. This put statutory services under great pressure, both financially and because they had to deploy a significant number of people to support the home closure.

We know that it is much more cost effective to promote good quality care by using an outcome based commissioning model, by educating care and nursing home staff and managers and by raising people’s expectations regarding the standard of care they can expect. This will lead to fewer home closures, less enforcement action taken by the Care Quality Commission and a better quality of life for some of the most vulnerable people. Approximately 400,000 people live in care homes in England and there are around 900 people on the Island currently living in a residential care or nursing home. Promoting a person's wellbeing will have wider effects on local services as a person who is well supported both physically and emotionally, will be less likely to be admitted to hospital or to require urgent primary care.

When ‘Quality of Care’ was identified as a priority work plan topic, targeted engagement work began and this along with an analysis of our feedback identified several themes and trends that informed our work. We felt that it was important not just to listen to people`s experiences of care and nursing homes, but to reflect on why some homes are performing better than others and what can be done to support those homes that are failing.

The methodology we followed is described below:

People’s experiences:

Conversations took place with people who had experience of living in a nursing or residential care home or with a close friend or relative of a person who had. We made sure that all of the people that we spoke to were talking about experiences within the last two years, to ensure that that their story was relevant to current standards. During our ‘enter and view’ visits to nursing and l care homes, we also spoke to many relatives and residents, supporting them to have a voice and speak up about the quality of care they or their loved one was receiving.

Registered Managers survey:

Healthwatch Isle of Wight carried out a questionnaire survey in 2015/16 which was sent to all registered nursing and residential care home managers on the Island. 40 registered managers completed our survey. The Healthwatch 'enter and view' representatives conducted visits to 13 nursing and residential care homes between November 2015 and February 2016. The homes were chosen following consultation with the Care Quality Commission and following an analysis of the feedback we had received from the public during the previous 12 months. During the project we faced several issues, one being lack of capacity to complete the work.

We are a small local Healthwatch and we rely heavily on the support of a fantastic group of volunteers (our ‘enter and view’ team). Due to lack of capacity in the staff team, our ‘enter and view’ team did much of the planning and preparation work and also completed all the ‘enter and view’ visits to the residential care and nursing homes. At the beginning of the project, due to general funding cuts and financial pressures, we faced an uphill struggle trying to convince statutory sector partners that we desperately needed to work together to improve quality of care and we utilised the registered managers’ survey to demonstrate simple measures which could make the life of a manager much easier. This was reflected in our recommendations.

A breakdown of the resources required for the piece of work is as follows: volunteer hours: 91, staff hours: 96, printing and postage costs: £45. The project was completed as part of our core work programme, so we did not need to recruit any additional staff.

We hosted the first IOW Care Awards at a ceremony in April 2016 to celebrate outstanding practice in nursing and care homes. Since then, due to the intense media coverage and success of the ceremony, other local Healthwatch have expressed an interest in hosting similar awards. As a result of our report, the local authority restarted their quality monitoring visits to nursing and care homes, enabling them to pick up issues and concerns early on. They set up an integrated quality surveillance group with membership from the CQC, the local authority, Healthwatch Isle of Wight and the IOW CCG. The CCG have recruited a care/nursing home quality lead who provides support to home managers.

A managers’ network has been established along with quarterly newsletters to social care managers with links to support and training resources. As a result of these initiatives, the CQC rating for care and nursing homes has dramatically improved with 69% of all care and nursing homes receiving a good rating, 30% require improvement and no homes rated as inadequate.

Healthwatch England published a report highlighting our winning project and described it as follows:

 “Healthwatch Isle of Wight heard that the quality of care in some nursing and residential homes was not up to standard. They visited 13 care homes and spoke to residents and their families about their experiences. People told them in some cases basic care needs were not being met, there were restrictions on food and drink, and families often found their loved ones wearing other people’s clothing. Although most homes offered activities for residents, there was a general feeling that staff did not understand the effect meaningful activities could have on a person’s quality of life.

After sharing what they’d heard with the Clinical Commissioning Group (CCG), local authority, and Care Quality Commission (CQC), a variety of steps have been taken to make things better. Residents now have a say in the types of activities they want to do, which has helped improve their quality of life. Care homes are also developing activity planners and organising trips to nearby attractions to support this.

Thanks in part to Healthwatch Isle of Wight’s efforts, the majority of care and nursing homes have since received a good rating by CQC and no homes are rated as inadequate. Healthwatch Isle of Wight’s work was also awarded the NICE Better Care Award”.

Looking back at the project, although we had a successful outcome and I believe we supported service providers to improve the quality of care given to older people on the Isle of Wight, there are several things that we reflected on at the end of the piece of work.

We underestimated the time it would take to plan and prepare for the work. We spent months developing a relationship with nursing and care home providers and managers. We visited individuals, attended several care home forums and emailed every manager before we began the work, introducing ourselves and explaining what we would be doing and why.

We felt it was very important to develop a positive relationship with providers, but this led to the project taking longer to complete than expected. Taking a proactive approach is always the best way to engage service providers to improve what they are doing and this is something we have replicated in other projects.