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Improving quality in care homes using an electronic tool


A trust developed an electronic tool to measure the quality of care home services, giving managers immediate feedback and an objective report on standards

In this article…

  • Developing a quality monitoring framework
  • Cutting delays so action can be taken immediately
  • Identifying good practice that can be shared



Sandra Horton is quality monitoring officer at NHS Nottingham City


Horton S (2010) Improving quality in care homes using an electronic tool.Nursing Times; 107: 11, early online publication.

Measuring the quality of healthcare provision in care homes and domiciliary care settings is vital for the effective commissioning and the safety of residents. However, the process is often costly and time-consuming. NHS Nottingham City developed an electronic tool to streamline the process and improve the feedback provided to homes.

Keywords: Care homes, Quality monitoring, Older people

  • This article has been double-blind peer reviewed


5 key points

1.      Commissioners of residential and domiciliary care are responsible for ensuring it is of an acceptable standard

2.      Auditing care providers can be a cstly and time-consuming process

3.      Auditing systems must be consistent and objective

4.      Care providers should be given clear and timely feedback on their services

5.      Electronic systems can collect monitoring data quickly and reduce the time taken to generate reports


An estimated 378,000 people live in residential care homes in England. More than half of these (55%) receive state funding for their care (Putting People First, 2011), most from their local authority. Around 50,000 receive NHS funding for long-term healthcare, at an annual cost of more than £410m (Department of Health, 2009).

In 2010-11 it is estimated that NHS Nottingham City, a primary care trust responsible for the healthcare of a population of 325,000, will spend over £5.8m on continuing healthcare in care homes and people’s own homes, providing funding for over 600 people.  An additional £1.9m will be spent on funded nursing care.

Considering the huge costs of continuing healthcare and funded nursing care NHS and local authority providers need to be sure that the outcomes, choices and quality of care delivered for these people are of a high standard. It is also vital that residents, who are often frail and vulnerable, are cared for in a place that is clean, safe, friendly and meets their physical and social needs.

However, Netten and Forder (2007) point out that there are deficiencies in the care system, with unmet needs resulting in gaps between expected outcomes and reality.  They suggest that in order to establish how far services need to improve to bridge these gaps, outcomes need to be measured in a systematic and comparable way.

In 2010, after a period of assessment using a newly developed framework, NHS Nottingham City found that over a half its care home providers were failing to achieve what can be considered good standards of care. Public confidence in residential care homes is based on the fact that the Care Quality Commission, which regulates health and social care, assesses the quality of care these homes provide. Where standards are inadequate, the CQC can enforce improvements. However, according to the DH (2009), the commissioners of services themselves are responsible for ensuring the quality of services they purchase from care homes and domiciliary care agencies.   

Continuing care funding

The National Framework for NHS continuing Healthcare and NHS Continuing Nursing Care (DH, 2009), defines continuing care as a package of care arranged and funded solely by the NHS for people aged over 18 years who require care over an extended period to meet physical or mental health needs due to disability, accident or illness.  However, individuals who require continuing care may need services from the NHS or from the local authority. Where an individual may not be eligible for continuing healthcare funding, they may qualify for funded nursing care, or a joint care package funded in partnership with the local authority.  This enables nursing care to be funded by the NHS alongside other services. 

A quality monitoring framework

In late 2009 I was recruited by NHS Nottingham City as a quality monitoring officer to work alongside a graduate student from the NHS Institute of Innovation and Improvement to design a quality monitoring framework for use in care homes. Before this, the PCT had no consistent, identified method to enable commissioners to monitor the quality of healthcare provided in care homes and domiciliary care settings. After a scoping exercise, we designed, developed and implemented i-Care, an electronic quality monitoring framework. The development process included consultation with a wide range of healthcare professionals, including infection control nurses and dietitians, to ensure the framework was evidence-based and in line with best practice. 

Existing audit tools

Before developing i-Care, we undertook a scoping exercise to establish which audit tools were being used by other quality monitoring teams in the East Midlands.Most were using tools developed by local authorities. However, focused primarily on social care delivery, and there was no specific tool to measure the quality of healthcare provision. Carrying out the audit for both health and social care also meant the audit process was being duplicated.

We also assessed the resources required to undertake quality monitoring in care homes. This included the time taken to conduct audits within the home, write reports after the visit, complete the audit tool itself to determine the scores, and provide feedback to care home managers. 

We found that monitoring and inspecting teams could take more than two weeks to generate reports after completing their assessments; care home managers received little feedback at the end of assessment visits, and did not know how well their home had scored until they received their typed reports. 

The i-Care tool

i-Care is designed to measure care outcomes, rather than care delivery, providing an overview of how care homes manage their residents’ healthcare needs. It covers four domains: care planning; safeguarding; clinical effectiveness; and operations. Some of these contain a number of elements (Box 1).

Box 1. The elements scored using i-Care

  • Care planning;
  • Safeguarding;
  • Clinical effectiveness;
  • Elimination;
  • Tissue viability;
  • Nutrition;
  • Moving and handling and falls;
  • Infection control;
  • General wellbeing and mental health;
  • End of life;
  • Medicines and service provider equipment;
  • Operations
  • Communication;
  • Record-keeping and reporting;
  • Training and equipment;
  • Resident and/or relative survey.



Care homes are scored on each individual i-Care element and scores are colour-coded using the traffic light system:

  • Red: 0-49% (poor care – immediate action required);
  • Amber: 50-89% (reasonable care – 12-week timeframe for action);
  • Green: 90% and above (good care – share this practice).

Scores for each element are combined for an overall score for that domain, but scores for individual elements enable care home managers and quality monitoring officers to see exactly where action is required to improve services. All calculations are done automatically through preset formulas once data is keyed in by the monitoring officer, making the tool quick and easy to use.

Developing i-Care

We decided to make i-Care available in an electronic format to allow for the following:

Audits focused on health outcomes:

It was important to have an assessment process that did not replicate others, focused only on health outcomes and could be aligned to the continuing healthcare and nursing-funded contracts. 

Face-to-face feedback:

The ability to generate immediate results through i-Care would enable quality monitoring officers to give feedback before leaving the care home.  

Promoting dialogue:

Face-to-face dialogue with the care home manager would allow areas of improvement to be discussed. It would also enables care home providers to produce written action plans and to identify improvement strategies without delay.

Saving NHS resources:

i-Care could reduce significantly the time taken to produce quality monitoring reports. Results are generated during data inputting, so reporting takes only as long as it takes to monitor the home. Paper costs are also reduced as most managers prefer to receive their report electronically.

i-Care also enables healthcare providers to demonstrate they are complying with the quality, innovation, productivity and prevention (QIPP) programme, which requires them to demonstrate that they are supporting quality and productivity in their local area.  We believe i-Care meets all four of the core QIPP principles in that it aims to improve quality in care homes, uses an innovative approach; aims to increase the productivity of health services to care homes and assist in preventing unnecessary attendances to hospitals.

Pilot and consultation

During the design stage we consulted specialist healthcare professionals from NHS Nottingham City, Nottingham Citihealth and NHS Nottingham Health Care Trust, as well as quality teams and service commissioners from our own organisation and Derby PCT. i-Care was piloted in Nottingham between January and July 2010. It was trialled in a variety of care home settings covering a wide range of service user needs. During the pilot stage, the tool went through consultation with both Nottinghamshire County Local Involvement Network (LINk) and the Care Homes Association. 

Audit results

Since the pilot began in January 2010, a total of 42 quality visits have been completed in both nursing and residential care homes to date; a number of homes have also been revisited. On completion of the audit, care home managers are asked to provide an action plan for improvement.

NHS Nottingham City medicines management and infection control teams already undertake annual audits in care homes, so these elements are not assessed by the i-Care quality monitoring officer. However, they are included in the overall quality monitoring framework and remain in i-Care for use by colleagues outside the PCT.

The first set of results was encouraging; 49% of care homes met the expected standards of care, achieving scores of 90% and over. However, 12% scored less than 50% placing them in the red zone, while the remaining 39% scored 50-89%, placing them in the amber zone. The main areas of concern centred around clinical care practices, including clinical assessments, care planning and documentation and lower than expected standards of clinical care delivery. 

Care homes that scored less than 50% were offered additional support to help them make the necessary improvements. An advanced nurse practitioner worked with their staff on areas such as clinical assessments, care planning and long-term needs management; this has succeeded in increasing staff confidence and knowledge.  When reassessed most of the homes had made significant improvements and their scores had moved into either the amber or even the green zone. There are now just 5% of all care homes in Nottingham City scoring less than 50%.  Work continues to raise standards of care in these.

Where there were concerns about potential cases of abuse, safeguarding issues were raised during the quality visits. The local authority and PCT have strong relationships that enable a joint approach to managing these events, promoting the safety of care home residents.


Assessing the quality of commissioned services is vital, and i-Care enhances this process. It also reduces the time taken to conduct assessments, and cuts printing costs.

Since the pilot i-Care has been accepted as the preferred monitoring tool for use in a number of East Midlands PCTs. From May 2011 it will be directly linked to the new regional service specifications and continuing care contracts in several PCTs across the East Midlands. The possibility of applying the tool to contracts monitoring in care homes is now being discussed.

i-Care has been extended for use within NHS Nottingham City’s medicines management and infection prevention and control teams. We have also developed new version for use in specialist areas such as mental health, learning disabilities and brain injury.


The majority of care homes in Nottingham are owned and managed by independent providers, yet the local authorities and PCTs who contract their services have equal responsibility to ensure the safety of residents of these care homes. The development of i-Care has enhanced quality monitoring assessments, saving time and resources that can then be used to help service providers to improve the quality of the care they offer. The providers also receive face-to-face feedback at the ends of their assessment and a comprehensive and objective report showing clearly any areas requiring improvement, without the delays associated with other reporting methods. This enables them to begin addressing any shortcomings immediately. 


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Readers' comments (2)

  • sounds like a really useful tool
    would love to see more!

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  • Christopher Cooper

    Sounds very interesting - as an ex 'clinical audit anorak' I would love to learn more about the tool and whether sharing it with others is a possibility.

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