The Quality Assurance and Improvement Team (QAIT) at Plymouth City Council designed an education and training package in order to encourage their local care provider community to implement the recommendations from NICE guidance for managing medicines in care homes (SC1).
This example sets out how the team engaged with local providers, the methods and interventions used to encourage alignment and uptake with the guidance and key lessons learned from their experience.
Aims & Objectives
The aim of this initiative was to raise awareness of the relevance of NICE guidance SC1 to local care home providers.
The objective of this exercise was improving uptake of the guideline and encouraging local providers to deliver practice which was in line with NICE recommendations, adapting local policies where required in order to do so.
The QAIT team is co-located with integrated commissioning CCG colleagues at Plymouth City Council. The team consists of 3 care home practitioners who work on a full-time basis. The team started with a focus on care quality in the wake of the Winterbourne View with the intention of having a commissioning arm to have a closer working relationship with local care home providers including residential nursing homes in Plymouth.
The main objective of the team’s work is to provide a quality review of all services that the council commissions both within and just outside the city boundaries. This covers approximately 105 care homes and a similar number of out of county services. The team’s work covers any care provider that is registered with the CQC and can be providing, for example: residential care, substance misuse services, care for the elderly etc.
The team carry out planned 2-day quality reviews involving health and public health colleagues where appropriate and Healthwatch to undertake lay visits where possible. This is not an inspection but a collaborative, supportive approach. The review focusses on policies and procedures, staffing and rotas, care planning, training matrices, risk management processes, service user involvement and mental capacity.
The team also links with colleagues from other teams on an ad hoc basis where specialist input may be required e.g. public health and CCG colleagues. For example if the team are visiting a drugs rehabilitation service, they would take a senior drugs officer from the public health team with them, likewise they would take a community nurse reviewing home care.
The team facilitates the delivery of a ‘Dignity Care Forum’. Local providers are invited to the forum on a quarterly basis to network and share local best practice. The forum also provides the opportunity, to discuss the implications of new regulations coming through and to invite guest speakers on key topics.
Quality review work is holistic assessment of where a service is, draw from a thematic analysis, the team make recommendations from it and pick up themes that they want to highlight at the Dignity Care Forum.
The team observed that following the publication of NICE guidance for managing medicines in care homes guideline (March 2014), they identified through the quality reviews that many services were not aware of guidance.
The QAIT team felt it was important both from a regulatory perspective and good practice generally, if commissioned providers were delivering evidence-based medicines management, in line with NICE guidance. They were concerned that providers reported that they didn’t know where to start and how to implement the recommendations.
Through local quality reviews, the QAIT team gathered a picture of current practice locally through their work and identified the obvious difficulty for providers and subsequent gap in service that this had created.
The team sub-contracted a pharmacist who is ‘Care Home Lead’ in the Clinical Effectiveness and Medicines Optimisation Team at the CCG who was given a designated role as care homes lead for this project. Having this expertise within the team has aided them to encourage some consistency of practice within care homes in medicines management and recognition of the importance of local audits.
A dedicated workshop session was held within the Dignity Care Forum to raise awareness of the new guidance and to create impetus for its implementation locally. Regular attendance at the Forum is typically 50-55% of local care providers and so the forum provided an opportunity to reach a significant portion of the target audience. The session was designed and led by the Care Home Lead. The content is included in the supporting material.
The session was evaluated and was found to be partly successful although subsequently there was still found, via quality reviews and care home visits, to be a shortfall in positive uptake of the NICE guidance. The team therefore decided that a more proactive intervention strategy was required. The medicines optimisation pharmacist designed a more targeted package which consisted of workshop presentations coupled with practical elements to match the NICE guidance recommendations to local practice.
The team delivered 6 dedicated workshops for care providers. The workshops lasted 3-4 hours and then the medicines optimisation lead pharmacist went through each of the recommendations in the NICE guideline. The team also asked attending providers to bring their own local medicines management policies to the workshop where these were compared to the NICE guidance recommendations to assess the current policy against 2 key recommendations from the guidance.
The session was designed in this way so that the QAIT team and the providers were able to identify to what extent the local policy aligned with NICE guidance and how much of a journey was still required by the provider in order to bring the policy into alignment. The workshops also provided an opportunity for those who delivered best practice to share their knowledge and experience to support each other. There were no additional costs attached to provide these workshops as they were delivered within council premises in the city.
An additional session was also delivered which was specifically targeted at local pharmacists in order to encourage parity between local prescribers and care providers within the city
Results and evaluation
The team evaluated the dedicated workshops in order to assess whether they had met the intended aims and improved uptake of the NICE guidance in the local care provider community. A total of 141 care professionals attended the 6 workshops, this represented approximately 60-65% of local care providers and was an increase in attendance compared to the first session delivered at the Dignity Care Forum. A mop-up workshop was delivered at the end of the programme which captured about another 15% of local providers, a total of 75-80%.
Evaluation of care providers who attended the workshops found that:
- 89% of attendees were very satisfied that the workshops had refreshed/raised awareness
- 89% of attendees were very satisfied with the practical advice provided
When asked: what parts of the training did you feel were the most useful to you and why? Attendees’ responses included:
- How to construct the home’s policy
- Going through the NICE checklist and relaying it to current policy in place, which helped identify areas of the policy missing or which needed to be more accurate
- The NICE guidelines and checklist run through against current home policy
- Always help and support at the end of the phone
- NICE Checklist for policy – will go back and review until more confident
- Every aspect was very informative, especially around medication policy and NICE guidelines
- All parts of the training were of benefit to assist everyone to update policies and procedures to meet latest requirements
When asked: What 3 things from the session today will you take back to your service? Attendees’ responses at the pharmacist session reported:
Reducing medicine waste;
- Communications between the pharmacy, care home and GP;
- Where to find information;
- Look more carefully at NICE Guidelines and providing a better service to the care homes;
- How we can support care homes.
The team have a checklist set out by medicines optimisation in order to assess on continued alignment with the NICE guideline. One of the questions on the Medication Audit checklist which is undertaken at each quality review is around the home’s checklist being NICE compliant. Through this work, the team have observed revisions to local medicines management policies in a positive direction. Of the homes who had their Quality Review prior to the workshops, the rate of homes who were ‘NICE compliant’ was 65%, and after the workshops the rate was 76%. It should be noted that there is some variation in the cohort of homes reviewed pre and post-workshops. The results are indicative.
Where local providers are part of a larger corporate organisation, the team have noted that making changes to amend medicines policies takes longer to achieve than smaller providers where a change in policy might be implemented more quickly as organisational process is closer to the provider itself.
Key learning points
The QAIT team has observed that some of the attendees who came to the workshops have now moved on from their local provider organisations. In order for implementation to be sustained, commitment from the employing organisation is required so that there is continuity in delivery of the change locally. In order to encourage sustained momentum, the quality review team are considering the delivery of an annual review session so that any homes which have new staff can attend and receive the same training as their former colleagues. It is proposed that these sessions would again be delivered by the lead pharmacist for medicines optimisation.
The QAIT team consists of care home practitioners who all have previous experience of frontline service delivery in care settings. The team has found this to be an asset in their work, particularly when designing intervention packages to encourage change in local care provider organisations, as they are able to draw on their own knowledge and experience of what is most likely to be able to achieve the best results in practice.
In the workshops, the team has actively endorsed the NICE guideline and sought to raise awareness in the care provider community that NICE is no longer just a clinically-focussed organisation but is delivering evidence-based guidance for both health and social care.
Finally, the New Devon CCG website has a website resource: ‘Caring 4 Care Homes’ which includes a selection of medication audit tools, guidance sheets and newsletters. The resources can be accessed here.