Clinical needs of residents in care homes are becoming more complex. NHS Derbyshire County carried out an audit to assess clinical care in its care homes
Hayley Veal,BSc, SP, DPSN, RGN, is head of clinical quality; Georgina Greensmith, PGCE,BSc, RGN, is clinical quality manager (care homes); both at NHS Derbyshire County.
Veal H, Greensmith G (2010) Evaluating the standards of nursing in residential care homes across one region. Nursing Times; 106: 38, early online publication.
Members of the nursing and clinical quality directorate, part of NHS Derbyshire County, a primary care trust, developed a clinical audit tool to assess standards in care homes across the region. This article examines how the team used clinical audit to evaluate services and make recommendations for improving the quality of nursing home care in the future.
Keywords Older people, Audit, Care homes
- This article has been double-blind peer reviewed
- What nurses need to do to run a clinical audit
- Identify key clinical areas the audit should focus on.
- Meet care home managers and owners to inform them of the audit, its aims and objectives.
- Design audit questions to identify whether appropriate risk assessment tools are in use, if care is being correctly planned, implemented and evaluated on a regular basis, and whether correct referrals to specialist services are being carried out.
- Use audit information on areas such as initial assessments on admission, falls prevention and standards relating to dementia care to target improvements.
- Use examples of best practice captured by the audit to share across the health community.
As the clinical needs of residents in care homes become increasingly complex, care homes that provide nursing are playing an integral part in the care of some of society’s most vulnerable people.
In Derbyshire, people living in nursing and residential homes have some of the highest risk of ill health of the local population, with over 60% having mental health problems and many identified as being at high risk of falls. A high proportion also have needs relating to tissue viability, nutrition and hydration, and end of life care.
Core to nursing – wherever it takes place – is a commitment to care for individuals and to keep them safe (Dougherty and Lister, 2008).
NHS Derbyshire County is responsible for commissioning high quality, effective care for nursing home residents. Following the formation of the primary care trust in 2006, the nursing and clinical quality directorate was established to ensure quality was embedded into the commissioning process.
Historically, the role of ensuring quality was carried out by the Care Quality Commission and the local authority.
What was missing under the previous system was an in depth review of clinical standards and delivery once services had been commissioned. Posts were created for the first time to ensure a focus on clinical quality within care homes providing nursing care.
The PCT board decided that understanding and monitoring the level of clinical quality in care homes should be one of its priorities and that a mechanism to do this was required.
This led to the directorate of nursing and clinical quality developing a clinical quality framework that would focus on the clinical care being delivered within care homes in Derbyshire.
As the Nursing and Midwifery Council (2008) states: “You must work with colleagues to monitor the quality of your work and maintain the safety of those in your care.”
The care home nurses and managers who advised on the framework welcomed the initiative, as clinical care in these homes had never been audited in the past.
Since many of the contracts with care homes are funded jointly by the PCT and the local authority, a shared working approach was recommended.
Both organisations are ultimately responsible for the quality of the services they commission so a shared approach was likely to have the best effect.
Standards for Better Health (Department of Health, 2004) (Box 1) has become a benchmark for safer service delivery in the health service.
The standards apply to the provision of all NHS services in all settings, including private and voluntary sectors insofar as they provide care to NHS patients.
Bradford City Council and Bradford and Airedale Teaching PCT [had previously embedded Standards for Better Health successfully into their contracts for nursing homes so they could manage quality jointly.
The PCT and the local authority in Derbyshire agreed that a similar approach would facilitate the introduction of a clinical quality framework into contracts for both private providers and those held within continuing care. By taking a joint approach, the two organisations would be be able to demonstrate effective working relationships and improve outcomes for the local population.
Box 1. Standards for Better Health
In July 2004, the Department of Health published Standards for Better Health. This documentdescribes the level of quality that organisations providing NHS care – including private and voluntary providers – are expected to meet. These standards are divided into seven domains:
- Clinical and cost effectiveness;
- Patient focus;
- Accessible and responsive care;
- Care environment and amenities;
- Public health.
Each domain of Standards for Better Health has individual standards that fall into two categories:
- Core standards: these bring together and rationalise existing requirements for the health service, setting out the minimum level of service patients and service users have the right to expect;
- Developmental standards: these provide a framework for NHS bodies to plan the delivery of services that continue to improve in line with increasing patient expectations.
The directorate of nursing and clinical quality developed an audit tool using six clinical domains (Box 2). These were chosen because of their links to Standards for Better Health. The domains were also as areas requiring improvements in some care homes that had been identified through monitoring patterns in complaints or safeguarding concerns.
A stakeholder day was arranged jointly with the local authority, which was very supportive of this process. The aim was to inform the care home managers and owners of the proposed contracts and quality schedule that would be introduced by the PCT.
Following the event, a small group of care home managers representing the care home community attended a meeting to agree and finalise the schedule and discuss the impending audit.
We wrote to the home managers informing them they would be contacted by a member of the clinical quality team to arrange a convenient date for the audit to take place.
Box 2. Six clinical quality domains
The audit tool included the following quality domains:
- Infection control
- Tissue viability
- Management of falls
- End of life care
- Nutrition and hydration
- Dementia and mental health
In June 2009, the audit began its pilot phase. Following some adjustments to the audit tool, the full study took place between July and October 2009. It involved a visit to every home there were 86 homes by a clinical member of staff from the clinical quality or continuing care team.
Five randomly selected sets of nursing notes were audited per home, as well as one set of notes from an admission to the home that had happened in the previous three months. Data was then collected, recorded and entered into a database. The audit took on average three hours to complete for each home.
The audit questions were designed to identify whether appropriate risk assessment tools were in use, if care was being correctly planned, implemented and evaluated on a regular basis, and whether correct referrals to specialist services were being carried out for each clinical domain.
The results were scored and weighted and a target of 80% assigned to each domain as a pass mark. We felt that this was a fair target to meet within this first developmental year that we could then stretch to 90% in subsequent years.
All home visits were completed by October 2009 and the results were also entered into a database for analysis.
Overall, 21.7% of homes achieved a score of greater than 80% in each of the seven clinical domains, with 78.3% failing to meet a minimum standard on all seven clinical areas.
Of the homes that failed to achieve a pass in all seven domains, 35% passed six domains, 21.4% passed five domains, 10.7% four domains, 14.2% three domains, 10.7% two domains, 3.5% one domain and a further 3.5% failed on all seven domains.
Fig. 1 below illustrates the variation in the numbers of clinical domains passed by each care home across the county. This ranges from 21% of homes achieving a pass score of 80% or more in all 7 clinical standards to 3% of homes not managing to score 80% or above in any clinical area.
Fig 1.Numbers of clinical domains passed by percentages of homes
Homes were most successful in achieving standards relating to nutrition and hydration (80%), tissue viability (73%), end of life care (78%) and infection control (76%). Only 44% achieved standards relating to dementia and mental wellbeing, 55% achieved standards for prevention of falls and 58% met minimum standards relating to clinical assessments on admission (Fig 2).
The Care Quality Commission rates care homes into four categories with star ratings: 0 is poor; one star is adequate; two are good; and three stars equal excellent.
The audit tool captured the data relating to the star ratings of each home to identify any relationship between the ratings and the clinical standards achieved within each home.
The results identified that, on average, the 0 and one star homes failed to achieve the overall pass rate of 80%, with 0 star homes achieving an average of 67.5% and one star homes achieving 73.3% across all standards. The two and three star homes achieved the 80% score collectively across the county, with two star homes achieving 82.6% and three star homes 80.7%.
Across Derbyshire, 73% of homes achieved the 80% pass mark for standards relating to tissue viability, with those caring for older people and people with learning disabilities performing best overall.
Where a resident did have a wound, there was generally evidence of a care plan in place that met their needs, and a recognised, validated assessment tool had been used.
Homes that did not perform well in this area failed to do so because of a lack of regular evaluation of both assessment and care plans.
End of life care
The majority – 78% – of homes achieved the 80% pass mark in end of life care, which required a recognised end of life pathway to be in use.
Homes registered to provide care for older people and those with dementia and mental health beds performed best within this domain.
Overall, 91% of homes in the south of the county achieved this standard, which reflects the success of the greater level of support available to them historically through dedicated facilitator posts.
This support is now mirrored in the north areas and, already, homes in Chesterfield can be seen to be benefiting, with a 93% pass rate.
Prevention of falls
More than half of homes – 55.5% – achieved the pass mark in falls prevention.
Those for people with learning and physical disabilities performed best overall, with homes for older people achieving the lowest score of 58.8% in this domain.
The majority of homes were using a validated risk assessment tool on initial assessment and making appropriate referrals to other healthcare professionals where required.
Of those that failed to achieve the standard, many were failing to demonstrate that they had appropriate care plans in place or undertook regular evaluations of the care plan and identified risk.
Nutrition and hydration
Homes performed well within this domain, with 80% overall achieving the required pass mark.
Where they did fail to achieve the standards it was, again, due to a lack of care planning and regular evaluation. However, good use of assessment tools was seen to be in place.
There were wide variations in results between areas, with over 90% of homes in some localities achieving the pass mark but only 60% achieving a pass in others.
In this domain, 76% of care homes achieved the 80% pass mark.
The homes were audited on whether or not they had up to date infection control policies in place and whether or not they were using the Department of Health Essential Steps infection control package (2005) being rolled out by the PCT infection prevention and control educator for care homes.
As with the end of life standards, homes that received dedicated support through a facilitator achieved the highest results.
Dementia and mental health care
This domain had the poorest result, with 44% of homes meeting the standard. Some 40-50% of all care homes achieved the pass mark of 80%, ranging from 16% of homes in one area to 72% in another. Most homes assessed the mental health needs of their clients, but most failed to produce targeted care plans for behavioural needs and had low numbers of staff trained in dementia care.
This highlighted the need for improved access and availability of dementia care training, especially for nurses. The local authority provides training for care assistants in independent sector homes.
Overall, 58% of care homes achieved the required pass rate for admission assessments.
Learning disability homes achieved the highest results, with 75% achieving the standard. However, only 52% of homes registered to provide dementia care achieved the pass mark.
Again, a similar pattern of wide ranging results across the county was observed, from 83% of homes achieving the pass rate in one area to just 10% in another.
A total of 80% of homes did not identify infection control issues on the initial assessment and 42% also failed to record baseline clinical observations on admission.
This baseline audit has shown the wide differences in clinical standards achieved by care homes providing nursing care across NHS Derbyshire County.
Many examples of good practice were found and observed in the use of assessment tools, prompt referrals to other specialist healthcare professionals and the use of care pathways. It has also highlighted the domains where homes need to improve and need targeted support, such as initial assessments on admission, falls prevention and standards relating to dementia care.
Overall, homes that failed to achieve the 80% pass mark did so largely because they did not reassess residents and evaluate their care regularly.The results clearly show that, where targeted work has been widely undertaken by care homes in areas such as end of life care, infection control and tissue viability, higher standards have been achieved.
Many examples of best practice have been captured by the auditors, which can be written up and shared across the health community. These include good examples of record keeping and paperwork, partnership working with the wider primary care team including attending meetings at GP practices to discuss residents, shared training and resources across homes within a locality and unusual and inventive fun days and activities for residents.
The results will be shared with care homes individually, enabling them to benchmark themselves within their localities and countywide. Staff will be able to see how well they performed against other individual homes, which were anonymised. The information in the form of the audit report has been made public, but individual homes have not been identified at this stage as we are still working out how to do this jointly with our local authority colleagues. In addition, targeted action plans will, we hope, lead to improvements in care provision.
This study has clear implications for practice not just locally but nationally. The work highlights the importance of understanding not only the quality of care being delivered within care homes but also the difficulties and challenges faced by nurses working within the care home sector who often report feelings of isolation and frustration as they are working outside the NHS. Access to training and information can be difficult at times and the care needs of their residents are becoming increasingly complex.
Good links and effective transfer of information between care homes and PCTs, general practice and community and acute services are essential to improve the quality of care received by care home residents.
A clear quality schedule based on evidence based practice will ensure that all parties understand the level of care that is being commissioned.
National and regional work is under way to develop consistent clinical quality standards and service specifications for people in different client groups living in care homes who receive continuing care funding? These standards will sit within a national contract for care homes being developed by the Department of Health.
It is anticipated that this will be finalised in October 2010 if all goes well with the national consultation. This will allow for a more consistent approach to nursing in care homes across the county and will benefit both commissioners and providers of residential care in the future in developing closer working relationships where these may have not previously existed.
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Department of Health (2004) Standards for Better Health.
Department of Health (2005) Essential steps to Safe, Clean Care.
Dougherty L, Lister L (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell.
Nursing and Midwifery Council (2008) The Code: Standards of Conduct, Performance and Ethics for Nursesand Midwives. London: Nursing and Midwifery Council.