In March 2012 the Care Quality Commission (CQC) published a review looking at how well the healthcare needs of people living in care homes are met. Martin Hodgson discusses its findings.
Health Care in Care Homes: A Special Review of the Provision of Health Care to those in Care Homes not only considers practice in individual care homes but also focuses on the rights of people in care homes to access NHS services that met their needs. This includes GP services, pathways for continence care, the direct provision of district nursing services, and training for care home staff.
How was the review conducted?
The initial data for the review was collected between February and April 2010, with the intention of publishing a national report later that year. However, due to the heavy workload involved in registration the report was rescheduled and the data reviewed in April 2011.
The CQC has subsequently analysed the data to produce a report which will be used to shape a series of thematic inspections on dignity and nutrition to be undertaken across 500 care homes with nursing provision from the summer of 2012.
The results are based on an analysis from the actual inspections of 81 care homes in 9 primary care trusts. During the inspections the CQC interviewed or observed care being delivered to 386 residents in these 81 care homes during January and February 2011. The sample type of residents receiving healthcare included both older adults in care homes and younger adults with learning disabilities in care homes. The sample size was too small for any of the results to be interpreted into national findings and the CQC states that the results must therefore be treated with caution
All inspections included an expert to work alongside the CQC inspector and a pharmacy inspector.
What are the main findings of the review?
The data was analysed and mapped against the most relevant themes in the Essential Standards guidance about compliance as follows.
Involvement and information
The key findings under this outcome were as follows.
The majority of homes (86%) had a policy on consent issues, but there was variability in whether key subject areas such as non-verbal communication were included in these policies.
74% of residents felt that their personal information was kept private; 42% did not feel that staff asked them for their permission before sharing information more widely.
54% of homes did not provide residents with information about which healthcare services were included in the home’s basic fees or in their care contract and agreement.
Where referrals to healthcare professionals were undertaken, the majority (91%) were felt to be appropriate.
The review found some variability between care homes in the services provided by GPs and who pays for these services. It reports that 33% of homes said that GPs did not provide post-admission assessments for residents, 53% said they were provided and paid for by the local primary care trust and 7% said that they were provided but paid for by the care home.
Only 44% of care homes indicated that GPs undertake scheduled surgeries or visits in the care home.
Personalised care, treatment and support
Under this outcome the review found the following.
In the majority of homes (present in 77% of case files inspected) there was evidence that care planning took into account the views of the person. However, inspectors felt that some homes did not adequately demonstrate person-focused care planning and in many homes the views of the person’s relatives and carers were not taken into account or not documented in care plans.
Information from interviews with residents indicated that most (85%) felt that staff often or occasionally talked with them about their healthcare needs but only 55% of those interviewed were aware that they had a care plan in place that set out their needs.
30% of nursing homes did not have a “Do Not Attempt Resuscitation” (DNAR) policy in place. Where DNAR policies were in place, most staff (76% of staff in nursing homes) were aware of the policy, although very few (37% of staff in nursing homes) had received formal training in the policy.
With regards to medication, over half of homes (59%) indicated that they offered residents the option to self-administer their medicines but only a small number of case files contained evidence of such self-administration.
Most homes (85% of nursing homes and 78% of residential homes) provided residents with information on continence care but interviews with residents suggested that about a third (38%) did not feel that they were offered choices about how their continence needs are managed. 25% of residents with continence needs felt that they did not have a choice of male or female staff to help them use the toilet.
The majority of homes (96%) identified changes in the healthcare needs of residents through informal monitoring, such as responding to issues they or their carers raise, and 94% stated that they identified such changes through formal monitoring.
Safeguarding and safety
The review spent some time looking at medication and found the following.
The majority of homes (93%) indicated that they “always” recorded medicines errors and had arrangements in place to learn from errors relating to prescribing, monitoring, dispensing or administering medicines.
85% of homes had a policy on homely medicines in place.
40% of the homes had residents that were receiving anti-coagulation therapy, and in the majority of cases (84%) an appropriate anti-coagulation record was in place. However, under a third (31%) of these homes were aware of a recent National Patient Safety Agency safety alert regarding anti-coagulation therapy.
35% of homes indicated that getting medicines to residents on time was “sometimes” a problem, while three homes (4%) indicated that this was often a problem.
49% of homes recorded the actual time of administration of medicines.
43% of homes did not have a policy in place covering the decision to administer medicines to be “taken as prescribed”.
The review also looked at whether systems were in place to support residents who lacked the mental capacity to make decisions and found that just over half (59%) of homes that care for people who lack capacity had best interest decisions in place for all these people.
Suitability of staffing
The review found that both general and specialist training was provided in a variety of topic areas in care homes. When looking specifically at nursing and residential homes the review found that most homes (93%) provided training about dementia but only half (52%) provided staff with training about stroke.
Training attendance was noted in the review, which found that medicines management was the healthcare area with the highest attendance in the previous 12 months (59% of all staff interviewed), while a much smaller proportion of staff (36%) had attended training about continence care.
Other key findings under this outcome were as follows.
Staff confidence in relation to the healthcare needs of residents varied across homes. In 75% of homes all staff interviewed said they felt confident that they understood the healthcare needs of people living in the care home and what to do to help meet these needs. However, in the remaining homes some or all staff interviewed indicated that they only felt confident to some extent or did not feel confident at all.
While tools and guidance were available to staff for processes and procedures in care homes, there was some evidence to show these were not always used by staff. For example, where inspectors found DNAR decisions in case files, less than half (42%) had been made in line with the home’s DNAR policy.
The CQC states that the healthcare review featured in the report was one of the last planned using a methodology for reviews that is no longer a part of the CQC regulatory framework. The new framework includes themed inspections of services as part of an annual cycle of activity. Since this change in approach, the CQC states it has carried out thematic announced inspections looking at care and welfare and safety and safeguarding across 150 learning disability, mental health and challenging behaviour services, and dignity and nutrition inspections of 100 older people’s services in acute hospitals.
The findings from this last old-style review will therefore be used to shape and inform thematic inspections of dignity and nutrition in care homes scheduled for the summer of 2012.
“Failing the Frail”
The CQC’s upcoming inspection programme will be further influenced by another analysis of the healthcare review data carried out by the British Geriatrics Society (BGS).
Failing the Frail: A Chaotic Approach to Commissioning Healthcare Services for Care Homes was published at the same time as the CQC review and concludes that the healthcare needs of care home residents may be seriously neglected in some areas of the country.
In particular it looked at how older people and people with learning disabilities living in care homes access healthcare services, whether they had choice and control over their healthcare and whether they received safe care that was respectful of their dignity. These are all aspects of care that are considered fundamental to the delivery of the CQC Essential Standards.
Good practice was noted in areas such as care planning, as it was in the CQC review. However, the BGS review also found that basic healthcare needs were unmet in some areas.
For instance, it was found that in 40% of the homes surveyed those needing an initial continence assessment had to wait more than two weeks, a wait considered likely to have an impact on the welfare of service users. In addition, the BGS drew attention to the fact that only 38% of care homes said that GPs made routine visits while 35% reported they “sometimes” had problems getting medicines to residents on time. 10% of care homes said they paid for their GP surgeries to visit.
The BGS concludes its report by stating that, according to the data, over half (57%) of older people resident in care homes may not have access to all the NHS services that they may require. Particular concerns are expressed that primary care trusts demonstrate a lack of knowledge of the needs of older care home residents, a situation that may well get worse in view of future changes to commissioning practice in England.
It therefore strongly recommends that local NHS planners and commissioners ensure that clear and specific service specifications are agreed with their local NHS providers to meet the needs of older care home residents.