14 November 2018

Improving quality in care homes: a story of creativity, engagement and spread

Lesley Cruickshank, Quality Innovation Manager at Essex County Council

Lesley Cruickshank describes how an innovative approach to improving care in care homes has achieved positive results for staff and residents, and has gained traction across the county.

Traditionally, local authority improvement work with care homes has tended to be in the form of monitoring with performance measurements: homes are inspected and marked down if they don’t comply with contractual specifications, with little in the way of support on how to go about implementing improvements.

In Essex, we have taken a different approach. We are focusing on what works well, supporting care homes on what doesn’t work so well, and using a quality improvement methodology – something which has been widely used in health care but not social care.

Four years ago, I led the implementation of the PROSPER project, a quality improvement initiative for care homes on the prevention of falls, pressure ulcers and urinary tract infections. Initially the project, which was funded by the Health Foundation and implemented with the support of UCLPartners, seemed straight forward: we (the Quality Improvement team) were to teach the homes about quality improvement methods, using Plan Do Study Act (PDSA) cycles to implement small tests of change and to ask the homes to collect data, using the NHS Safety Thermometer, to find out whether their changes were having an impact.  The aim was to move homes away from using data only for performance measurement and to focus on prevention rather than being reactive.

We have some amazing care homes who have come up with some great initiatives such as Pimp My Zimmer (decorated walking frames so that residents can easily recognise their frame, reducing falls) and Light My Night (luminous footprints showing the way to bathrooms and light-up toilet bowls), and care staff who have created The Three F’s falls poster (Footwear, Ferrules and Frames). Care homes have also created a 24hr Falls Clock plotting time and place of falls for deeper analysis, introduced hydration games and used aromatherapy to encourage appetite and help with maintaining skin integrity.

The key success of PROSPER was the care homes were in control of how the initiative progressed, they were the experts in care delivery – not myself or my team – and therefore we shaped the programme and the tools used according to their feedback. This led to changes in the delivery of the quality improvement methodology training, dropping the NHS Safety Thermometer as the data collection tool, introducing Safety crosses (a visual data collection tool used to identify areas for improvement) and a PROSPER toolkit of ideas and information.

Implementing quality improvement methodology has not been enough on its own, with the homes asking for ideas on what they could test out for their PDSA cycles, support with the basics of clinical knowledge and ideas on how to get care staff involved. So we introduced PROSPER Champion Study days and a PROSPER newsletter with top tips and information – both of which are still going strong four years on. Managers tell us care staff return from the study days enthused and eager to put ideas into practice.  We try to make it fun for the care staff – at our recent PROSPER Champion study day we devised the PROSPER Pictionary Game which had us all laughing but also helped to share ideas with homes who have just joined PROSPER; in our newsletter we have included a resident riddle section and encourage the homes to get their residents involved.

PROSPER has been the start of our improvement work with care providers and has resulted in Essex County Council investing in a Quality Innovation team led by myself and my colleague Jenny Peckham. We have expanded PROSPER to include learning disability services and are working with domiciliary care providers to support their care staff to manage the ever-increasing difficult situations they face on a day-to-day basis. We have an extensive train-the-trainer programme focusing on areas that care staff do not normally get training in such as Stoma Care, Parkinson’s and mental health. We are working with registered nurses from nursing homes to assist them with their continuous professional development to support their validation of registration and to create a forum of peer support in an environment that is otherwise very isolating.

It’s a privilege to work on an initiative that has so much traction and is spreading across our area and across different parts of health and care. In Essex, 164 care homes have now used the methodology, and four care homes rated ‘outstanding’ by the Care Quality Commission (CQC) and many rated ‘good’ have had PROSPER tools and methodology heavily mentioned in their inspection reports. I am very lucky to have a role that allows me to be creative and has the flexibility to try new ideas to help improve care in my region and spread our learning nationally.

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