Report on care homes in Nottingham North & East, Nottingham West and Rushcliffe CCGs 2013/14

Transcription

1 GB 14/040 Report on care homes in Nottingham North & East, Nottingham West and Rushcliffe CCGs 2013/14 Introduction This report gives an overview of the key risks and opportunities in relation to contract management and quality of care homes in the south of Nottinghamshire. The paper is set in the context of national publications and gives an outline of the local picture. Overview The profile of Care Homes has risen over the past few years with an increasing focus on the quality of service delivered within them. This is in part due to media coverage and increased public awareness of poor quality services such as Winterbourne View, plus the financial collapse of a large nationwide Care Home provider (Southern Cross) with a subsequent impact on frail elderly residents who have required placing in alternative accommodation. As a consequence there has been more intensive scrutiny of Care Home providers by regulatory and commissioning organisations. Nationally, CQC have increased the frequency and content of their inspection processes in light of new regulations and locally there has been joint working between Health and Local Authority commissioning teams to develop a more streamlined, collaborative process for monitoring and auditing of Care Homes plus joint working in response to care deemed as consistently poor quality or affecting the safety of residents. Local context The South Nottinghamshire Clinical Commissioning Groups (CCGs) commission care for residents who have healthcare needs via the NHS Continuing Healthcare s (CHC) list of Care Homes who are on the approved Any Qualified Provider (AQP) contract. NHS funded nursing care contributions are paid to those residents assessed as having nursing needs but who do not qualify for full NHS funding by CHC and these payments are made by the local authority who then recharge the CCGs. (See Appendix 1 for description of these funding streams) The CCGs also commission funding for people in Care Homes which are not part of the AQP contract list through a spot funding contract. Currently there are 31 care homes which are not on the AQP contract list but have residents funded by the CCGs. Of these care homes, 11 care for people with learning disabilities, 17 care for people with nursing needs and 3 care for people with residential care needs. The table below shows the number of care homes in each CCG which are either part or not part of the AQP contract for Continuing Healthcare with the CCGs Number of registered care homes (residential Nottingham North & East CCG Nottingham West CCG Rushcliffe CCG On AQP list 1 On AQP list 2 On AQP list 0 Not on AQP list 11 Not on AQP list 9 Not on AQP list 16

2 care only) Number of registered care homes with nursing Number of registered care homes providing care for people with Learning Disabilities Total number of care homes On AQP list 12 On AQP list 8 On AQP list 8 Not on AQP list 2 Not on AQP list 4 Not on AQP list 2 On AQP list 8 On AQP list 3 On AQP list 9 Not on AQP list 6 Not on AQP list 4 Not on AQP list The Quality and Patient safety team for the 3 south CCGs has a responsibility to support and assure CCGs of the quality of care delivery in care homes where a contract to provide healthcare is in place, ie. an AQP contract to provide NHS Continuing Healthcare funded care. The team also cover those care homes with nursing who may not have an AQP contract but provide the Funded Nursing Care element (FNC) to residents. The operational team consists of the Adult Safeguarding Lead (Band 7) and Quality Monitoring Facilitator (Band 5), who are responsible for auditing the Care Homes identified above, which includes review visits, providing support and guidance around best practice and escalating concerns where needed. Ultimately the work of the team leads to assurances of quality and safety of residents to the CCG Governing Bodies, which includes timely escalation of concerns about consistent poor quality or patient safety and subsequent action required. National and local drivers 1. Winterbourne View Following the Panorama program in May 2011 revealing the systematic abuse of adults with learning disabilities, the Department of Health DH) commissioned an in depth review of the circumstances surrounding this service and produced a report Transforming Care: A National response to Winterbourne View Hospital (Dec 2012). This report timetabled actions for health and local authority commissioners in working together to transform care and support for people with learning disabilities or autism who also have mental health conditions or behaviours viewed as challenging. It emphasised the importance of listening to this very vulnerable group of people and their families, meeting their needs, and working together to commission the range of services and support which will enable them to lead fulfilling and safe lives in their communities. 2. Safeguarding and quality in commissioning care homes guide 45 (SCIE February 2012) This guidance paper provides both health and social care commissioners with a robust framework for commissioning and monitoring the quality of care in care homes with an emphasis on good safeguarding practice and includes service user involvement, partnership working, developing the market, workforce development, accountability, and legislative frameworks, such as the Mental Capacity Act.

3 It describes the empowerment and involvement of residents and relatives, duties of protection of vulnerable people, prevention by robust training, policies and shared learning from incidents, and the importance of robust quality monitoring mechanisms both locally and nationally. This guidance has influenced the quality assurance visits that take place in care homes and the ongoing work in developing robust monitoring tools. 3. The state of health care and adult social care in England 2012/13 (CQC, 2013) This report highlights the findings of CQC in their inspections of health and social care establishments during the year April 2012 March 2013 and also describes the new methodologies for inspection for the future, which are based on 5 key standards; Safeguarding and safety Care and welfare Respect and dignity Suitability of staffing Monitoring quality CQC carried out over 35,000 inspections nationally during 2012/13 and found that in around 90% of cases people were treated with dignity and respect and received safe care and support, yet despite improvements, there are still a significant number of people who still receive poor care. The table below shows care home performance against the 5 national standards, depicting the national average, average for the East Midlands region, and position against the other 8 regions in England National Standard Standards Met Residential homes (National) Standards Met Nursing homes (National) Concerns of major / moderate impact Residential homes (National) Concerns of major / moderate impact Nursing homes (National) Standards met Residential homes (East Midlands region) Standards met Nursing homes (East Midlands region) Regional position (9 regions) Residential homes Regional position (9 regions) Nursing homes Safeguarding & safety (outcomes 7, 8, 9. 10) Care & Welfare (outcomes 4 & 5) Respect & Dignity (outcome 1) Suitability of Staffing (outcomes 13 & 14) 87% 89% 95% 88% 89% 82% 83% 88% 82% 87% 55% 56% 45% 50% 48% 58% 65% 46% 57% 59% 84% 82% 94% 82% 84% 78% 74% 85% 74% 80% 7 th 9 th 7 th 9 th 8 th 9 th 9 th 8 th 9 th 9 th Monitoring Quality (outcomes 16 & 17)

4 This data indicates that the East Midlands region has a high number of poorer performing care homes compared to the other 8 England regions. This trend is also reflected in data from our Nottinghamshire CQC area profile which in January 2014 showed the following levels of non-compliance by outcome over 292 locations Outcome Number Outcome Name Number of Locations 01 Respecting and involving people who use services Consent to care and treatment Care and welfare of people who use services Meeting nutritional needs 8 06 Cooperating with other providers 1 07 Safeguarding people who use services from abuse 9 08 Cleanliness and infection control Management of medicines Safety and suitability of premises Safety, availability and suitability of equipment 2 12 Requirements relating to workers 9 13 Staffing Supporting workers Statement of purpose 1 16 Assessing and monitoring the quality of service provision Complaints 5 20 Notification of other incidents 5 21 Records Care and Support Bill In summary, the Bill: modernises over 60 years of care and support law into a single, clear statute, which is built around people s needs and what they want to achieve in their lives; clarifies entitlements to care and support to give people a better understanding of what is on offer, help them plan for the future and ensure they know where to go for help when they need it; provides new guarantees and reassurance to people needing care, to support them to move between areas or to manage if their provider fails, without the fear that they will go without the care they need. 5. Strategic review of care homes in Nottinghamshire and Nottingham City In early 2013 the Chief Executive of the former Nottingham City and Nottinghamshire County Primary Care Trust and the Directors of Adult Social Care for Nottinghamshire County and Nottingham City Councils commissioned a strategic review of the care home sector in Nottinghamshire. This is laid out in a separate paper. 6. The Community Programme

5 The Community Programme was launched in July 2011 by Nottingham University Hospitals to identify issues between primary and secondary care to improve the patient, carer and clinical experience. It has 4 project areas, comprehensive assessment for frail older people, care homes bundle, information bundle and risk stratification. The care homes bundle includes 2 elements, Leadership development framework for care home managers and clinical quality framework for care home frontline staff. The purpose of these interventions is to provide support to the care home sector in order to help remove variation in the quality of care delivered in care homes, up skilling staff and providing care home staff with the confidence and capability to manage residents in the most appropriate way, location and environment. It aims to: Support care home managers to lead with confidence Empower care home frontline staff to embrace best practice and make effective changes within the workplace Build relationships across sectors and enhance partnership working Improve the lives of older people living in care homes Reduce avoidable admissions into hospital through improved clinical practice and effective preventative care in care homes Share best practice and benchmark clinical effectiveness of each care home Reduce the unwarranted variation in the quality of care home provision Create support networks and a learning community amongst care home managers and staff Key Achievements My Home Life awarded contract to deliver a leadership development programme for care home managers following formal procurement process My Home Life Nottinghamshire Launch event complete with care home managers, commissioners, clinicians and practitioners all in one room discussing topical issues and challenges. Significant progress in developing strong relationships with care home managers in Nottinghamshire The creation of a Facebook page with integrated discussion forum in response to the need for care home managers to have a trusted network to help facilitate a local learning community. My Home Life is a UK-wide movement for quality of life in care homes. It aims to support the sector, celebrate positive practice and communicate the vital role that care homes play for our frailest citizens. They have developed a bespoke Leadership Support and Community Development Programme for care home managers to help them take forward change in their care homes. Outcomes reported by managers already on the programme: Increased resilience, less at risk of burn -out Advancement of skills and strategies to drive forward transformational change A calmer more relational environment to live and work Reduced staff turnover and sickness Care homes driving forward their own quality agenda Improved relationships with external agencies Progress report from the South CCGs Quality and Patient Safety Team (Dec 2012-Feb 2014) 1.)South Nottinghamshire Care homes sub group was formed in December 2012, following experiences in dealing with a care home closure and the recognition that CCGs need to have a more proactive role in this process. The care homes sub group is a sub group of the Quality and Risk

6 committee and reports directly to them. It meets quarterly and includes representatives from all local health and social care providers and CQC and its key functions are to: Act as a central information sharing point for concerns about the quality of care identified by stakeholders, areas of good practice and review of audits of quality of care Develop systems, processes and working relationships to ensure quality monitoring is robust and consistent Review, monitor and report on quality of care as received from provider organisations Monitor action plans, review progress on key actions and identify any on-going concerns Report decisions on any action to be taken in relation to the monitoring of the quality of care provided to residents of care home placements Escalate concerns about processes and resources related to monitoring quality in care homes Approve monitoring processes and ensure compliance Make recommendations to the Quality and Risk Committee regarding the monitoring processes and requirements 2.) Healthcare professionals feedback form this was developed early 2013 in response to GP requests for guidance on what triggers they should be looking for when visiting a care home, which may indicate that a home is experiencing difficulties. This was introduced across all 3 CCGs via their clinical cabinets / forums as a tool for practice staff to inform the team of any care homes that may be causing concern but also to celebrate examples of good practice. A dedicated account was also set up to receive this information. 3.) Additional resource - During 2013 funding was secured for an additional post of Quality Monitoring Facilitator, to support the increasing demands on the existing team in addressing concerns of poor quality care in care homes across the 3 south CCGs. 4.) Database of activity and information about Care Homes - A Database of all care homes in the 3 south CCGs has been developed which logs activity, key stakeholders, funded placement and status of Care Homes which will provide a comprehensive timely information resource for the team and colleagues 5.) Audit and Quality Assurance visits Existing audit program - The Adult Safeguarding Lead and Quality Monitoring Facilitator undertake quality audits in nursing homes where: There is a concern raised either via CQC compliance, local intelligence, media interest, safeguarding referral or local authority assessment reveals poor quality Care homes for older people banded as either 1 or 2 through the annual LA quality monitoring framework (care homes are banded 1 to 5, 5 being the highest level) Any care home known to be in administration or has undergone a change of ownership in the last 6 months In those homes that are on the AQP list for Continuing Healthcare Funding and who currently have funded residents in place In residential homes, where there are no health funded residents, but there are areas of concern, then the Adult Safeguarding Lead may be invited to do joint visits and audits where appropriate with the Local Authority Quality Development Officers The standard of care is monitored through an annual audit programme and responsive quality monitoring visits. Intelligence is also gathered via a monthly information sharing meeting with Nottinghamshire County Council (NCC) and the Care Quality Commission (CQC). Development of joint audit process with LA - As part of the Strategic Review of Care Homes in Nottingham and Nottinghamshire, it was identified that audit and quality assurance process could be

7 more streamlined and thus reduce any overlap and perceived burden of inspection visits by providers. To this end, the audit tool used by the Local Authority is being reviewed to not only provide a view about the lived experiences of residents but will also include elements of health care. This tool was developed in conjunction with representation from healthcare professionals on the South CCG Care Home sub group and will be used in 2014, although the practicalities of implementation have still to be agreed between the local authority and CCGs but partnership working will be key in ensuring the success of this new process. 6.) Proactive monitoring Whilst monitoring is in place which is planned or reactive due to concerns, exploration of proactive tools which can be used to predict issues, (eg, falls, staff turnover, pressure ulcers, hospital admissions) should enhance triangulation of data about Care Homes. A Quality dashboard and Barometer have been developed, based on information from existing tools used in other areas. The Barometer tool is about to be piloted in 3 care homes during March Feedback from these care homes will lead to refinement and roll out of the tool in April It is recognised that the information in proactive tools will only be as good as the information it is possible to obtain at present there are limited systems in place to collect this data from Care Homes. 7.) Quality assurance toolkit - To complement the previously described audit process and the ongoing work regarding the Quality Dashboard and Barometer, within the CCGs there will be a suite of tools to support and guide quality assurance visits to care homes. These will include; The Hull University Indicators of Concern for Learning Disability Homes The Hull University Indicators of Concern for Nursing Homes An adapted version of the 15 Steps Challenge, currently being developed for the care home environment. The team are constantly looking at evidence based tools and processes which can be used or adapted to improve our quality assurance processes within the care home sector and our vision is that this toolkit will continue to grow over the coming years. 8.) Partnership working Operational links with local authority are essential to ensure effective communication and reduce duplication of visits and work streams. The Adult Safeguarding Lead and the Quality Monitoring Facilitator regularly undertake joint visits and share information with the LA Quality Development Officers. At a more strategic level, the Quality and Patient Safety team are involved in policy and process development with the LA and are included in strategic meetings to guide future service developments. Information sharing meetings and maintenance of a risk register take place monthly. Representatives from Nottinghamshire County Council, CQC, Bassetlaw CCG, Newark & Sherwood CCG and the Quality & Patient Safety team for the 3 South CCGs attend these meetings to share information on homes of concern. This information, where relevant, is shared across the CCG via the Quality Report (care homes of concern section) at each Governing Body and via the quarterly South CCG Care Home sub-group meeting. Communication mechanisms and reporting across the 3 CCGs continues to improve and evolve. A care homes cascade list and a template for clear concise information sharing to partner practices and CCG colleagues has been implemented. 9.) CCG Care Home initiatives

8 Nottingham North & East CCG have developed their local enhanced service (LES) with member practices, which provides clear guidance on levels of care that should be provided to care home residents. They have also commissioned intermediate care beds in a new care home development in the locality using winter pressures monies, which will be evaluated and reviewed over the coming months. Nottingham West CCG have also developed their local enhanced service (LES) with member practices. Rushcliffe CCG are developing the alignment of GP practices with care homes in the 1 practice, 1 care home initiative. This is being supported by Age UK by providing support and advocacy for care home residents and relatives. Key themes and ongoing challenges identified in relation to quality in Care Homes Staffing and training Recruitment and retention of high quality staff and managers within care homes is an ongoing challenge. This was recently highlighted by a BUPA correspondence about the shortage of good quality managers in the south east region. The role and registration of skilled knowledgeable Care Home managers are key to ensuring quality in Care Homes. There appears to be an increased reliance on e-learning training within some larger providers which may tick the box for training compliance, but does not allow discussion and debate around professional issues with peers. There is a lack of standardised accredited training for staff which is includes a balance of approaches such as taught and e-learning and is of a certain standard, which incorporates competency based assessment and action learning. Mental Capacity Assessment (MCA) and Deprivation of Liberty (DoL) There appears to be issues with Care Home staff fully understanding and consistently applying the principles and practice of MCA and Best Interest decisions. Evidence indicates that some Care Homes use MCAs inappropriately whilst others do not use it at all. Despite a major training program during which provided accredited training for care home managers and providers about MCA and Deprivation of Liberty, there continues to be variable compliance and it is clear that a lot of people who attended this training have since moved on and taken their knowledge with them. There is a need for ongoing training and updates regarding this complex legislation, but this requires a central steer on how this is achieved. Care planning Planning of care for residents remains very variable amongst Care Homes. Care Home managers often state that they get conflicting advice and opinions from health, social care and CQC staff. There is potential for support from the community program to be helpful regarding this, or for local agreement between the commissioners and regulators about what a good care plan should look like, which could be taken forward as part of the Care Homes sub-group. Quality assurance processes It appears that Care Home providers may respond to audits and inspections by providing specific action but they lack an awareness of their role in monitoring and sustaining quality in their Care Homes on an ongoing basis. The work of the Strategic review of Care Homes has promoted an approach whereby Care Homes have a strategy to monitor and sustain the quality of care in their Care Homes and this will be monitored in an agreed timeline. Learning from incidents

9 Care Home providers need to identify that there is full understanding of what is required and processes to ensure shared learning is in place, such as ensuring link nurses can function effectively to improve skills and knowledge within the homes. Care Home Escalation & closure policy Nottinghamshire County Council is leading on a joint policy for health and social care. This policy has yet to be finalised and so in the interim, local guidance for CCG staff is in place. When quality issues are identified, the care home is required to develop an improvement action plan and progress against this is monitored. If the standard of care is found to impact on the safety of people receiving care then the CCG will suspend the contract until the standard of care improves. This means that the CCG will not place any further people in this care home until it is established that there is safe quality care. If a provider is unable to demonstrate that safe care will be maintained in the longer term then termination of the contract is considered. This means that the CCG will not place any further people in this care home and remove the home from the AQP contract list. Residents and families are informed of the CCG decisions to terminate the contract and offer the option to relocate to another care home. Support to move to alternative care homes is provided should residents and /or their families choose to move. Residents who wish to remain at a home where the contract has been terminated will continue to receive CCG support for care costs through a spot purchase contract as long as the care home remains open. To date the role of CCG staff in care home closures has varied depending on the type of home (nursing or residential) and the level of involvement through quality monitoring processes. The Care Home Escalation & Closure policy will provide clear guidance on roles and responsibilities, timeframes and levels of involvement. Partnership working is essential to ensure that health and social welfare of residents is paramount throughout this process, and communication with key stakeholders and healthcare professionals is crucial. Infection control Within Nottinghamshire we have a small team of Infection Prevention & Control leads who are now hosted by the Local Authority (Public Health England) who will undertake infection control audits in care homes. Due to recent staffing pressures this has been reactive to concerns rather than proactive as in the past. In light of the significant number (22) of care homes who in their most recent inspections have been non compliant in this area, this would suggest that investment in this service to increase capacity and identify escalating issues before they become a concern would be beneficial. Medicines management team and CCG pharmacists A finite resource within the CCGs but who have a significant role to play in the monitoring and support of care homes in medication practice. The County wide medicines management team have noted significant variation, and in some cases very poor policies and guidance for care home. Staff, and are consequently working on template policies for care homes. There has been some useful work done by CCG pharmacists in supporting prescribing in care homes, but this has been sporadic in some areas and could be implemented more widely to support practices and care homes. NHS Continuing Healthcare Management of the Continuing Healthcare budget for Nottinghamshire is hosted by Rushcliffe CCG. The Continuing Healthcare team are hosted by the Greater East Midlands commissioning support unit (GEM) and includes a team of nurse assessors and reviewing nurses who undertake health needs assessments to assess for eligibility for NHS Continuing Healthcare funding. This team will also

10 complete Safe & Well checks for health funded residents in a care home of concern if this is required. Care homes have in the past been invited to submit tenders for the Any Qualified Provider contract (AQP) and those homes that were successful are now utilised to provide fully funded care for those patients assessed as having a primary health need. There were a number of AQP batches and as such the NHS standard contracts are not current. Contracts require transfer to the new NHS 14/15 contract. In addition a number of homes not currently on the AQP list have approached the CCG requesting an application process. Having the Continuing Healthcare team in a separate organisation has proved challenging when trying to ensure effective communication. As a consequence a relationship manager has been transferred back from GEM to the CCG. However resources remain scarce. GEM have requested a CCG nurse representative for the retrospective funding reviews. The south Nottinghamshire CCGs currently do not have this resource available. Contract management is not resourced within GEM and therefore CCGs are not getting regular information against defined quality metrics. This remains a significant risk and therefore monitoring quality proactively more challenging. A quality schedule for the Continuing Healthcare contract has been drafted led by Derbyshire CCG and adopted across Nottinghamshire. An attempt has been made to introduce a CQUIN for care homes across the region, however, there has been disagreement about its application and there is currently no administrative capacity or funding within GEM to be able to effectively administer this process. As a result for those care homes on the 14/15 contract they will receive CQUIN monies without the requirement to achieve a CQUIN. Risks and Opportunities The care home market is complex and varied, with a wide variety of providers who have their own ideas about care delivery and quality. In working together with providers, commissioners and regulators we aim to provide a comprehensive and consistent framework for monitoring quality. However some challenges and risks remain, regardless of the work already taking place: The lack of resources within the CCG to proactively monitor Care Homes and deliver full quality assurance The separation from the CCG of the contract management to GEM The lack of contract management The current system of allocation of commissioning responsibilities means as a CCG we are responsible for care homes outside of our geographical area The lack of ongoing AQP process means some care homes are outside of the contracting process The growing number of care homes unable to meet the quality standards CCG quality team cannot continue to provide support to failing care homes The opportunities from the multi-agency working and previous year s work are outlined as: Increasing partnership working with the CQC and LA New CQC inspection regime will lead to in-depth inspections Strategic working group have signalled future direction and are driving the market CCGs have responded to challenges by creating a tiered audit and proactive response to monitoring quality

11 Greater intelligence is being shared across the health and social care community Increased awareness of Care Home providers about commissioner expectations of quality Summary Within the last 2 years the CCGs have recognised the increasing challenges to quality in care homes and have set out a comprehensive framework for quality. A number of initiatives have been put in place to support the improvement and monitoring of quality. A greater sharing of information between agencies and organisations has resulted in a greater level of intelligence. Improved partnership working has led to joint working and the delivery of key objectives. There remains, however, significant risks. There are still a number of homes within south Nottinghamshire that do not deliver consistent high quality care and use a great deal of CCG resources. The strategic working group have set out the future direction of travel and are committed to working together to improve the quality of care for all our residents.