Improving quality and safety in care homes

Background

The East Midlands Patient Safety Collaborative (EMPSC) piloted an
audit tool to measure the prevalence of common care problems found in
nursing and residential homes. The audit tool was first rolled out to 26
care homes across Nottinghamshire and Derbyshire in 2015, extending to
30 care homes across the East Midlands in 2016 and 30 in 2017.  Fourteen
of the year one pilot homes have continued to take part in the audit
into years two and three.

The tool is called the International Prevalence Measurement of Care
Problems in Care Homes (Landelijke Prevalentiemeting Zorgkwaliteit, or
LPZ for short, in Dutch).  LPZ was developed in the Netherlands to
provide a reliable mechanism for measuring the prevalence of common care
problems within care homes and provide consistent recording of data to
drive, or measure, the impact of quality improvement initiatives in the
sector. It is currently used to deliver an annual audit of data for care
settings in the Netherlands, Germany, Austria, Switzerland, New
Zealand, Indonesia and Brazil.

The tool supplies participating care homes with insight into the
quality of care provided in their setting through measuring the extent
of common care issues.  This can support decision-making by care homes,
regulatory bodies and policymakers regarding implementing measures such
as preventative screening and specific interventions to improve the
quality and safety of care provided. Moreover, the large scale and scope
of the audit tool enables the participating care homes and regions to
compare themselves with similar settings and populations, using the data
to facilitate benchmarking.

LPZ has provided valuable learning from local, national and
international comparisons and demonstrated quantifiable improvements in
standards of care problems (which we refer to as safety). More details
of the tool can be found at www.lpz-um.eu.

Aims, objective and scope

Care home providers in the UK use different indicators and metrics
for care quality. With no nationally agreed benchmarking tools it is
impossible to know the true incidence or prevalence of common problems
such as pressure ulcers. In particular, large chains / providers with
multiple care settings collect data in different ways, making
cross-sector comparisons difficult.  Evidencing system-wide improvements
in quality and safety of care is also challenging due to a lack of
consistent recording of comparable indicators and data.

In the absence of a reliable mechanism for measuring instances of
common care problems across UK care homes, the LPZ tool was adopted to
establish a mechanism for measuring, recording, analysing and sharing
prevalence of common care problems in care homes across the East
Midlands, and to use such benchmarks to drive quality improvement and
improve patient safety.

The EMAHSN Patient Safety Collaborative (PSC) worked with a selection
of care homes to trial LPZ in order to ascertain whether this proven
system could be successfully implemented in the UK in order to improve
the care and safety of care home residents. The initial 2015 pilot and
two associated research projects established that the tool was feasible
in the UK setting and so the programme was repeated in 2016 and 2017,
and expanded to cover the following six domains:

  • Falls
  • Pressure ulcers
  • Continence
  • Restraint
  • Pain management
  • Hydration and nutrition.

Working with Dr Adam Gordon, Clinical Associate Professor in Medicine
of Older People, colleagues from The University of Nottingham, regional
community services and Clinical Commissioning Groups (CCGs), the PSC
assisted with care home staff training and supported the audit from
start to completion over each 12 month data collection period. The aim
was to increase care home capacity and capability to recognise, prevent
and manage care problems through the introduction of measurement tools
and techniques supported by quality improvement interventions.

Method and approach

The EMPSC approached care homes through Clinical Commissioning
Groups’ Quality Teams and community nurses through local community
providers and Trusts. Developing these relationships gave direct access
to the care homes we invited to take part. This was facilitated through
information and networking events which brought care home leaders, CCG
quality teams, community nurses, commissioners from health and social
care and care home staff together to share challenges and understand the
benefits of joining LPZ. A team of people, including the Care home
leader owner and NHSI Chief Nurse plus a social care commissioner, CCG
commissioner, PSC project manager, clinical champion, and project nurse
went to visit the Netherlands to see LPZ in action and bring back
learning for implementation. This involved visiting care homes and the
University of Maastricht where the data is analysed.

image

Prior to launch in 2015, we wrote to all East Midlands Safeguarding
Boards to inform them of the project and to provide assurance that as a
pilot we would be asking for individual consent from care home residents
in allowing their care home to record patient-level data. As data
collection through LPZ became standard practice within many of the homes
we omitted individual consent in year three. This has resulted in a
greater number of residents being entered into the audit. It is
important to enter all eligible residents to improve data volume and
quality and achieve a more accurate picture of true prevalence.

The PSC co-ordinates and hosts two events each year, one in September
to prepare staff for the audit and provide training in pressure ulcer
recognition and grading and the other in January to share results,
learning and support continued quality improvement.

As a result we have developed a ‘React to Moisture’ educational
resource (building on the React to Red model) as care home audit results
indicated a high prevalence of moisture lesions and in some cases a
misunderstanding between the presentation of moisture lesions and grade
one pressure ulcers.

The following actions were key to successful implementation:

  • Training in pressure ulcer recognition took place using the locally developed ‘React to Red’ training package in all three years
  • Training in continence management was added during year two and a further resource developed: ‘React to Moisture’
  • Annual training events were held to prepare homes for the audit
  • Individual support was provided to care homes to support understanding of audit results
  • NHS staff supporting the ‘Head to Toe’ skin inspections (known as
    verifiers) were supported to understand their role and verifier training
    was developed
  • The PSC wrote to Safeguarding Boards and prepared information for care homes, residents, staff and relatives, including consent
  • Active promotion of dignity and respect for residents as a priority.
    The audit involved a head to toe skin inspection and therefore
    examinations were scheduled for the time the resident usually woke and
    dressed to minimise inconvenience and any avoidable distress
  • PSC project team support to those care homes with limited IT
    infrastructure. This resulted in a combination of paper and electronic
    data recording to complete audit requirements During year two,
    masterclasses covering all audit areas were made available to care homes
    at follow up learning events, utilising specialist expertise from
    within the region
  • Action planning around the findings were incorporated as part of the
    year two audit and care homes were introduced to basic quality
    improvement tools at a dedicated training event facilitated via the PSC
  • Promotion of the LPZ model was undertaken across the East Midlands
    at a number of different events and forums to increase participation
    across the region in readiness for the 2017 audit
  • Agreement was achieved with programme partners to fund additional care home training resources to address audit findings
  • Infographics were developed which proved to be a more successful way of using and displaying data
  • The first LPZ Awards were held following the 2017 audit to recognise
    excellence in care homes as a result of LPZ implementation and
    learning.

Measurement plan

The initial measure was to test whether LPZ could be translated to
the UK and implemented successfully. Researchers were employed to
develop field notes about the process.

  • Process measures: The number of care homes taking part in LPZ,
    number of residents entered into the audit, number of case studies
    generated by care homes showing evidence of improvement.
  • Outcome measures: Prevalence of pressure ulcers, incontinence, falls, pain, restraint and malnutrition.
  • Balancing measures: N/A.

Results and evaluation

image
  • The 2015 pilot demonstrated that the LPZ tool can be used
    effectively in the UK setting and was therefore repeated in 2016 and
    2017
  • The LPZ tool provides a validated and consistent measurement of common care problems
  • 26 care homes took part and 489 residents’ data uploaded in year one (2015)
  • 30 care homes and 511 residents’ data uploaded in year two (2016)
  • 30 care homes and 634 residents’ data uploaded in year three (2017)
  • The tool can be used to improve care through identification of
    trends in common issues / health and wellbeing indicators and
    opportunities for early interventions / treatment
  • Audit results have been shown to be a reliable measure of how many
    residents are affected by the common problems so that care homes can be
    assisted to make improvements and, through the PSC funding, resources
    have been developed to support improved training and education within
    the homes
  • Care homes have actively engaged in quality improvement capability
    events in order to support the development of improvement approaches.
    More than 180 care home staff have attended the events across the East
    Midlands to prepare care homes for audit and to share results afterwards
  • More than 6000 React to Red resources shared across the UK, this has
    now been evaluated and is the only training resource of its kind been
    shown to improve care.
  • Staff that took part were engaged and reported back positively on the process
  • Care homes report greater awareness and early recognition of skin
    damage and other common problems, and less reliance on community nursing
    staff
  • Barriers broken down and improved relationships between care homes
    and community nursing teams through collaborative working as part of the
    ‘top to toe’ skin inspections conducted on audit day
  • An introduction to quality improvement methodologies was introduced to support care homes in March 2017
  • Care homes starting to implement changes to practice to improve care
    using recognised tools to support them in 2017, which will be built on
    as the LPZ programme progresses
  • Increased confidence and leadership skills of participating care home managers and staff
  • A care home in Lincolnshire has used the LPZ findings for focused
    work on implementing changes and improvements in the nutrition of
    residents using Wessex AHSN’s toolkit and resources
  • Five case studies from homes demonstrating improvements and outcomes in the quality of care for residents
  • Six LPZ awards to care homes and individuals recognising quality improvements as a result of LPZ
  • Six new quality standards developed to support ongoing improvements in care homes
  • The Care Quality Commission (CQC) has highlighted the implementation
    of LPZ as a proactive approach that care homes are taking to improve
    quality and safety in two of its recent inspection reports of homes in
    the region
  • The EM PSC has created various infographics about this work and more information can be found on their website.

Learning points

  • The care home sector is a dynamic sector, with high staff turnover and this affects engagement and relationship building
  • Quality Improvement training needs to be tailored to this sector
  • Care home staff receive little training in common care areas, such as pressure ulcers, continence, falls etc.
  • Verifiers are required for the head to toe skin inspection
  • Measurement leads to improvement through the identification of issues and trends
  • Care homes do not wait for the annual results to improve, they are motivated to act immediately during the audit
  • Using Infographics is an effective and engaging way of displaying data and is well received
  • Whilst LPZ improves transparency, true prevalence is difficult to
    achieve and therefore benchmarking data more difficult to establish.

Plans for spreading learning and encouraging adoption

  • The EMPSC is working with Prof. Dr. Jos M.G.A. Schols, Professor of
    Old Age Medicine, Maastricht University to progress the development of
    international benchmarking
  • The PSC will be working with stakeholders to scale up this work
    across all five counties within the region and working with other
    AHSNs/PSCs for potential for wider roll out
  • Ongoing awareness raising with regulators (CQC) to recognise the
    impact on quality within participating homes and correlate improvements
    with LPZ implementation
  • The PSC has commissioned an economic evaluation and academic
    evaluation of the project and development of a business case for
    longer-term sustainability
  • Continued support to staff to develop the quality improvement skills and educational awareness of participating care homes.

Published by Residential Forum

The Residential Forum is to promote the achievement of high standards of care and support for children and adults living in residential care and nursing homes, supported housing, residential schools and colleges, hospices and hostels. It contributes to improving the quality of service to the public. Members of the Forum are people of standing and experience drawn from the public, private and voluntary sectors, as well as some who can speak for service users and carers.

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