Studies have shown that nursing assistants in a care home can spot signs of illness in people 5 days before they were seen in observations. (ref: Boockark1, Brodie HD, Lachs M, Geriatr Soc. 2000 Sept;48(9):1086-91.) The study found that nursing assistants were able to spot behavioural and functional state changes in residents before physiological signs were present.
Wessex PSC is working to implement a standardised common language for managing deterioration across all healthcare settings including the Care Home Sector and this work aligns with the NHSE Enhanced Health in Care Homes initiative.
Emergency admissions to hospital from care homes: how often and what for? (Health Foundation 2019)
This Health Foundation briefing presents the results of a national analysis of emergency hospital admissions from care homes across England, to provide insight into how often care home residents are being admitted to hospital and the types of conditions that are causing their admissions.
The second part of the briefing draws on evaluations of four enhanced care packages provided to care home residents. By comparing and contrasting the different elements and contexts of these sites and bringing in other local evaluations of these sites, the report explores the factors that may be most influential in reducing hospital admissions.
The briefing concludes by pointing to the next steps for local health and social care providers and commissioners looking to better understand the quality of care being provided in order that they may improve care further.
The full briefing can be downloaded from the resources zone on the right hand side of this page.
Enhanced health in care homes framework (NHSE)
The EHCH framework (NHSE 29 Sept 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.
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 document can be downloaded from the resources zone on the right hand side of the webpage and more information about the Enhanced health in care homes initiative can be found on the NHSE website.
Improving safety in care homes (AHSN Network)
A new report from the AHSN Network is shining a light on ways we can do more to improve safety for residents of care homes.
The publication showcases over 30 examples of projects delivered by England’s 15 Patient Safety Collaboratives (PSCs) and the Academic Health Science Networks (AHSNs) which host them. They include case studies in medicines safety, dementia, monitoring and screening, and workforce development.
The report notes: “Care homes are a crucial part of our national health and care system infrastructure and the safety and wellbeing of residents, who are among those with the greatest care needs, is no less important than in any other setting.
The report can be viewed on the AHSN Network website or downloaded from the resources zone on the right hand side of this webpage.
Access to out of hours/urgent care when needed (EHCH Sub Element 1.4)
Out-of-hospital services form a vital part of the urgent and emergency care system at all times of day and night. The EHCH sits within a streamlined system of health and social care teams that provide advice and care both in hours and out-of-hours. These teams include GP services, NHS 111, rapid-response health and care teams, and the local ambulance service.
Interacting with the multidisciplinary team helps facilitate prompt hospital admission when indicated but it also helps ensure residents remain in their homes where appropriate. In a study at one hub, over 1,500 calls were received in one month more than half of which occurred out of hours. Of those more than 1,300 resulted in the patients being able to remain in their place of residence.
Soft Signs of Deterioration
An emerging area of interest is the identification and use of 'soft signs' to enable the earlier recognition of physical deterioration in individuals before changes in physiological signs (heart rate, blood pressure, respiratory rate etc.) are evident.
These soft signs include changes in behaviour, diet and habits etc. and are particularly helpful in home settings, care homes and hospital wards.
See below for more information about our work around Soft Signs across Wessex including Interserve Healthcare's Soft Signs Taxonomy, West Hampshire CCGs RESTORE2 and Southampton City CCGs REACT to Soft Signs.
SBAR communication tool (Situation, Background, Assessment, Recommendation)
NEWS2 AND CARE HOMES
RESTORE2 (West Hampshire CCG & Wessex PSC)
National ‘Excellence in Primary Care’ Parliamentary Award Winners July 2019 (read more here)
One element of developing an aligned model of care pathways across Wessex includes the application of the Wessex All Cause Deterioration Guidance (see our Deterioration and NEWS web page) to the Care Home setting.
RESTORE2 is a physical deterioration and escalation tool for care/nursing homes co-produced by West Hampshire CCG and Wessex Patient Safety Collaborative and based on nationally recognised methodologies including early recognition (Soft Signs - see below), the national early warning score (NEWS2) and structured communications (SBARD).
Full information about RESTORE2 including training videos and downloadable resources can be found on our RESTORE2 webpage
A Taxonomy of Soft Signs of Deterioration (Interserve Healthcare & Wessex PSC)
As part of a Wessex PSC Breakthrough Series, Interserve Healthcare identified a number of flags of “soft signs of deterioration” and incorporated them into their organisations care concern reporting system.
They described these "Soft Signs" as "subtle changes, which with hindsight could have been used as a pre-diagnostic indicator of concern" which, if spotted sooner, could facilitate earlier treatment and avoid unnecessary, and often distressing, transfers to hospital. This is particularly important for people with learning disabilities.
Their system works on the basis that everyone’s soft signs indicators are individual to them. What works for one person may not work for another. A selection of soft sign indicators is put in place which is relevant to each individual and therefore most likely to help staff spot the early beginnings of deterioration. These can be changes in sleeping patterns; feeding; toilet habits; an increased lack of interest in wanting to get out of bed, or more fatigue than usual.
A taxonomy of around 120 'soft signs' developed by Interserve Healthcare, and a copy of a presentation given at the national Patient First Conference describing the challenges of identifying “soft signs” of deterioration and raising staff awareness to the need to respond promptly and effectively, can be downloaded from the resources zone on the right hand side of the webpage.
Interserve's approach is also described in a "Recognising Deterioration" Learning into Action Bulletin from the Learning Disabilities Mortality Review (LeDeR) Programme. This bulletin can also be downloaded from the resources zone on the right hand side of the webpage.
REACT (REcognise and Act) to Soft Signs of Deterioration (Southampton CCG & Wessex PSC)
The Wessex PSC REACT cards are based on a project by Southampton City CCG which prompted staff to look out for 'soft signs' of Deterioration in their residents. Using a deceptively simple question 'Is my resident well today?' the card includes a series of prompts to support staff to consider possible 'soft signs' of deterioration and to suggest actions to take if any triggers are present.
Possible triggers include (amongst others): Breathing difficulties; changes in appetite, mobility, consciousness or confusional state; bowel or urinary tract problems.
Suggested actions include (amongst others): Raising the alert, recording observations (using NEWS2/RESTORE2) and communicating concerns by using the SBARD communication process (more information about SBARD on our webpage here).
Staff are also prompted to ensure that residents personal End of Life care preferences are considered as part of the response process.
The REACT cards can be downloaded from the resources zone on the right hand side of the webpage and further information can be obtained via the contact link at the bottom of this webpage.
ALERT (Portsmouth Hospitals NHS Trust)
ALERT™ (Acute Life Threatening Events Recognition & Treatment) is a multi-professional course designed to train staff in recognising patient deterioration and acting appropriately in treating the acutely unwell.
ALERT HQ have developed a suite of courses for different care settings including: ALERT (Adult); ALERT Obstetrics; BEACH (for unregistered healthcare staff) plus an ALERT Train the Trainer course.
More information about the ALERT Programme can be found on the ALERT HQ website.
The Significant 7 Signs of Deterioration Toolkit for Care Homes (NELFT)
The award winning Significant 7 Signs of Deterioration Toolkit supports care workers to identify the health needs of residents in the care home setting.
The Significant 7 Training Package was developed by North East London NHS Foundation Trust (NELFT) following research with care homes, hospital doctors and local authorities for over six months. It supports staff to identify deterioration earlier, resulting in residents receiving care at home rather than a hospital admission which greatly improves quality of life. Staff also report feeling more confident in their role and residents are treated in the right place and at the right time.
A Powerpoint presentation about the Significant 7 approach can be downloaded from the resources zone on the right hand side of of the webpage.
Stop and Watch Early Warning Tool (Interact)
Stop and Watch is a clinical alert, part of the American INTERACT toolkit, intended for use in nursing homes. The tool is intended for use as a clinical alert to provide early identification of, and communication about, acute changes in the condition of a patient or resident. The Stop and Watch Early Warning Tool can be downloaded from the Interact website.
A presentation about using STOP and Watch across North Cumbria CCG by Director of Nursing and Quality Anna Stabler at the 'Don't let me die too young - Mortality Conference' on 1st March 2019 can be accessed on the NHS North Cumbria CCGs website.
LPZ – improving quality and safety in care homes ( East Midlands Patient Safety Collaborative)
East Midlands Patient Safety Collaborative (EMPSC) have introduced an audit tool to measure the prevalence of common care problems found in nursing and residential homes 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.
More information about LPZ and the EMPSC project can be found in the NHSI Atlas Directory.
A ‘NEWS’ system for residential care settings (Sunderland CCG)
A multidisciplinary team from Sunderland CCG have developed and applied an electronic system based on an adaptation of the National Early Warning Score (NEWS) tool to support the monitoring of residents’ health. The system has improved residents outcomes and experience. More information about this project can be obtained from the NHSEs Atlas of Shared Learning.
Living Well Essex (Essex County Council & Healthwatch Essex)
The Living Well website has been created by Essex County Council in partnership with Healthwatch Essex to provide information on services and organisations across Essex. They have signposted two documents of particular relevance to Care Homes on their Care Provider Information Hub.
Copes of these documents and information about the Living Well initiative can be found on their website here.
Early warning through camera based vital signs monitoring
Wessex Academic Health Science Network (AHSN is working with Hampshire-based digital innovators xim, and Badgerswood Surgery in Bordon to develop new technology capable of monitoring patients’ vital signs.
The LifeLight® system can check a patient’s vital signs - their pulse, breathing rate, blood pressure and blood oxygen level - by simply sitting in front of a computer screen.
LifeLight® does this by using a standard camera on the screen, which detects very small changes in a person’s forehead skin colour, and may help identify unknown health conditions or underlying problems.
Further information on this workstream can be obtained from Geoff Cooper (Programme Lead) via email or via the contact link at the bottom of this page.