The Orders of St John Care Trust, a charity care provider have translated 5 NICE Quality Standards into audit tools whereby care homes can evidence their performance against the standards to inform practice both at an individual and home level.
These Quality Standards are:
• Supporting people to live well with dementia (QS1)
• Mental wellbeing of older people in care homes (QS50)
• Managing medicines in care homes (QS85)
• Pressure ulcer management (QS89)
• Care of dying adults in the last days of life (QS144)
Since the original audit exercise, across 68 geographically dispersed care homes, we have also now evolved the process such that homes are also encouraged to specify how they are going to improve practice above and beyond the standard and this evidence is audited as part of the regular Trust-wide audit process, to support a culture of continuous learning and improvement.
Aims and objectives
To raise awareness of NICE and the quality standards/guidance that relate to care homes, and to ensure and be able to evidence that each care home was:
- Aware of the Quality Standards and,
- Delivering care that was consistent with the standards/guidance. An internal survey questionnaire identified that awareness of NICE and its guidance was low, particularly amongst care staff.
Reasons for implementing your project
The Orders of St John Care Trust (OSJCT) cares for 3,500 residents and has a similar number of employees. Care is provided across 70 geographically dispersed sites. Prior to the implementation of the referenced audit documents, NICE guidelines and standards were not referenced within the organisation outside of a few care quality policy documents.
A survey was conducted to elicit the awareness of NICE across the organisation which was a starting point for this project. 83 responses were received, a response rate of 50%. Most respondents were home managers (63%) followed by heads of care (20%), operations managers (9%) and trainers (5%).
Key findings showed that at that point, awareness of NICE guidance and its functions was limited. Although two thirds of those who replied knew about NICE and its clinical guidelines, only one in four were aware of the existence of Quality Standards. In the survey OSJCT employees were asked for their views as to how NICE guidance should relate to the Care Quality Commission’s (CQC) inspection process. Replies reflected that they saw the inclusion of NICE guidance into the process as a positive way to tackle inconsistencies in approach and as a means to formally acknowledge the use of evidence-based practice within a care home setting.
“If clinical triggers and NICE clinical guidance/standards are used alongside the CQC outcomes, this would lead to a more robust system”.
“Providing clear guidelines on clinical expectations and standards would enable CQC inspectors to make clear cut assessments rather than subjective interpretation.
As a follow up to this survey, the NICE Implementation Field Team were invited to attend the care home manager meetings in each respective county that the Trust operates, as part of an organisation-wide exercise to improve awareness of NICE Quality Standards.
How did you implement the project
A professional lead from with the Trust’s care quality team was assigned to each respective NICE Quality Standard and developed the audit tool for that standard, drawing on the statements within the standard as audit measures.
A consistent template to be applied across all the standards was devised for each home to complete, to ensure consistency in approach across all the homes in the Trust.
The audit template documents detailed the existing Trust-wide strategic actions; that is training, policies and best practice that should be in place, aligned with the statement in the NICE Quality Standard. For example, the pressure ulcer management guidance (QS89) states ‘People at high risk of developing pressure ulcers and their carers receive information on how to prevent them’. The OSJCT audit document for QS89 refers to the ‘Trust pressure care and skin management’ leaflet that is available for carers to provide to residents and their families.
The audit templates were issued to each home. Each home was asked to complete the template detailing the actions being taken at a home level and to display the completed documents on a notice board in the home. Evidence of satisfactory completion was audited, as part of every home’s annual internal audit, undertaken by the Trust care quality team. This was done within existing CQ team resources.
All homes inherently wish to do well in the internal Care Quality (CQ) audit process, as this is an indicator of the standard of care provided by the Home to its residents. Results of the CQ audits are shared transparently across the organisation in a league table format.
Homes can apply for various accreditations, for example accreditation in infection control or medicines management if they achieve 100% in these respective areas of the CQ audit tool. The inclusion of questions in the CQ audit document relating to the satisfactory completion of the various NICE audit templates was the requisite driver for NICE audit templates completion in the majority of cases.
Training was not provided initially as it was not considered to be a difficult piece of work to complete the audit documents and most homes are well used to undertaking audits across a variety of areas of practice within the home. At the time a worked example was circulated to illustrate how they should be completed. However what we have learnt that has worked subsequently is that when new managers have joined the Trust, more experienced managers have been allocated to show them how to complete the templates often referring to the experienced home managers ‘best practice’ examples.
Evidence of satisfactory completion was audited across 70 sites, as part of the homes’ annual internal audit process.
To keep the quality improvement process alive in relation to the existing NICE quality standards, we have subsequently revised the format of the NICE Audit Templates to include a column which encourages the home to identify further actions to develop practice in excess of the NICE quality standard.
Tangible impacts of the use of the NICE audit templates has varied depending upon the quality standards in question. For example, our practice in relation to medicines management for the past 10 years has always been consistent with best practice, so additional resources actions were not needed. Conversely, for actions with respect to the QS1 (Supporting people to live well with dementia) have included investment in three additional Admiral Nurse posts, the ongoing establishment of dementia cafes, training across a range of dementia specific areas and investment in arts engagement opportunities.
An impact though difficult to quantify is the value of the NICE templates as a framework for reflection with carers, to helping them to identify whether or not that they are providing care that is consistent with and follows national best practice. The care sector is one that is regularly targeted by the media and often portrayed in a negative light; it is imperative therefore that employees see and understand the value of delivering care in accordance with recognised and agreed best practice.
Enhanced awareness within the organisation of NICE guidance and quality standards has meant that we are now more proactive in terms of responding to NICE Quality Standards relating to social care. For example, the oral health care QS has meant that we have changed our assessment documentation and will require additional investment to provide training to care teams on oral assessment and mouth care. A baseline survey has been conducted to establish care workers’ current level of knowledge of oral health practice and attitudes towards providing oral care and results from this will inform future training.
All homes are audited on an annual basis as a minimum. If a home does poorly on the initial audit they will be audited again between 3-6 months later.
Key learning points
As with the implementation of any change or practice there needs to be ownership and buy in at a senior level and some form of monitoring, particularly when you have such a geographically dispersed organisation as OSJCT.
OSJCT has always been committed to providing evidence-based or best practice care and considers itself to be a progressive organisation, so adopting and increasing awareness of relevant NICE guidance that enshrines or summarises agreed best practice is a logical fit.
There are three simple specific learning points:
- Whoever is championing or supporting this process needs to understand the difference between NICE guidelines and quality standards. One clinical lead spent a great deal of time and effort into translating one of the NICE guidance documents into an audit document and it produced a document 34 pages long. This made the document unwieldly. On reflection it would have been better to have waited till the QS had been issued.
- Document control measures. Many homes wanted a document that they could edit on the computer. What we have found in some areas is that some of the quality statements have been ‘chopped off’ the audit document. For example, QS30 lost 3 quality statements in some of the versions in use.
- Use the NICE QS numbering system on each document. This can avoid confusing titles and quality statements, particularly with some of the quality standards which are focused on similar areas.