Dr Adam Gordon is Clinical Associate Professor in Medicine of Older People at The University of Nottingham and an Honorary Consultant Geriatrician at Derby Teaching Hospitals NHS Trust; he tweets @adamgordon1978. Here he describes a project to benchmark and report the prevalence of care problems in UK care homes.
Care homes do a lot of good work. There are almost three times as many beds in UK care homes as there are in National Health Service hospitals. Care home residents are amongst the most vulnerable members of our society.
Up to 80% have cognitive impairment, some two thirds have behavioural symptoms, all need help with their activities of daily living and many are approaching the ends of their lives. Much of the excellent care that takes place to care for these very vulnerable citizens in the 320,000 UK care home beds goes unreported. When things go wrong, however, the media are quick to respond.
When the worst happens – the consequences for residents and their families can be shameful. The issue is not, though, that care is universally bad, but that the quality of care is unacceptably variable. Some of the responsibility for this variability lies with the care home sector, whilst some lies with the organisations that commission and regulate health and social care in care homes. It is worth remembering that healthcare delivery to care home residents, with an average of 6 diagnoses and 8 medications per resident, remains the primary responsibility of the National Health Service. The NHS therefore has a key role to play as part of the broader health and social care sector to improve consistency of care.
Reliable numerical data on the quality of care in care homes is hard to come by. There are Care Quality Commission inspection reports, local datasets compiled by individual commissioners and larger national datasets collected by large corporate providers. But this information is not collected consistently or in a standardised way. The CQC produces an annual state of care review, but this doesn’t produce the sort of detailed picture that might be necessary for individual homes to start to benchmark their practice and drive up quality.
Against this background the East Midlands Academic Health Science Network Patient Safety Collaborative set out to work with care homes to reduce variability in the quality of care across our region. The first step was a stakeholder exercise which identified the core safety priorities as pressure ulcers, falls, incontinence, malnutrition, delirium, dehydration, sepsis and social isolation. The next step was to find a way of counting these problems. To do this, we worked with colleagues at Maastricht University to import the LPZ (Landielijke Pravelentiemeting Zorgproblemen, which translates to “Prevalence measure of care problems”) from the Netherlands to the UK for the first time.
The LPZ has been developed and improved the Netherlands since the 1990s. It is now used there, once a year, to benchmark the prevalence of common problems in the Dutch Nursing Home sector. It comprises a number of measurement modules, including one for each of incontinence and pressure ulcers. It has been studied extensively and the measurement properties of the tool are well understood. Since the introduction of the tool the prevalence of all major care problems across the Dutch nursing home sector has reduced. They only know this because of the tool and it is possible that the tool has played an instrumental role in highlighting care problems and driving up standards. More recently, the tool has been used to compare practices between the Netherlands and other countries, including one study that allowed a better understanding of why pressure ulcers were more common in the Netherlands than in Germany, which provided Dutch colleagues with a further opportunity to improve their practice.
The EMAHSN PSC ran an LPZ audit for the first time across 26 East Midlands Care Homes on 26th November 2015. To make it easier, for the first time, we focussed just on the prevalence of pressure ulcers and continence problems. All audits took place on the same day through the concerted effort of care home staff and a team of tissue viability nurses providing an in-reach function. We were able to collect data from 597 residents on a single day.
The next step, now, is to work out what the data means to care home staff and how the counting and benchmarking of the prevalence of care problems can be used to drive quality assurance and improvement mechanisms within care homes. We will be working in partnership with the participating care homes in the first part of 2016 to explore this.
The East Midlands Academic Health Science Network Patient Safety Collaborative is holding a stakeholder meeting in Nottingham on Wednesday 9th March 2016. Details of the meeting can be found here: https://www.eventbrite.com/e/safety-in-care-homes-event-tickets-20298235569 booking is now open.
Please come and join us if you’re interested in learning more.
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