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Our values: clinical engagement, patient involvement, local ownership, national support

www.england.nhs.uk/vanguards

Enhanced Health in Care Homes

Low Cost High Impact

Learning guide

January 2018

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First published: 29 January 2018 Revision History Revision date Version Number Summary of changes

First published 29 January 2018

v1 N/A

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Contents

Low Cost High Impact project 4 & 5

New care models and enhanced health in care homes framework 6

The EHCH framework 7 & 8

Library of initiatives 9 - 37

FutureNHS platform 38

Key documents 39

Evaluation tips 40

Acknowledgements 41

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Low Cost High Impact Project

Overview • The Low Cost High Impact learning guide captures initiatives focused on improving the health and well-

being of residents of care homes, nursing homes, assisted living sites and those who require support to live independently in the community or who are at risk of losing their independence.

• The initiatives contained within this guide have been developed by the six enhanced health in care homes (EHCH) vanguards (see slide 6 for more information) and other health and social care systems across the country. These are examples of effective, low cost and easily implementable projects that have already been rolled out across the country.

• The document has been co-produced with the EHCH vanguards in line with the new care model programme values of local ownership and national support.

Purpose • The purpose of this guide is to present the initiatives in a simple and accessible format so that other

heath and social care systems can learn from the successful work of others.

• The guide is intended to support the reader to think about the collaborative examples shown here that are both economical and simple for the partners involved. These can be used for building and developing cross-working relationships, and used as a starting point for discussions about change.

• It is proposed that you use these initiatives to build upon and enhance the existing services available. It

is also important to acknowledge that care home services in each local area will differ, and so implementing the initiatives within this guide will vary in cost and time and have varying degrees of impact depending on how developed current services are.

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Low Cost High Impact Project

Audience • While the learning guide has been written so it is accessible to anyone in the health and social care

system, the intended audience for this document are: Care home providers and managers (nursing, residential and supported living) and domiciliary

care providers. Local authority (LA) and clinical commissioning group (CCG) leaders who are responsible for

commissioning care home services. Partner organisations in community, mental health and acute sectors of the NHS and in the

community and voluntary sector.

How to use the guide • This library of initiatives contains a single summary slide for each initiative which includes a brief

overview of the initiative, resources required for implementation, prompts for what to consider and links to further information.

• We encourage you to draw out those initiatives most applicable to your area, and make adaptions to

ensure the perfect fit. Not all initiatives will have been evaluated robustly and impact may be measured on anecdotal level. For evaluation tips please refer to page 44.

• We invite you to read through the whole guide and use it in a way that best suits your team. The colour

of the title box on an initiative page refers back to an element of the EHCH framework. Please see page 8 of this document to review the colours of the elements.

• To open the blue underlined hyperlinks, please right-click and select ‘Open Hyperlink’.

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New care models and EHCH framework

• The new care models programme (NCM) was established in 2015 with the aim of transforming health and social care across the country, overhauling old systems and services to reshape the way care is provided. As part of the programme, 50 vanguards were chosen to take the first steps towards delivering the Five Year Forward View (published October 2014) and support improvement and integration of services. There are five vanguard types: acute care collaborations, enhanced health in care homes, integrated primary and acute care systems, multispecialty community providers and urgent and emergency care.

• Across England, there are six enhanced health in care homes (EHCH) vanguards working to improve the quality of life, healthcare and health planning for people living in care homes.

1. Connecting Care – Wakefield District 2. Newcastle and Gateshead Clinical Commissioning Group 3. East and North Hertfordshire Clinical Commissioning Group 4. Nottingham City Clinical Commissioning Group 5. Sutton Homes of Care 6. East Lancashire Clinical Commissioning Group

• Within these six vanguard areas, care homes are working closely with the NHS, local authorities, the

voluntary sector, carers and families to optimise the health of their residents.

• The EHCH framework (published 29 September 2016) lays out a clear vision for working with care homes to provide joined up primary, community and secondary, social care to residents of care and nursing homes, via a range of in reach services.

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The EHCH framework

• The framework document was co-developed in partnership with the six EHCH vanguards, commissioners, providers and partners across health and social care.

• It is based on the lessons learned by the EHCH vanguards and highlights the components that have had the highest impact on the resident’s quality of care, which can be adopted to meet the local needs of the population. The framework is divided up into 7 core elements and 18 sub-elements, which can be seen in the image on the next slide.

• The EHCH model has three principal aims: • To ensure the provision of high-quality care within care homes.

• To ensure that, wherever possible, individuals who require support to live independently have

access to the right care and the right health services in the place of their choosing.

• To ensure that we make the best use of resources by reducing unnecessary conveyances to hospitals, hospital admissions, and bed days whilst ensuring the best care for residents.

• The EHCH framework is designed to be implemented in a coordinated, sustainable way, at scale to

deliver person-centred care that promotes independence. Maximum impact is achieved by implementing all elements of the framework.

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1. Enhanced primary care support

1.1 Access to consistent, named GP and wider primary care service

1.2 Medicines review

1.3 Hydration and nutrition support

1.4 Access to out of hours/urgent care when needed

2. Multi-disciplinary team (MDT) support including coordinated health and social care

2.1 Expert advice and support for those with complex needs

2.2 Helping professionals, carers and those with support needs navigate the health and care system

3. Reablement and rehabilitation to promote independence

3.1 Rehabilitation/reablement services

3.2 Developing community assets to support resilience and independence

4. High quality end of life care and dementia care

4.1 End of life care

4.2 Dementia care

5. Joined-up commissioning and collaboration between health and social care

5.1 Co-production with providers and networked care homes

5.2 Shared contractual mechanisms to promote integration (including Continuing Healthcare)

5.3 Access to appropriate housing options

6. Workforce development 6.1 Training and development for social care provider staff

6.2 Joint workforce planning across all sectors

7. Data, IT and technology 7.1 Linked health and social care data sets

7.2 Access to the care record and secure email

7.3 Better use of technology in care homes

The EHCH framework

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1. Enhanced primary care support

Library of initiatives

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Root Cause Analysis (RCA) of avoidable admissions and action planning

Element 1.1 - Access to a consistent, named GP

What needs to be thought about?

Is there an RCA template already in place in the care home? Is it fit for purpose or can it be adapted?

Are care home staff appropriately trained in and aware of the RCA procedure, and how their roles fit within it?

Are the MDT team meeting regularly?

Do you have the facilities (e.g. rooms) to accommodate regular MDT meetings?

Is there an appropriate system/processes in place to: Conduct regular assessments/monitor

residents? Allow for remote-access to MDT meetings? Act upon the suggestions/resulting actions

of MDT meetings?

What’s the innovation?

• This is a framework that multidisciplinary teams (MDTs) can use when conducting a root cause analysis (RCA) to identify and plan against avoidable admissions.

• The framework ensures a structured, systematic and holistic approach to RCA with respect to avoidable admissions and the resulting action planning.

• Newcastle Gateshead CCG has introduced a clear and intuitive template, which is used by the MDT to review cases flagged by the acute provider or care home as a potentially avoidable admission.

Key benefits RCA can help identify: • areas for improvement in care pathways. • areas where education or support is required for staff. • important themes to consider while implementing the wider

enhanced health in care homes (EHCH) care model.

Where can I get more information?

• Root Cause Analysis (RCA) of avoidable admissions and associated action plan

• RCA worksheet (PDF)

• NHS webpage: Patient Safety Resources, RCAs

What is needed to implement this?

An MDT, as well as a dedicated time and space for them to meet regularly.

Appropriate technological capacity for remote meetings, in case it is not practical or possible for the MDT to all meet face-to-face (e.g. video or teleconference).

Training for staff in conducting RCAs.

An appropriate, defined lead on RCA procedure, and a clear chain of responsibility.

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Medicines Optimisation Trigger (MOT) Tool

Frequent Faller Analysis and Response

Element 1.2 - Medicines Review and Optimisation

What needs to be thought about?

How can I tailor the FFAR pathway to suit the local needs of the local care home population and capacity of staff?

What do care provider staff and wider clinicians need to understand about this tool in order for it to be used extensively across the care home?

Consider how the use of this tool will affect the demand on pharmacists for medicines reviews.

How do I effectively engage all care staff involved in the frequent faller pathway?

How will you communicate the initiative to all relevant stakeholders?

Where can I get more information?

• Preventing falls in older people – NICE • Strictly No Falling – Derbyshire Community Health

Services • Falls in older people: assessing risk and prevention • Managing medicine in care homes (overview)

What is needed to implement this?

An agreed referral criteria specifically for care homes. A relationship with a GP and pharmacist, preferably one who has the

authority to prescribe as well as assess. A multidisciplinary team (MDT) to support and review the resident as

appropriate. Communications to the resident and all staff.

What’s the innovation?

• Frequent Faller Analysis and Response (FFAR) is a systematic process that can be applied to medicine reviews. N.B. It is not the medicines review itself.

• FFAR systematically identifies residents who are most at risk of falls and, therefore, most likely to benefit from an in depth medicines review.

• The basic FFAR pathway: Resident falls and then falls again within defined time period. Does the resident take more than four medicines? Employ Medicines Optimisation Trigger (MOT) tool(see diagram). Conduct review of medication in the presence of the resident

(Level 3 Medicine Review). Changes made to prescription OR referral to GP, as appropriate. Decreased falls risk.

• This systematic approach has been pioneered in Hardwick CCG and Derbyshire Community Health Services.

Key benefits: • Facilitates medicines optimisation higher quality care for resident. • Empowers care homes to proactively assess and manage fall risk factors. • Provides a clear rationale and structure for medicine reviews. • Can deliver cost savings from de-prescribing unnecessary medicines.

Fallen more than once in

past 12 months?

Check for polypharmacy

(>4 medications)

Check for meds that

increase risk of fall ing?

>1 medication that can

increase risk of falling?

Score >6? High risk (RED) =

3 Moderate risk (AMBER) = 2

Refer to the GP practice (high falls risk

medicine review)

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What needs to be thought about?

How do I train staff to use the cards and measure the impact to understand what difference the cards have made?

How can residents be involved in developing the cards? Could you use existing questionnaires to understand the service user experience?

How to save money on printing. Printing on paper and using a laminating machine can be a low cost option.

What’s the big idea?

• Sutton Homes of Care have developed a set of nutrition and hydration cards to help care home staff recognise the early signs and symptoms of poor health. The cards assess health against easy to use charts, for example the Urinary Tract Infections (UTI) card to the right of this page, helps the care home staff to identify the status of a residents hydration; and includes a brief description of the UTI.

• Sutton Homes of Care have in addition created reference cards on sepsis, pain, stool chart and falls pathway. In your care home as a team you can decide what topics can be made into reference cards to support care home workers prevent and manage a range of poor health conditions.

• The cards are available in various size and formats, including key-rings, posters, and A5 cards, this is to ensure the cards are user friendly and accessible.

Key Benefits: • The cards are a great way to learn about specific food requirements and various

health subject areas. • The reference cards can support care home staff to raise concerns with another

member of staff/GP if they feel a resident has a is displaying symptoms of a health care condition and discuss if a diagnosis needs to be made. When a diagnosis has been made health care plans can be adjusted to ensure continuity of care for the resident which will lead to improved heath and well being.

Where can I get more information?

• Video- Sutton Homes of Care Vanguard – Reference cards • Video - Improving, Reducing, Saving - Newcastle

Gateshead's nutrition & hydration journey • Vanguard learning guide – hydration and nutrition support • Sutton CCG - Guidelines, pocket reference cards and

posters

What is needed to implement this?

A nutrition champion will hold vital information about food, drinks and nutrients. They would also be able to signpost resource guides, training materials and coordinate external subject matter expertise if required.

A joined-up workforce across GP, community health and the voluntary sector, to enable shared learning and good practice.

Hold a series of events and workshops to develop the cards and further learning in specific subject areas. Use internal rooms to save money on hiring venues.

Nutrition and hydration reference cards

Element 1.3 - Hydration and Nutrition Support

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Nourish resource pack

Element 1.3 - Hydration and Nutrition Support

What needs to be thought about?

Are hydration, nutrition and oral health included in the resident’s care plan?

Are hydration, nutrition and oral health for each resident being monitored and reviewed regularly?

Does the care home have a formal nutritional screening policy in place?

What training do care home staff need to support this?

Is there a staff champion for this initiative?

What’s the innovation?

• This is a resource pack that aims to enhance residents’ hydration and nutrition. It can be used in a variety of ways, for example, as a food-focused week, as a rolling weekly programme or as a source of ideas and inspiration for activities both residents, staff and family can enjoy.

• Each day of the week has a different health message, with educational content for staff and themed activities for residents. The pack also includes a checklist to help care home staff incorporate a focus on hydration and nutrition into their regular work.

• Newcastle Gateshead CCG, Connecting Care - Wakefield District and Sutton Homes of Care vanguards have implemented service models around hydration and nutrition.

• East Lancashire has commissioned an Enhanced Nutrition service and have seen a good return on investment and benefits to the resident’s Oral Nutritional Supplement (ONS) medication.

Key Benefits: • Overall improvement in health and quality of life for the care home resident. • Promotes comprehensive assessment, monitoring and evaluation of residents’

needs. • Facilitate staff training and development.

Where can I get more information?

• Nutrition and hydration resource pack for care homes

• VIDEO: Newcastle Gateshead CCG - Improving, Reducing, Saving - our nutrition & hydration journey

• Happy Health at Home: The Nourish Resource Pack

What is needed to implement this?

Hydration and nutrition as a core part of multidisciplinary and partnership working.

A nutrition and hydration screening tool, such as the MUST tool for nutrition.

Formal processes for assessment, monitoring and evaluation.

A staff nutrition and hydration champion.

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What needs to be thought about?

How often are food and drinks available?

Will this initiative work for all residents or only a select group?

Will some residents need to be supported to use the stations?

Speak to your local CCG for advice on how to source hydration and nutrition stations.

Where will the stations be placed?

How will I measure the impact of the initiative?

What’s the innovation?

• Hydration and nutrition stations enhance the health and wellbeing of residents. Stations are decorated to look more appealing and encourage residents to find the stations.

• At Buckingham Lodge, a new residential care home in Aylesbury, Buckinghamshire, have introduced nutrition and hydration stations (self-service drink dispensers) around the care home. These items are carefully selected by health care professionals.

• Newcastle and Gateshead CCG have stations in their care homes to encourage

fluid intake. There are fluid stations in the lounge areas and in residents rooms. Key Benefits: • Residents can receive vital nutrients, maintain their independence and improve

their practical skills, as well as prevent dehydration and poor health. • The initiative promotes person centred care by giving residents more choice in

self managing their health. Where can I get more information?

• Newcastle & Gateshead CCG Nutrition Hydration WebEx

• Newcastle - Reducing ONS Prescribing through improving nutrition and hydration care

• Hydration and nutrition stations launch at Buckingham Lodge care home.

What is needed to implement this?

Engage with health care professionals, nutritionists and GPs to help co produce a nutrition and hydration support plan to cover needs of all the residents, and ensure that healthy food and drink options are selected.

Engage with families and residents to gain their view and ensure a person centred approach is provided to consider the needs and wishes of all involved.

Health and safety training for residents and care home staff.

Hydration and nutrition stations

Element 1.3 - Hydration and Nutrition Support

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Urgent and emergency care poster

What needs to be thought about?

What services will be included in the out of hours/emergency support network, and how to secure agreement from the team.

What information will be provided to a service when a call is made, and how this information can be consistent between all care home staff.

Keeping a record of the number of times staff call a particular service and make an evaluating how this could be reduced.

What’s the innovation?

• A poster which provides a range of out of hours and emergency services in the local area, and can be accessed by care home staff.

• North Lincolnshire CCG have created an urgent and emergency poster (to the right of this page) which helps staff to access the right care at the right time, and who to call and in what situation. This simple measure can reduce hospital admissions by using alternative methods to deliver urgent care other than calling for an ambulance or GP.

Key Benefits: • Increased chance of resident remaining in the care home without having to

attend hospital if out of hours services are used. • The poster can lead to improved quality of care for residents and a more

consistent way of delivering clinical input into the care home. • This initiative supports integration of local services, and enhances knowledge

sharing.

• Gaps in training and education are identified, thus enabling training to be provided.

Where can I get more information?

• Urgent and Emergency Care video

• Similar posters to the North Lincolnshire CCG have been created by, Sutton Homes of Care vanguard, Stockport CCG, and Hertfordshire CCG.

What is needed to implement this?

Dedicated time to research urgent and emergency care networks in your local area and nationally, contact your local CCG for advice.

Set up learning sessions and invite colleagues from urgent and emergency out of hours services to discuss the initiative/services in more detail.

Advice on data sharing protocols and the use of technology.

Promote posters in visible staff areas of the care home.

Consider the situations care home staff may be in when they call a specific service and tailor the poster to reflect this.

Element 1.4 - Out of hours emergency support

North Lincolnshire CCG poster

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2. Multi-disciplinary team (MDT) support including coordinated health

and social care

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What needs to be thought about?

How to train your staff to use the poster effectively.

How do I find out who my local community health services are?

How to work with local heath care services in a effective way.

How will I measure the impact of this poster? What will I measure?

What’s the innovation?

• Sutton Homes of Care have created the poster to the right of this page, which provides essential information about the local community health services and essential numbers to call in an emergency.

• Community resources can be of great value in your organisation: create a similar poster as a useful tool for care home staff and to develop strong relationships to wider services, as well as provide a platform for learning and good practice to be shared.

Key Benefits:

• Better communication with local health care services, shared learning and better access to community resources.

• Able to measure impact at service planning level and understand the challenges that are faced in your local community.

• Quicker referral to the appropriate service.

What is needed to implement this?

Hold working group sessions with staff to discuss the content of the poster and discuss how to use the poster effectively, and ways of working with partner organisations.

Dedicated time to research local health care services and have conversations with them to enable a joined up health care system.

Have a follow up or review meeting to discuss how the poster has worked in practice.

Strong relationships with partner organisations which can be built over time. Having regular contact can facilitate a strong and productive workforce.

Where can I get more information?

• Navigating the system (single point of access to advice) • Health Education England: Care Navigation Competency

Framework • East and North Hertfordshire – concerned about a

resident poster

Signposting tools for staff

Element 2.2 - Navigating the system (single point of access to advice)

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3. Rehabilitation and Reablement to promote independence

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What needs to be thought about?

How do I encourage residents to participate in the activity? Can friends and family be involved?

What materials will I need and where can this be sourced at a low cost?

Health and safety of the activity.

Measuring how the activity has an impact on the residents health and wellbeing.

What’s the innovation?

• Walking frames are decorated to enable residents to recognise their walking frames more easily. Chalkney Farm care home in Essex has reported that since residents decorated their walking frames they have had fall rates reduce by 60%. Reduced fall rates mean reduced hospital admissions.

Key Benefits • The process of decorating walking frames provides a fun and creative

session which enables the residents to express their personality. Bonds and friendships can form, helping residents to reduce feelings of isolation and loneliness.

• The initiative enables a interactive and stimulating environment and sets

the precedent for future activities. • Encourages residents to choose their own walking frame and promotes

heath and safety in the care home.

Where can I get more information?

• Managing falls in care homes

• Essex County Council video

What is needed to implement this?

Engage with the local community and charities to find resources.

A working group with care home staff and activity coordinators to agree principles and plan the session.

A method of communicating the initiative e.g. through posters or activity coordinators.

Inspire residents to participate by using an example decorated walking frame.

Customise my Walking Frame

Element 3.1 - Rehabilitation and Reablement Services

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What needs to be thought about?

Cost - (Portrait of a life) review the website for more information. (LEAF 7) Based on a quote.

Measure the impact of the tool to show its benefits.

How will residents respond to certain questions asked.

Will care home staff need mental health support?

What’s the innovation?

• Portrait of a l ife is a multi -media toolkit which builds a picture of a person’s l ife developed by a team of clinicians and experts at South West Yorkshire Partnership NHS Foundation Trust.

• The toolkit is a series of e-learning modules which provides holistic questions for the resident to answer and there are modules for health care professionals. Care home staff can use the questions to put the resident at the heart of the discussion to enable a conversation centred around the resident. The modules have themes on key stories, psychological needs, relationship centred care, benefits and ethical issues.

• Staff will learn about the resident’s l ife experiences and memories which can support care planning. Knowing more about the resident can provide an insight into providing the best experience for the resident during their time in the care home.

• Resources within the tool enable staff to build their knowledge on key topics and learning from experts on dementia. The tool involves participation from loved ones and carers and engages them in the planning of the resident’s care.

• The LEAF 7 is another holistic based tool, started by Age UK Wakefield District in 2009. It is an effective assessment and outcomes measurement tool. The questionnaire facilitates a meaningful discussion between the care home worker and the resident. Information from both of these tools can help shape a positive future for the resident.

Where can I get more information?

• Portrait of a life tool and video

• EHCH benchmarking, planning and resource guide (Page 10)

What is needed to implement this?

Dedicated time to speak to residents and their families to gain agreement about how to use the tool.

Time for staff to go undergo training.

Trust and strong relationships skills between yourself and the resident to enable an effective conversation.

Working group meetings to discuss the tool and how best to use it.

LEAF 7 and Portrait of a life

Element 3.1 - Rehabilitation and Reablement Services

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What needs to be thought about?

What training do staff and residents need?

How can residents in home settings be involved in the breakfast club?

How will benefits and progress be measured?

Carry out a risk assessment to ensure the activity is appropriate for residents.

Health and safety of all activities.

What’s the innovation?

• A breakfast rehabilitation group for elderly people from Newcastle’s Community Rehabilitation Service (based within Connie Lewcock Resource Centre), enables residents to enhance their cooking skills and activities in the kitchen. Residents are asked to participate if they are likely to complete any kitchen activities at home.

• Residents work with Occupational Therapists and are encouraged to make a hot drink, prepare food and transport this to the table for washing up afterwards. This initiative aims to promote practical life skills in a safe environment under the supervision of health care professionals.

• Findings from a Newcastle Gateshead CCG breakfast rehabilitation group evaluation showed resident’s who participated in the group had increased their confidence by 81% and their practical skills improved by 63%.

• The breakfast club can help friendships to form and provide an opportunity for residents to increase their knowledge of food preparation, as well as improve health and well being. Where can I get more information?

• Audit to assess the outcome measures following

the introduction of the breakfast rehabilitation group in The Community Rehabilitation Service

• Learning from Vanguard Web Ex – Intermediate care

• Recording of learning from Vanguard Web Ex – Intermediate Care

What is needed to implement this?

Encourage residents to join by demonstrating the class to them.

Support from family and loved ones in providing residents with confidence and encouragement.

Meeting with residents to brainstorm breakfast food ideas they would like to make, this may aid memory in residents with dementia.

Intermediate care breakfast club

Element 3.1 - Rehabilitation and Reablement services

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What needs to be thought about?

Health and Safety of all activities.

Evaluation - to understand the benefits of activities.

Consider how to learn from Activity Coordinators in

your local area. Research local forums and groups.

What’s the innovation?

• Activity Coordinators meet regularly in the care home to discuss activities suitable for resident’s health care needs. Topics discussed can range from activities that will increase mental stimulation and physical health giving residents autonomy and choice.

• The forum can share good practice tips, resources, lessons learnt and opportunities for training.

• Nottingham City CCG vanguard have introduced poetry and book reading from students at a local university into care homes, which has been a great way to engage with the local community and improve the resident experience. This was implemented following an activity coordinators forum.

Key Benefits • The outcome of the meeting can create the production of an activity care

plan, this can be developed with care home staff, for example a Dementia activity care plan may involve input from clinicians and family members.

• This initiative aims to improve the consistency of activities in the care home and health and well being of residents.

Where can I get more information?

• Nottscity care homes activity coordinators forum Sept 16

• East and North Hertfordshire CCG Complex Care

document (Engagement Champions).

What is needed to implement this?

Dedicated time to speak to residents and their families to find out more information about what activities they enjoy doing. These discussions can support person centred care planning, which aims to provide care based on the needs and wishes of the resident.

Organise a trial run with care home staff, use action logs and meeting agendas to support the meeting.

Activity coordinators forum Element 3.2 - Community Engagement

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What’s the innovation?

• Age UK in Nottinghamshire have launched a worry catcher service commissioned by the Mental Health Services for Older people. ‘Worry catcher’ volunteers spend one on one time with the resident, which provides a safe and confidential space for residents to express their thoughts about their health and care planning.

• Volunteers have an informal discussion with the resident and identify any concerns or worries the resident has and passes them on to the care home manager.

• For example, one resident expressed he was lonely and desired companionship. Another resident in the same care home expressed his love for football, and because of this the care home staff started a club which has sports videos and pub style games. The club increased social interaction amongst the residents and thus helped to reduce feelings of loneliness.

Key Benefits: • Worry catcher volunteers can help improve the quality of life for residents by

picking up on worries or concerns that have not been shared to care home staff. • Feedback information on the worry catcher service to your CCG to improve

services.

What is needed to implement this?

Research voluntary organisations in your local area and send a letter asking a representative to visit the care home to discuss volunteer opportunities.

Dedicated time to speak to residents and their families about what a worry catcher is, and discuss how the resident would feel having a volunteer record their worries to enable effective care planning.

Trial run with care home staff and volunteers to practice how the conversation will run with residents.

What needs to be thought about?

Sourcing volunteers in the local area.

Who is the appropriate person to be a worry catcher.

What type of training do volunteers need to provide efficient information back to the care home manager?

Engagement with care home staff and residents to communicate the initiative.

Develop a framework for volunteers to use when speaking to residents, to help guide the conversation.

Where can I get more information?

• Age UK Notts launches new worry catcher service

• Nottingham City Clinical Commissioning Group - the vanguard and the people it serves

Worry catchers

Element 3.2 - Community Engagement

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4. High quality end of life care and dementia care

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ABC End of Life Care

Element 4.1 - End of Life Care

What needs to be thought about?

What form of professional support is already

available, and how can it be used to enhance implementation and engagement?

Ways of incentivising residents, relatives and staff to engage in the ABC programme.

How to foster collaborative working between staff, residents and their relatives?

How to respectfully flag residents at end of life?

Is there sufficient bereavement support in place to

support staff?

What’s the innovation?

• The ABC End of Life programme is designed to increase the confidence and capability of nursing staff to support people at the end of their lives, and prevent unnecessary hospital admissions.

• This is a blended learning programme consisting of six end of life care modules (delivered face to face or as e-learning) and a range of follow-up resources.

• St. Catherine Nursing Home in Letchworth, part of the East and North Hertfordshire CCG vanguard, has been involved with the ABC programme for over two and a half years.

Key benefits: • Better quality end of life care in the preferred setting of the resident.

• Empowers residents to take ownership of their end of life care.

• Respectfully prompts and facilitates end of life conversations between staff, residents and their loved ones.

• Improves confidence of care home staff to deliver end of life care.

• Blends staff learning and development with high quality care.

Where can I get more information?

• East and North Hertfordshire - ABC End of Life Care

Education Programme (2015)

• St Catherine’s (North and East Herts) End of Life Training

• eHospice’s website: ‘ Collaborating with Impact’

• Train the Trainer project.

What is needed to implement this?

Appropriate resources, including time and space, for the training for care and non-clinical staff.

Sufficient communication to raise awareness amongst residents, relatives and care of the scheme.

The time and the space to allow residents to discuss and take ownership of their end of life care, should they wish to.

St Catherine’s Nursing Home in Letchworth has

introduced a wicker heart door hanger to identify residents at

end of life.

Also applicable to

Element 6.1 – Workforce

Training and

Development

26

What needs to be thought about?

How to provide training and education to staff, for example Sutton Homes of Care have EOLC champions and Nurses, who work on site with care home staff to deliver gold standard EOLC.

When is the appropriate time for a meeting to take place between residents, family members and staff?

What will the agenda of an EOLC meeting look like?

How to incentivise support from residents and families to take part in the meeting.

What’s the innovation?

• Dying can be a difficult subject talk about. Encouraging the families and carers of residents to discuss end of life care (EOLC) before the resident enters the last stage of their life may be beneficial for the carer and the family. This approach supports strong communication to co-produce a care and support plan.

• Sutton Homes of Care vanguard have introduced a ‘space to have a chat’ system and one-to-one conversations. Airdale and Partner’s goldline provides a one point contact for residents and their carers for help and advice, 24 hours a day, seven days a week.

Key Benefits: • The meeting can introduce the sensitive topic in a caring and empathetic

environment, this can help loved ones to prepare for a difficult time as they build their knowledge and understanding of the next steps of care.

• The meeting can support residents, family members and staff to speak about what is important to them and feel valued, motivated and supported.

Where can I get more information?

• Future NHS platform – End of Life Care workspace

• High Quality End of Life Care learning guide

What is needed to implement this?

A private and confidential space to hold the meeting.

An information pack for the family outlining the support offer and what the potential outcomes of the meeting might be.

Create a meeting template to help guide the conversation of the meeting. Work with GPs, care home staff and multidisciplinary teams to provide support in

planning for the meeting.

Families and care home planning meeting

Element 4.1 - End of life care

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What needs to be thought about?

The job roles and responsibilities of a EOLC champion.

Who is the appropriate staff member to become a EOLC champion.

Data and metrics - find out how your staff currently feel about EOLC in your organisation. Can improvements be made to the service? Use surveys to conduct an evaluation.

Joint collaborative working with local EOLC services. Contact your local CCG for advice.

What’s the innovation?

• End of life care (EOLC) champions provide vital information about: recording end of life, auditing, policies, lessons learnt, signs and symptoms of death, advanced EOLC plans and support for families after death.

• Sutton Homes of Care have commissioned EOLC champions to improve the skills of the workforce in the effective and compassionate delivery of EOLC and in advanced communication skills, to enable clinical and care staff to have difficult conversations.

Key Benefits: • EOLC champions will ensure residents have fair access to EOLC support,

regardless if they are located in a hospice, hospital or residential setting. • Residents will receive a personalised EOLC plan which will take into

consideration their needs and wishes.

Where can I get more information?

• Skills for care - Real stories - real insight video

• Skills for care - Qualifications for end of life care

• News article - Staff ‘champions’ encouraging talk about end of life care

• High quality End of Life Care vanguard learning guide

• East and North Hertfordshire have 6 end of life care champions as part of their complex care program.

What is needed to implement this?

Hold an event or workshop in your care home attended by GPs, Clinical EOLC Nurses or EOLC champions to learn more about the subject. For example, Sutton Homes of Care hold a palliative care meeting in a GP practice to discuss EOLC services.

Engage with the voluntary sector, hospices are the experts in EOLC, and can provide essential advice or training in designing advanced EOLC plans.

Explore the possibility of using digital tools to share EOLC plans with the GP via the electronic patient record to maximise support in providing EOLC services.

Use NHS mail to share patient records confidentially, and increase joint working with partner organisations. Contact your CCG for information about NHS mail and information governance.

End of life care champions

Element 4.1 - End of Life Care

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React to Red

Element 4.1 - End of Life Care

What needs to be thought about?

What form of professional support is already available, and how can it be used to enhance implementation and engagement?

Are staff appropriately trained to identify and treat pressure ulcers? What (if any) further training do they need? Can the “React to Red” competency checklist be incorporated into existing staff training schedules?

What is the most effective way of securing resident, family and staff buy-in?

How can one ensure adherence to the “React to Red” process?

What’s the innovation?

• “React to Red” is a pressure ulcer prevention initiative. Pressure ulcers affect around 700,000 people in the UK every year, with many cases occurring whilst an individual is being cared for in a formal care setting, or receiving end of life care.

• “React to Red” is a simple competency checklist that allows managers to assess staff competencies regarding pressure ulcer prevention. It aims to educate residents, family and carers about the dangers of pressure ulcers, how to recognise them, and the simple steps that can be taken to avoid them.

• There are a number of initiative resource packs available for carers and managers.

• The competency checklist can be used in conjunction with a Pressure Ulcer Triggers (PUT) form, which helps staff systematically identify which residents are at risk or pressure ulcers.

• East Lancashire CCG care home vanguard has employed this initiative alongside a champions network.

• Some of the non-vanguard areas employing this initiative include Hackney, Worchester, Warwickshire and Coventry.

Key Benefits: • In Nottingham Trust: cases of avoidable pressure ulcers were reduced by 87%

across 28 care homes (nursing and residential).

Where can I get more information?

• “React to Red” Competency Assessment

• React to Red website

• Pressure Ulcer Triggers Form

What is needed to implement this?

A “React to Red” champion.

Effective training for all staff members and carers.

Effective communications to increase awareness and vigilance among residents, their families and the care home staff.

Dedicated time and space to train and assess staff competencies.

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De-AR GP (Dementia Assessment Referral to GP)

Element 4.2 - Dementia Care

What needs to be thought about?

What form of clinician support is already available, and how can it be used to enhance implementation and engagement?

Is this tool accessible for individuals for whom English is not their first language?

What communications are needed to raise awareness and secure buy-in from staff, residents and their families?

Are staff appropriately trained to identify sign of dementia?

What’s the innovation?

• Research has shown that between 75% and 89% of care home residents have dementia, and that many of these residents are undiagnosed.

• Co-designed by the Health Innovation Network, the Dementia Assessment Referral to GP tool (DeAR-GP) supports care workers to identify people who are showing signs of dementia and refer them to their GP or other healthcare professional for review. It acts as a communication aide between care workers and GPs, and is provided free of charge.

• DeAR-GP has been tested in three care homes in the South London Care Homes Network. Specifically, Sutton Homes of Care vanguard use the DeAR-GP tool to aid with identification, assessment and care planning of residents suffering with dementia.

• The DeAR-GP package contains a simple case finding tool and observation chart, and a template referral letter, addressed to the local GP or registered healthcare professional.

• Resources are readily available online and can be accessed free of charge.

Key benefits: • Better care and support for residents living with dementia. • Improved communication between GP practices and care homes. • Streamlined process for identification and treatment for residents living with

dementia.

Where can I get more information?

• DeAR-GP User guide

• DeAR-GP Reporting tool

• DeAR-GP Assessment referral template

• DeAR-GP Guide for care home managers

• DeAR-GP Guide for care workers

• Care worker training plan

• NICE Guidance on DeAR-GP

What is needed to implement this?

A defined care pathway of assessment, medication and post-diagnosis support for residents with mild/moderate dementia.

Relationships with relevant stakeholders, particularly to local services and health professionals.

Comprehensive communications strategy that reaches residents, residents’ families, staff and other health care professionals.

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Memory box

What needs to be thought about?

How do I encourage residents to participate in the activity, can friends and family be involved?

What training do staff need to enhance the effectiveness of the activity? Consider using LEAF 7 and Portrait of life tool.

How to source materials at a low price.

Measuring the impact the initiative has on the residents health and wellbeing.

What’s the innovation?

• A memory box which contains a collection of items or images from a resident or loved one's past which can help aid memory. This initiative can support high quality dementia care.

• Blackhall Colliery care home created a wedding themed memory box, which was part of an art competition in the care home.

• Be creative and make memory boxes with different types and themes, and engage the local community to help make the memory boxes with the residents.

• Care home staff and family members can help residents to source materials such as letters, pictures, jewellery and other items which can bring meaning for the resident.

Key Benefits: • Memory boxes can help residents feel more at ease and provide an activity

that is a social experience. • Residents can gain a sense of identity and go on a journey to rediscover

parts of their life that hold meaning to them. • Boost mental stimulation. Where can I get more information?

• FutureNHS platform element 4.2 of EHCH framework

• Example memory boxes that can be created by category

• Wedding themed example of a memory box from Blackhall Colliery care home

What is needed to implement this?

Dedicated time to prepare example memory boxes and actual memory boxes.

Agreement with friends and relatives to see how the resident would react to the initiative. Send a letter or speak to families and friends.

Contact charity shops and art shops to source materials.

Element 4.2 - Dementia Care

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“This is me” pen portraits

Element 4.2 - Dementia Care

What needs to be thought about?

Are all staff engaged and equally informed about the initiative?

Will the original Alzheimer’s Society form need to be adapted to local needs?

How will this initiative be communicated to relevant stakeholders, particularly the resident's family?

How will the existence of this documentation be communicated and used between health professionals and across multiple care settings? (e.g. at Great Western Hospitals a blue butterfly is attached to patient notes to signpost the presence of a “This is Me” document)

How frequently will this information be updated?

Where can I get more information?

• Dementia Partnerships: ‘This is me’ in Bristol

• Alzheimer’s Society: Information on ‘This is Me’ and opportunity for download

‘This is Me’ in action: • Mid Cheshire

Hospitals

• Great Western Hospitals

• Plymouth Hospitals

• Sutton Homes of Care Red Bag Journey Poster

What’s the innovation?

• “This is me” is a form that provides an easy and practical way for residents and their family to communicate relevant personal information to the care home staff and clinicians. There is space on the form to include details on personal, cultural and family background, preferences, routines and their personality. The booklet is simple to fill in and can be acquired through your local Alzheimer’s Society branch, or simply download from their website.

• Sutton Homes of Care use “This is Me” in their red bag hospital transfer pathway paperwork.

• Mid Cheshire Hospitals NHS Foundation Trust has successfully used “This is me” for residents with cognitive impairment. Anecdotal evidence suggests that it is a useful tool for all residents, either as inpatients or residents in the care home.

• At Great Western Hospitals, a blue butterfly is attached to the resident’s notes and ward documents to alerts staff that they have a “This is me” document.

• Sheffield Teaching Hospitals developed their own booklet, based on the form available from the Alzheimer's Society and designed for local needs.

Key benefits: • Increased patient-centred care planning. • Decreased anxiety for residents and their families. • An overall improvement in care quality and coordination.

What is needed to implement this?

Numerous and diverse means of communicating this initiative to both staff, residents and their families.

Dedicated time set aside with the resident and their family to record and update all relevant personal information for the form.

An effective means of communicating the presence of a “This is me” document to different health professionals across multiple care settings.

An agreed schedule to ensure that information is updated regularly.

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5. Joined-up commissioning and collaboration between health and

social care

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Setting up a Joint Intelligence Group (JIG)

Element 5 - Joined-up Commissioning and Collaboration

What’s the innovation?

• The Joined-up Commissioning and Collaboration (JIG) brings together a wide range of organisations across health and social care, and is responsible for identifying low level concerns regarding quality and safety within care homes.

• The JIG can also identify and support gaps in training and knowledge by monitoring trends using tools such as an information dashboard and soft intelligence from the members.

• Pioneered in the Sutton Homes of Care, where JIG membership includes representation from the ambulance service, acute hospital, mental health services, community services, continuing healthcare, adult safeguarding from each organisation and the CQC. The JIG is jointly led and chaired by Sutton Council and Sutton Homes of Care.

Key Benefits • Improved quality of care for residents, and an increased likelihood of safe care

delivery. • Facilitates strong relationships networks, encourages cross-disciplinary

collaborative working and data and intelligence sharing across multiple care settings.

• Performance challenges are identified sooner and supported (e.g. learning, training and development) more proactively.

• More co-ordinated quality oversight between local authority, CCG and CQC teams.

Where can I get more information?

• Documentation from Sutton Joint Intelligence Group

• Multi-Agency Risk Assessment Conferences (MARACs)

• Example dashboard outputs

• Sutton JIG case study (March 2017)

• Sutton JIG case study (July 2016)

• Paper - setting up a Joint Intelligence Group

What needs to be thought about?

Is there an adequately sized membership and are members of a sufficiently senior level to enable change?

Consider how to recruit membership and promote engagement among members?

Is there capacity to create an information dashboard? What other ways of disseminating information from

member organisations are available?

Who will organise and chair these meetings? How can a joint approach to quality can support

implementation of other EHCH framework elements?

What is needed to implement this?

Knowledge of the Multi-Agency Risk Assessment Conference (MARAC) principles.

Agreement to share data and intelligence – whether using technology or not. A method of effectively disseminating information. An information dashboard is

not essential but incredibly useful. A commitment to confidentiality. Strong, trusting relationship networks across appropriate health care settings. Agreed principles to underpin the meeting.

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Care Home Newsletter

What’s the innovation?

• Sutton Homes of Care send out a newsletter after each care home forum to care homes in the area, team partners and stakeholders. The newsletter shares content on:

Key Benefits: • Sharing a newsletter can increase collaborative working between

neighbour care homes and CCGs. • Encourages your care home to network and inform residents family and

friends of activities within the care home.

What is needed to implement this?

Hold a working group session with staff residents and carers to brainstorm initial content for the newsletter.

Appoint an individual or a team to be responsible for finding content and writing the newsletter.

Open lines of communication between all staff for regular content to be shared.

Share the newsletter in locations and platforms accessible to care home staff, for example staffrooms and reception areas.

• Achievements from individual care homes and colleagues

• Updates from networking events and focus groups

• Good news stories • Introducing new schemes or incentives • Activities within the care home • Recruitment

What needs to be thought about?

Who will design the newsletter and will they need training? Contact your local CCG and find out if there are any communications colleagues who you can work with to produce and to understand the local regulations on communication guidance.

Establish publication dates which will help with scheduling the newsletter.

How to establish health care provider relationships in your local area and grow a database of contacts.

Sharing the newsletter on you website and or social media pages.

Where can I get more information?

• FutureNHS platform – a place to find interesting content to put in the newsletter.

• Sutton Homes of Care newsletter as an example of content, layout and style.

Element 5.2 - Co-production with providers and networked care homes

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6. Workforce development

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What’s the innovation?

• A competency passport is a way for care home staff to record and track their competencies, while also allowing these to be clearly visible across multiple health and social care settings.

• The passports can be based around core and specialised competencies for care homes staff.

• Connecting Care - Wakefield District vanguard has developed a care homes workforce passport, created from learning of the Local Workforce Advisory Board aligned to the Sustainability and Transformation Partnerships (STP) footprint.

• Connecting Care - Wakefield District has also been working with Health Education England (HEE) on a ‘train the trainer’ model (e.g. for use of catheters) and also a skills passport and development of core competencies for care homes staff.

Key benefits: • Increase confidence of care home staff. • Help inform staff training and development planning. • Facilitates the development of a joint workforce plan.

Competency passports

Element 6.1 - Training and development for care staff

What needs to be thought about?

What information do you want these passports to tell you?

Are the passports consistent in their structure, and intuitive and unambiguous in their interpretation?

Can this be aligned to staff training programmes?

How do I effectively engage staff and employers in care homes and across other health care contexts?

How will you be communicating this initiative across your site, as well as those of other relevant provider contexts?

Where can I get more information?

• Health and Safety passport schemes: Health and Safety Executive

• Wakefield Workforce and Training Presentation (slide 13)

• NHS to roll out competency passport scheme

What is needed to implement this?

A clear and agreed competency framework for care home staff which the competency passport aligns to. This should cover both core and specialist competencies.

An effective way to communicate this scheme, both within the care homes and across all other relevant care settings that the staff may operate in.

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What needs to be thought about?

Consider doing a similar project in your care

home?

After the videos are watched how do you capture

information from the videos and build into care

plans for residents?

How to provide training on person centered care.

Access a range of resources from the Enhanced

Health in Care Homes FutureNHS platform.

What’s the innovation? • Pull Up a Chair is a training tool, commissioned by Age UK, which uses

filmed interviews and personal video diaries to capture directly the experiences of older people living in care settings.

• Person centred questions are asked through LEAF 7, a holistic assessment tool to allow the resident to express their views.

• The questionnaire facilitates a meaningful discussion between carer and resident. Information from both of these tools can help shape a positive future for the resident. Once the videos have been created they were shown to care providers and commissioners in Wakefield District and the UK.

• Use the videos to upskill your staff in person centred care training to enable holistic based care which will improve the health and well being of residents.

Key Benefits • Empowers residents to express their views. • Provide staff a ‘real sense’ of a living experience in a care home . • Allows the viewer to put themselves in the shoes of the resident. • Connecting Care - Wakefield District vanguard reported a ‘sense of

connection to the care home residents’.

Where can I get more information?

• Pull up a chair – Wakefield Case Study-Age UK

• Sharing vanguard learning – top tips to getting started.

• Health Education England - Person centred framework

• Leaf 7 and Portrait of life holistic assessment tool

What is needed to implement this?

Set up working groups with care home staff after they have watched the training video to discuss how best to implement the training.

Share the learning with local organisations you are working with to ensure there is shared awareness of the video to enable consistent care.

Ensure carers, residents and their families are engaged at the start of the design and planning process of providing care to build trust and confidence.

Pull Up a Chair training tool

Element 6.1 - Training and development for care staff

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• For further information, the FutureNHS platform has a range of resources to support local areas to implement the EHCH care model, both regionally and nationally.

• The platform includes a case study database, regional collaboration areas, care homes forum, vanguard learning guides, and resources on each care model element and sub-element. The resources are aligned to EHCH framework to make documents you need easier to identify.

• To gain access to the platform please email england.carehomes@nhs.net . Once you have gained access please watch the short video guide explaining how new users can benefit from and use the site.

• We are continuing to develop the site to ensure usability and compelling content. If you would like to provide feedback about the platform send an email to the above email address.

FutureNHS platform

FutureNHS platform (videos, case studies, resources and forums)

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• EHCH framework: Our framework lays out a clear vision for providing joined up primary, community and secondary, social care to residents of care and nursing homes via a range of in reach services. It contains seven key components and eighteen sub-components which define the care homes model are put forward, with practical guidance explaining how organisations and providers can make the transition and implement the whole model. Available here: https://www.england.nhs.uk/wp-content/uploads/2016/09/ehch-framework-v2.pdf

• Vanguard learning guides: This is a suite of documents created in collaboration with the six care home vanguards to provide learning and practical support on elements of the framework. The full suite of these is available at: https://futurenhs.kahootz.com/connect.ti/carehomes/grouphome

• EHCH resource guide: This document brings together in-depth prompts and questions with resources on each element and sub-element of the EHCH care model, to help local areas plan and carry out implementation of the care model locally. It is available here: https://futurenhs.kahootz.com/connect.ti/carehomes/view?objectId=28353765

• Sharing vanguard learning – Top tips to get started: Take a look at the top implementation tips from the vanguards here.

• If you have any queries, please contact england.carehomes@nhs.net

Key Documents

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Tips for evaluating initiatives

Qualitative evaluation

Questionnaires and feedback forms

• Can be used for both residents and staff • Use open questions with free text to tease out how people feel about the intervention • Explore using a number chart of 1 – 10 to measure responses

1-1 meeting

• Sitting down with residents, family and care home staff to ask questions and record feedback on a more personal level may produce more in depth feedback

General observation • General observation of resident and care home staff mood

Quantitative evaluation

Metrics

• Think about the metrics that you would like to measure and those that are available to measure e.g. 999 calls, emergency admissions

Data dashboard • Create a metrics dashboard so that metrics from a range of sources can be viewed together

Evaluation methodologies

PDCA cycle • PDCA stands for: Plan–Do–Check–Act/Adjust • It is an iterative 4-step systematic evaluation method used guide the evaluation and continual

improvement of processes and products

Pilot Programmes • The idea of trialling initiatives on a small scale first before scaling up • The pilot is a chance to learn from the experience and use this to improve the initiative before

scaling up

Evaluation is important to understand how effective an intervention has been. It is also important to understand what

has worked well and what hasn’t worked in order to improve. Try the simple evaluation methods below to measure the impact of the project you are implementing, bearing in mind a rich evaluation should include both quantitative and qualitative evaluation. Please note, the below table is by no means an exhaustive list of evaluation methods, rather it is a starting point for further reflection and conversation.

Top tip: Ensure measurements are taken before implementation of the initiative, so that baseline measurements can be compared against.

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Acknowledgements

Grateful thanks to the staff in the six enhanced health in care homes vanguards, and all non-vanguards, whose work made this guide possible.

• Connecting Care – Wakefield District • Newcastle and Gateshead Clinical

Commissioning Group • East and North Hertfordshire Clinical

Commissioning Group • Nottingham City Clinical Commissioning Group • Sutton Homes of Care • East Lancashire Clinical Commissioning Group • Hardwick Clinical Commissioning Group • Derbyshire Community Health Services • Mid Cheshire Hospitals NHS Foundation Trust • Great Western Hospitals • Sheffield Teaching Hospitals • Essex County Council • Blackhall Colliery Care Home • Alzheimer's Society • Warwick County Council • South Warwickshire Clinical Commissioning

Group • North Warwickshire Clinical Commissioning

Group • Coventry and Rugby Clinical Commissioning

Group

• Coventry City Council • University Hospital of Coventry • Warwickshire Partnership Trust • Redditch and Bromsgrove Clinical

Commissioning Group • South Worcestershire Clinical Commissioning

Group • Wyre Forest Clinical Commissioning Group • Worcestershire Council • Worcestershire Acute Hospitals NHS Trust • Worcestershire Health and Care NHS Trust • St. Catherine Nursing Home • Age UK • North Lincolnshire Clinical Commissioning

Group • Buckingham Lodge, Aylesbury