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​​Beating Winter Pressures in Care Homes​

​11 December 2015

Introduction

The Beating Winter Pressures in Care Homes Event was held on Friday 11 December at Nutfield Lodge.  The event had a combination of various speakers from local NHS organisations and participant group work.  Presentations included ESCCG Care Home project, end of life care, infection and falls prevention, care planning and sharing information (IBIS), supporting care homes, medicines optimisation, Continuing Healthcare. It was buzzy, interactive and was well received by all who attended.

Purpose

The event was organised to explore how stakeholders could work together this Winter to best care for people avoiding unnecessary admissions and to ensure timely discharge home, or to the usual place of residence. Through delivered presentations and group participation, the attendees were encouraged to work together as key stakeholders to agree how they could work in partnership in supporting each other to achieve this aim.

Attendees

There are 42 Residential and Nursing homes in the East Surrey area.  24 attendees representing 14 Care Homes and Care with Nursing Organisations attended the event, which were as follows:

  • Ridgegate Care Home
  • Coombe Dingle Nursing Home
  • Barnfield Care Home
  • Elizabeth Court Care Home
  • Orchard Court Care Home
  • Coppice Lea Care Home
  • Caring Homes
  • Anchor Care Home Organisation
  • The White Post Health Care Group
  • Advantage Nursing Agency
  • Loga Care
  • Sunrise Senior Living
  • Care Unlimited
  • Nuffield Care Centre
  • Bupa
  • Skills for Care (London and South East)
  • Surrey County Council Social Care

Programme

The programme agenda was a mix of presentations and interactive group work.  The event was introduced by Dr Elango VijayKumar Clinical Chair ESCCG and Fiona Allsop Chief Nurse Surrey and Sussex Healthcare NHS Trust. The speakers represented, East Surrey CCG Clinical Leads for Care Homes and the Medicines Management Team, First Community Health & Care, CHC Surrey Downs CCG and South East Coast Ambulance Service.

The agenda sequence was as follows:

  • Welcome and Purpose
    Dr Elango Vijaykumar, GP and Chair, East Surrey CCG
    Fiona Allsop, Chief Nurse, Surrey and Sussex Healthcare NHS Trust
  • Scene Setting and How Do We Work
    Dr David Hill, GP and Clinical Lead for Care Homes, East Surrey CCG
    Dr Selvi Bangalore East Surrey CCG, Karen Devanny East Surrey CCG and Jo Poynter SCC Adult &Social Care.
  • Rainy Day Thinking – Hospital Attendance/Admission Avoidance
    Caroline Hurman and Caroline Burns, Community Nurse Advisors for Care Homes, First Community Health and Care
  • Medicines Optimisation
    Ulrike Lukas & Reham Al-Shwaikh, East Surrey CCG
  • Continuing Healthcare
    Alma Trozado & Judith Dornan, Surrey Downs CCG
  • SECamb Case Study
    Peter Glover, South East Coast Ambulance Service
  • Group Workshop
    Where do we want to be and how do we get there
  • Action and Next Steps
  • Closing Summary

Key Messages and next steps

  • Care Homes signed up to a number of ‘pledges’ around sharing information, effective communication, maximise the use of training and the community nurse advisor resource
  • There was agreement to jointly progress a number of initiatives –
  • recruit and retain care home staff
  • develop proactive personalised care plans and ensure these are shared with the ‘team’ caring for the person
  • develop ‘patient passports’
  • maximise medicines safety and reduce waste
  • develop a ‘directory of services’ for care home use in and out of hours
  • East Surrey CCG, Surrey Social Services and Surrey Care Home Association will agree a work programme, success measures, communication plan including future events
  • East Surrey CCG speaking the next local care home forum

Questions and Answers

The group work session encouraged attendees to answer four key questions and on each table speakers facilitated, to encourage discussion and the answers were transferred to a flip chart, to feedback to the rest of the audience.

The answers to the four key questions were as follows:

What do Care Homes Do Well?

  • Know the pressure in hospital for discharges
  • Bad weather contingency
  • Refresher training e.g. infection control
  • Focus on recruitment for higher numbers over winter
  • Care Plans up to date including extra risks during winter
  • Flu vaccinations for residents and staff reducing infection rates
  • Changing the pathway
  • Giving ‘Winter Awareness’
  • Business Continuity Plans – a battle Box
  • Residents are warm & happy
  • Supporting hydration activities
  • Working closely with GPs (winter contingency plans – checking stock levels)
  • Working un ethos of prevention better than cure (putting plans in place, rainy day thinking, training)
  • Ongoing awareness, need for staff well being/temperature
  • Regulation within Care Home, responding to residents needs
  • Managing the environment (salt – access for GP/HCPs)

What do Care Homes need to do Better?

  • Training in Nursing Homes for IV’s
  • Catheter Management
  • Allow discharges at weekends
  • More staff to know what availability in their home
  • More using trusted assessor pathway
  • Improving Hydration – Hydration Stations
  • Recruitment – year round and sick cover and Retention
  • Sharing Information – e.g. beds in an emergency
  • More MDT meetings
  • Be more pro-active (carers, caterers – everybody)
  • Communication, communication, communication!
  • Keep pushing for Community HCP Support
  • More joint up working
  • Communication – family, GP, EOL discussions with families
  • EOL – regular updates with family
  • Mini surgeries in Care Homes – reduce call outs.
  • Better joint working with GP for contingency plans
  • Some homes do not always access training available

What does the System Do Well?

  • Care and contingency plans
  • Supportive District Nursing Team
  • EDT
  • Ambulance Service
  • 111 Service
  • Advise, support information available ‘in hours’
  • GP/Pharmacists working together DNs all MDT
  • Allocated named GP visits twice weekly
  • When it goes well, it goes well
  • Good GP Support
  • Telling us how badly we are doing!
  • Good training support
  • Support from the two Carolines from FCHC
  • Support from Medicines Management Team
  • Meeting the majority of needs
  • Good integration

What does the System need to do Better?

  • Crisis support e.g. mental health
  • Communication between providers/agencies/organisations
  • Be more proactive, rather than reactive
  • Flexibility
  • Consistency from GP Practices (different practices offer different levels of support)
  • Increase response intel time from OOH’s
  • Better engagement and teaching from mental Health Team and awareness of contact details
  • Communication from SaSH to Care Homes (servicing in information, care plans, DNACPR’s, medications, Walking aids, then hospital ring asking where they are?)
  • Different HCPs and Departments ringing to ask for the same information – need to improve process.
  • Reduce medication waste (transfer in with meds changed in hospital but Care Home not informed)
  • Better understanding of MCA when capacity fluctuating
  • End of Life Care
  • One or Two GP’s per Care Home
  • Communication
  • Take learning from other geographical areas (skype – consultation in Kent)
  • Medication training
  • Newsletter from all parties involved
  • Signpost resources available
  • Discharge of patients;
    • Summaries
    • Medicines
    • MFFD?
  • Plan and predict capacity for winter;
    • SCA bed vacancy report and link up
    • ‘Chronic’ shortage of POC’s
  • Mental Health Crises

Pledges

At the end of the workshop the attendees were asked to pledge how their organisation would act to help work as part of the wider system, to ensure people were safe and well cared for in their ‘own home’, in order to reduce emergency admissions and readmissions to hospital. 

The following pledges were made:

  • Chipstead Lodge – Ensure Staff awareness and feedback to staff
  • Anchor – More participant in groups and will attend events
  • Anchor – Investigate opportunities for a GP to visit the home once a week
  • Caring Homes – Encourage support and training for staff and communicate
  • Look at and take up more free training and co-operate with GP’s and community trusts
  • Lukasz Bogusz Barnfield - Introduce discussions around death to residents at an early opportunity.
  • Robert Thomas Nuffield Care Centre – Communicating to manager and Staff what opportunities are available to them
  • Sam Tobin – Ridgegate – Build a better relationship with discharge team at the hospital and be more flexible.
  • Price Mead – Be more pro-active with advanced planning
  • Chaldon Rise – Look at training opportunities and communicate these to staff.