Directorate of Adult, Community & Housing Services Dudley MBC

Transcription

1 Directorate of Adult, Community & Housing Services Dudley MBC Report to the Director of Adult, Community & Housing Services in respect of the work associated with the Think Tank on Sustainability of Personalisation, Quality & Safety in Care Homes 1. Purpose of Report 1.1 To appraise the Director on the outcome of Think Tank deliberations in respect of Personalisation, Quality and Safety in Care Homes, sustainability and associated costs 2. Background 2.1 Following a Directorate event with Care Home Proprietors and Managers in June 2011 the Director requested that work associated with the sustainable provision of a personalised approach to care, its quality and safety be undertaken by the Head of Service, Commissioning. Agreed Terms of Reference are presented in Appendix I It should be noted that the Think Tank was not a negotiating body. It presented the opportunity to scope aspects contained within the Terms of Reference and to make recommendations to the Director for consideration with the Lead Member and Assistant Directors 2.2 The Think Tank met on five separate occasions between July and September 2011 and the content of this report has been read by its membership prior to submission to the Director 2.3 In terms of sizing of the Independent Care Home Sector in the Borough details are presented in Appendix II 2.4 The current fee schedule is presented in Appendix III There is concern from WMCA that Dudley MBC prices amount to a discounted rate that would indicate cross-subsidisation from self funding residents 2.5 There has been considerable focus on the personalisation of care over past years culminating in the publication of the Concordat Putting People First 1 1 HM Government. Putting People First (December 2007) Page 1 of 40

2 2.5.1 Across Government, the shared ambition is to put people first through a radical reform of public services, enabling people to live their own lives as they wish, confident that services are of high quality, are safe and promote their own individual needs for independence, well-being and dignity This ministerial concordat establishes the collaboration between central and local government, the sector's professional leadership, providers and the regulator. It sets out the shared aims and values which will guide the transformation of adult social care, and recognises that the sector will work across agendas with users and carers to transform people s experience of local support and services The concordat also recognised the importance of people having the best possible quality of life, irrespective of illness or disability and to retain maximum dignity and respect this would include care homes 2.6 Contractual (The Agreement) arrangements with Independent Sector Care Homes, in the main, are on a spot basis with no agreement on the level of placements. The exceptions to this are for a respite care home and use of a Care Funding Calculator in Learning Disabilities The Care Funding Calculator function is to: - Assess in detail the level of staff support required to meet an individual s needs Agree a price based on relevant market knowledge, which is appropriate to the needs of the person Confirm agreed objectives for the service user and report on progress The price paid includes all expenses and costs required to comply with The Agreement and identifies The price shall be reviewed annually by reference to the prevailing headline rate of inflation, with affect from April each year as notified by the Council to the Provider, or such increase or decrease as shall be agreed by parties The price uplift over the past fourteen years has averaged at 3.48% per year. Detail of this is presented in Appendix IV with a comparison to the prevailing Retail Price and Consumer Price Indices 3 Think Tank Approach 3.1 The agreed Terms of Reference are presented in Appendix I 3.2 The initial meeting looked to scope issues on the sustainability of care homes in addressing personalisation, quality and safety Page 2 of 40

3 3.3 WMCA considered that there was an inextricable link to the price paid for care and its quality and that given increasing inflation there had been a 7% - 10% increase in pay, utilities and food costs 3.4 Whilst reference was made to the prevailing rate of inflation dropping 2 it was noted that this was largely due to recreation and leisure costs that had little or no impact on care home costs The fall in the Retail Price Index in June 2011 was not in relation to fuel and food costs It was noted that WMCA was working nationally to development benchmarking by client group in respect of price Note was made of past collaborative work between the Directorate and WMCA in developing the locally agreed Mental Health Premium Payment. See Appendix V 3.5 It is contended by WMCA that a price uplift of at least 6.4% was required to stand still without any further consideration of enhanced personalisation, quality and safety Standards in relation to the delivery of care are addressed in two documents being the Care Quality Commission Essential Standards of Quality & Safety 3 and the Dudley MBC Agreement for Care Homes. Adherence to both were noted as a requirement of all care homes 3.6 For some care homes there had been no cost / quality recognition (see Appendix III) of improvement in CQC Regulatory Standards post- October 2010 when the use of the quality rating system ceased on the introduction of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010, and the Care Quality Commission (Registration) Regulations Deliberations continue within CQC on a possible replacement approach. Current speculation is that the changes may involve the following: - Pre-October 2010 Possible change 4 Excellent High confidence Good Minor concerns Adequate Moderate concerns Poor Major concerns Current guidance 5 for CQC Inspectors explains where the bar is set when monitoring compliance of registered health and adult social care 2 Financial Times, 13/07/11 3 CQC, Essential Standards of Quality & Safety (March 2010) 4 CQC, Judgement framework (March 2010) Page 3 of 40

4 services in other words, the difference between complying and failing to comply with the essential standards and how this helps to determine what our regulatory response should be. 3.7 The inter-relationship between care home resident occupancy and the price of care was recognised. Given the finite budget associated with care home placements the higher the price the less resident referrals would occur This would impact on economies of scale The prevailing occupancy rates were acknowledged as : - Resident Group % Occupancy Older People - Residential 94.7% Older People - Nursing of which: - Nursing = 95% Residential = 96% Learning Disabilities Care 92% Homes Mental Health c100% Physical Disability c100% The number of people over the age of 65 years supported by Dudley MBC in care homes: - Year Supported Residents * * Abolition of Preserved Rights to Income Support It was noted that future capacity requirement was contained within the Care Home Commissioning Strategy. The Strategy would be impacted upon by pending Dudley MBC and Independent Sector home closures (the latter being of a voluntary nature to date) in changing the local landscape 5 CQC, Setting the bar: Monitoring of compliance (September 2010) Page 4 of 40

5 3.9.4 The current building of a new care home in Pensnett and the continued development of Extra Care Housing would also need to be taken into consideration A specific requirement for dementia places in both residential and nursing homes was further noted and that growth would be required to provide at least 16 to 20 places per 1,000 population over 65 years from the current places per 1,000 population over An increase in dependency levels, particularly in residential care homes, was put forward by WMCA. Increasing dependency levels were considered to require additional care and support staff The average length of stay in respective care homes was noted as: - Independent Sector Residential c2.5 years 6 Independent Sector Nursing c18 to 20 months Local Authority Residential (general) c3 years WMCA identified that some homes in the Independent Sector target the more able residents and that progression between homes due to increasing dependency The request for a Physical Health Dependency Premium Payment of a few years ago was noted however the CQC requirement for staffing to be commensurate with residents needs was acknowledged. People being maintained at home for longer and compression of morbidity 8 may be contributing factors. Compression of morbidity is in respect of a hypothesis that the burden of lifetime illness may be compressed into a shorter period before the time of death The incidence of death within care homes amounts to a national figure of 100,000 per year 9, this will place an additional burden on resources particularly in aspects of training, staff retention and bereavement support 6 DACHS, Dudley MBC Management Information Team 7 Ibid 8 James Fries, Stanford University School of Medicine (1998) 9 The Centre for Death and Society, University of Bath (2008) Page 5 of 40

6 4. Progression of the Think Tank 4.1 Throughout the Think Tank meetings reference was made to the Directorates requirement for additionality in relation to cost, quality and the potential for a price increase. Any price increase should be within the envelope of resources available This requirement was considered by WMCA to be unattainable from the present state of costs currently incurred particularly in relation to the Consumer Price and Retail Price Indices: WMCA identified that those proprietors / operators that were mortgage holders, based on a mortgage taken up in2006 on a 10-year basis accrued interest at 6.25% 4.3 Running cost increases of food were quoted as increasing 6.9% yearon-year with transport at 7.9% A basket of indicators based on a 42-bedded care home was presented by WMCA in terms of % turnover: - Commodity % Turnover Wages 56% Food 6.75% Utilities 4% Maintenance 5% Insurances 0.4% Page 6 of 40

7 4.3.2 Again, on the basis of a 42-bedded home, the increase in the National Minimum Wage (01/10/11) would add an additional wage cost of 18,800 per year recurring 4.4 It was noted that Independent Sector Care Homes in Dudley presented with a small, average size of 23 beds, with single owner structure and that they were potentially more financially pressured than larger homes or group ownership of homes 4.5 Investigation was made into supporting costs within care homes in respect of energy given the rise in both gas and electricity tariffs. The possibility of collaborating with the Eastern Shires Purchasing Organisation (EHPO), through which Dudley MBC procures gas and electricity, was considered. The outcome of this was that: - If an operator is a private limited company where the local authority commissions services on behalf of the authority but the company operates on a profit making basis then it is likely that they would fall outside the scope of the Local Authorities Good and Services Act which set out the limitations of who ESPO can act on behalf of and as a result would probably be unlikely to be able to use the contracts However if the operator is a Housing Association (and probably also a registered charity) or regarded as a 'social landlord' operating as not for profit then combined with the 'well being' provisions of EU Directives and UK Law these operators could probably (subject to a look in depth at their legal status) be able to use the energy contracts. 4.6 Another issue addressed was that of the invoicing of monthly placements costs by care homes incurred through by Dudley MBC. It is practice to raise an order against a placement and then to request monthly invoices. It is suggested that a no-order invoice approach be adopted relying on a cessation notice of placement to trigger no further payment. The administrative burden to both care homes and the Directorate would be reduced. It is understood that such an approach has been adopted in other local authorities and is now in development within the Directorate 4.7 It was noted that costs are incurred by care homes when inadequate notice of cessation of placement is made, this particularly arises when a resident is admitted to hospital and further assessment requires alternative care provision The Agreement states: - Paragraph 11: Ending Individual Placements 11.1 Without prejudice to any other rights of the Council contained in this Agreement but subject to Clause 11.2, where the Council Page 7 of 40

8 places a Client in the home of the Provider, the Council shall give the Provider at least seven days prior written notice to terminate the provision of the Service in respect of that Client After the first four weeks of a placement, unless there is agreement between the Council and the Provider that the placement is being extended on a temporary basis for a specified period, the Council shall give at least four weeks prior written notice to terminate the Service It was identified by WMCA that this agreement is not adhered to and that the room has been reserved pending return of the resident. This forces a void on the care home with resultant loss of income 4.8 An area of contention was that of residents pensions increases not being pass ported to care home prices. WMCA presented evidence of pension increases: - Year Pension Increase % Increase 2011/ % 2010/ % 2009/ % 2008/ % 2007/ % 2006/ % 2005/ % 2004/ % 2003/ % 2002/ % 2001/ % 2000/ It was noted that national statutory charging rules indicate what income and benefits can be taken into account when assessing a residents contribution towards their care. Most social security benefits, with the exception of Disability Living Allowance (Mobility) are taken into account. Residents must also retain a set weekly allowance out of their total income (benefits and any private pensions). This is currently per week (Personal Entitlement Allowance) Representation on behalf of WMCA was made to Directorate Accountancy with the following response: - As part of the budget setting process the council sets an inflation rate for fees and charges each year. Given that clients in residential and nursing homes receive a financial assessment the only way in which this income target can be reached is through the increase in benefits. If we transferred this sum to the care homes we would have a deficit on our income targets; Page 8 of 40

9 The Directorate had pressures and savings of 10m to find from last years budget settlement. Resources in the independent residential and nursing sector have been relatively protected in that process. Last year 2% inflation was built into Directorate budgets for external residential and nursing care this was used to contribute to the overall savings target for the Directorate. In % terms this was a lot lower cut than in other areas of the budget; The Directorate has received little or no resources to meet demographic pressures; Very few clients pay the full cost of their care and some of the benefits received are paid out in personal allowance On behalf of the Directorate it was stated that there are many interpretations of this and that it was not just a Dudley issue 5. Culture, Practice and Resident Experience Improving Quality and Proving 5.1 Desired outcomes in Adult Social Care, irrespective of location, are: - Outcomes Enhancing quality of life for people with care and support needs Delaying and reducing the need for care and support Ensuring that people have a positive experience of care and support Safeguarding adults whose circumstances make them vulnerable and protecting from avoidable harm 5.2 Additionally in Learning Disabilities outcomes of the Valuing People Now Delivery Plan 10 focuses on achievement of good health, housing and employment 5.3 The Audit Commission report 11 identified the inter-relationship between the following in relation to the best possible outcomes for people with resources available: - Economy Efficiency Effectiveness Cost Inputs Outputs Outcomes 10 HM Government, Valuing People Now Delivery Plan (2010) 11 Audit Commission, Value for Money in Adult Social Care (July 2011) Page 9 of 40

10 5.4 Given the absence of a price increase over two financial years WMCA stated that enhancement in Personalisation, quality and safety was not attainable within the current fee level 5.5 The CQC document Essential Standards of Quality & Safety and The Agreement with Dudley MBC sets out requirements to be met. Regular monitoring by the Directorate assesses core requirement of the contract and, albeit irregular, inspections by CQC the level of compliance with regulatory requirements 5.6 It was noted that despite years of regulatory standards many care homes nationally (17% - 25%) still fail to meet good / excellent outcomes for residents A local example of this was provided by reference to the last CQC Local Area Market Analysis (LAMA) presented in Appendix VI 5.7 It was identified that an unprecedented number of safeguarding issues had occurred within the Borough with at least one care home contract being terminated as a consequence 5.8 Aspects of staff recruitment and retention were discussed and noted that at this time recruitment was not problematic and that retention was improving. It was questioned if this was as a consequence of local and national economic conditions. Further noted that when leaving occurs this is often to pursue a job in the NHS Analysis of absence data 12 identified a variance between local authority care homes and the Independent Sector sickness rates: - Local Authority Average 17.9 days per annum Independent Sector Average 4.9 days per annum Considered that this may be in relation to Independent Sector paying Statutory Sick Pay after the first 3 days of absence 5.9 The relationship between training and the quality of care was addressed. Mandatory training, being subject to The Agreement, was identified as being: - Manual Handling Fire Infection Control Food Hygiene First Aid Safeguarding 12 Skills For Care, Absence Data (2011) Page 10 of 40

11 5.6.1 Whilst training on these areas was free-of-charge from the Directorate the cost of back-fill for staff attending was recognised The additional value of Dementia Awareness and Deprivation of Liberty training was agreed Noted that some areas of training were not given a high priority such as Diabetes, Bereavement and Customer Care due to financial limitations It was however important to further note that staff training and staffing levels need to be commensurate with residents needs 5.7 In relation to staffing levels discussion focused on no regulatory guidance apart from that in (5.6.4) above Monitoring of staffing levels in some care homes identified an incremental reduction throughout the day into night-time often on the ratio of Morning 1:5 am; 1:7 pm; 1:9 at night. It was questioned how this would allow for enhanced personalisation of care. It was agreed that throwing money at poorly organised homes was not a solution and that roster audits were an important aspect in enhancing quality and that good leadership in care homes could not be over estimated 5.8 Completion of CQC Provider Assessment Assessments (PCAs) were identified as a tool to focus on outcomes for the 16 essential standards that most directly relate to the quality and safety of care (See Appendix VII) This tool focuses on outcomes for the 16 essential standards that most directly relate to the quality and safety of care It was suggested that in evidencing practice a focus on PCAs may be used as an aid to quality improvement and to monitoring. Historically some homes had adopted this approach during the time of the National Care Standards Commission with the 38 Standards, pre-cqc (See Appendix VII) 5.9 Approaches to evidencing quality and payment of a quality premium were discussed. A number of local authorities had addressed this however the bureaucratic burden and additional staffing levels required were perceived as unaffordable 5.10 Currently within the Directorate, in collaboration with selected care homes, NHS Dudley and Local Involvement Networks (LINks) a proactive approach to have a common understanding of the status of a home and any current quality issues identified Page 11 of 40

12 Whilst monitoring the care delivered for individuals is important, this approach does not reliably facilitate the recognition of systemic or process failures NHS Dudley and Dudley MBC anticipate they would be better able to support a home with quality issues to improve if they are aware of problems early 5.11 A data set to enable assessment of quality has been developed and agreed by all parties involved. It is recognised that the data set is likely to evolve as regular submission and analysis of the data identifies that which is most valuable and that which is less so. The data set spans the dimensions of quality including safety, effectiveness, experience and workforce (See Appendix IX) 5.12 A positive culture within care homes is prerequisite to quality and safety. To promote a positive culture the use of a Value Base was considered to which all staff would be required to adhere whilst personalising care planning (See Appendix X) This approach had been used in the NHS as a checklist when care planning to ensure adherence and was not dissimilar to the Values, Treats people as Individuals, Perspective of service user, Supportive social psychology 13 Mike Marshall Head of Commissioning Directorate of Adult, Community & Housing Services Dudley MBC Tel Mike.Marshall@dudley.gov.uk 13 Dawn Brooker, University of Worcester (2010) Page 12 of 40

13 Directorate of Adult, Community & Housing Services & West Midlands Care Association (Dudley Forum) Terms of Reference for the Care Homes Think Tank (Approved 14/07/11) As part of the process the think tank will consider and report on: Quality of Care Personalisation Safety Barriers to attainment (of the above) Sustainability and Cost Purpose: The aims of the think tank are to: Assess challenges presented in the sustainability of quality, personalisation and safety within care homes Identify the barriers to achievement Produce a range of potential solutions APPENDIX I Terms of Reference: The think tank will review the current contractual and policy framework: The level of quality required as a consequence of Dudley MBC contractual requirements The impact of the Care Quality Commission s essential standards of quality & safety Occupancy levels within the Independent Sector Care Homes Current and future local authority and Independent Sector Care Home capacity The essentials for sustainability quality, price Further, the think tank will: Consider the implications for policy and practice of providers, commissioners, regulators and the Council Page 13 of 40

14 Establish facts about the current state of Independent Sector Care Homes within the Dudley Borough such as: - o dependency levels o recruitment factors within the local employment market o general workforce issues including training and retention o identification of best practice locally, regionally and nationally o cost pressures within and outside of the Sector The think tank will be informed by local, regional and national research and evidence including such aspects as PSSRU Adult Social Care Outcome Tool (ASCOT) and Lang & Buisson publications Membership: Timescale: Mike Marshall, DMBC Daniel Johnson, WMCA Debbie Le Quesne, WMCA Mike Higginson, Select Healthcare Steve Moore, DMBC John Povey, DMBC It was agreed that others may be co-opted or requested to attend ad hoc meetings The approach the think tank will adopt is that of task and finish being time limited to keep focused and reduces the burden on members. At the end of its lifespan will report findings to the Lead Member, the Director and Adult Social Care Assistant Directors. Agreed to complete the initial report by the end of September 2011 Output: The think tank will produce an initial report including a range of recommendations. Page 14 of 40

15 APPENDIX II Dudley Independent Care Homes Older People Nursing No. of Homes Capacity Younger People Nursing No. of Homes Capacity 2 37 Older People Residential No. of Homes Capacity Younger People Residential No. of Homes Capacity 2 37 Learning Disabilities No. of Homes Capacity Mental Health No. of Homes Capacity 3 61 Totals No. of Homes Capacity Page 15 of 40

16 APPENDIX III FEE SCHEDULE CARE HOMES PROVIDING NURSING CARE MADXIMUM COUNCIL PAYMENTS FROM 1 ST APRIL 2011 Effective from 1 st October 2008 fees paid for homes within Dudley Metropolitan Borough will be based on a structure that reflects individual homes achievement of CQC quality ratings. Weekly fees applied to each quality rating are shown below. There has been no fee uplift for 2011/2012 Poor ( 0 Stars ) 467 Adequate ( 1 Star ) 474 Good ( 2 Stars ) 487 Excellent ( 3 Stars ) 494 All fee tiers are subject to a reduction of 5.00 for shared accommodation. Respite Care The Council will pay 5% in addition to the rates quoted above for spot purchased respite care. Page 16 of 40

17 FEE SCHEDULE CARE HOMES MAXIMUM COUNCIL PAYMENTS FROM 1 ST APRIL 2011 (excluding care homes for people with a learning disability) Effective from 1st October 2008 fees paid for homes within Dudley Metropolitan Borough will be based on a structure that reflects individual homes achievement of CQC quality ratings. Weekly fees applied to each quality rating are shown below. There has been no fee uplift for 2011/2012 Client Group Poor (0 Stars) Adequate (1 Star) Good (2 Stars) Excellent (3 Stars) Older People Older People with a Functional or Organic Mental Illness or People below pensionable age with an Organic Mental Illness People with a mental illness / alcohol / drug dependency People with a disability under pensionable age * 393 * 397 * 405 * Note 1: Note 2: All prices in Bands B, C and D are subject to a reduction of 5.00 for shared accommodation The mental health premium payment (subject to individual resident assessment) included in these fees shall be 32 per resident per week during 2011 / 2012 Respite Care Page 17 of 40

18 The Council will pay 5% in addition to the rates quoted above for spot purchased respite care APPENDIX IV Independent Care Home Price Uplifts Comparison to Retail Price Index and consumer Price Index Year Price Uplift RPI at April CPI at April 2011 / % 5.2% 4.0% 2010 / % 5.3% 3.7% 2009 / % -1.2% 2.3% 2008 / % 4.2% 3.0% 2007 / % 4.5% 2.8% 2006 / % 2.6% 2.0% 2005 / %* 3.2% 1.9% 2004 / % 2.5% 1.2% 2003 / %** 3.1% 1.5% 2002 / % 2.9% annual rate 1.3% annual rate 2001 / % 1.6% annual rate 1.2% annual rate 2000 / % 2.9% annual rate 0.8% annual rate 1999 / % 1.6% annual rate 1.3% annual rate 1998 / % 3.4% annual rate 1.6% annual rate * Residential uplift 4.6% Nursing uplift 5.3% ** + One-off payment of 2,000 to each care home or 500 if > than 4 places (in respect of introduction of Commission for Social Care Inspection regulatory requirements The main differences between the CPI and RPI relate to: population base the RPI excludes very high and low income households and hence the CPI has a wider population coverage than the RPI commodity coverage - the CPI excludes owner occupiers housing costs and hence the RPI has wider commodity coverage than the CPI formulae used to combine prices at the first stage of aggregation - the CPI uses a combination of geometric means and arithmetic means, whereas the RPI only uses arithmetic means Page 18 of 40

19 APPENDIX V NUMBER & TITLE SOURCE STATUS DATE No. Premium Payment for Mental Health needs ASIG Current 25/03/2011 Contents Page No Section 1 Eligibility 2 CQC Registration Fees Implementation 3 Recording ESCR 4 Appendix 1 Dependency Profile Form 6 Appendix 2 Mental Health Premiums 7 Revision and Review History Procedure This Procedural Decision covers the instructions for field workers when considering premium payments relating to older people with mental health needs who are placed and need to be maintained in Residential Care placements, or are to be admitted to a Residential placement with premium payment. N.B This applies to people with Residential Care needs only within Care Homes inside the Dudley Borough boundaries. Eligibility A premium payment is applicable if the person has: A medical diagnosis of dementia OR Page 19 of 40

20 A medical diagnosis of a functional illness (AND over 65 years of age) AND Persistent behaviour over a period of time which requires enhanced care as indicated by the Mental Health Premium Dependency Profile score And the circumstances are: This would prevent or delay a move to a Nursing Home The assessed need is considered to be over and above that normally addressed within a Residential care home The Residential care home has demonstrated that staff have the skills to ensure interaction and engagement AND the management of challenging behaviour The home holds the appropriate registration status with the Care Quality Commission ( CQC Registration The Home should display their CQC Registration Certificate, which shows the number of places registered for each of the following: MD(E) over 65 years, functional, mental illness DE under 65 years, dementia DE(E) over 65 years, dementia Registrations Certificates should be displayed in a prominent place in the Home. Care Home inspection reports can be viewed by accessing the CQC website. Fees Fee Levels for enhanced payment according to the Four-tier fee structure are included on the fee schedule for Residential homes. If it is a Respite placement that qualifies for enhanced payment, the fee must be calculated by taking the standard fee for the given Care Home and adding the usual 5% payable for Respite, then adding the value of the premium payment. Implementation All Homes will use the agreed assessment form and Dependency Profile (appendix1) Page 20 of 40

21 Qualified Social Workers must complete the Assessment and form, together with the Home Proprietor/ Manager or other suitably qualified person prior to admitting Service Users to the Home or agreeing premium payment for an existing resident, approved for dementia or other mental illness. Residents with a score in excess of 27 would qualify for premium payments Residents with a score between 27 and 39 would be best cared for in a residential setting Residents with a score above 39 would ideally be best cared for in a specialised nursing home The Resident should be reviewed within the first 6 weeks and thereafter annually. Should a Resident deteriorate before the next Review (this would be shown by the dependency profile), the Manager should call an earlier Review with the Social Workers and the Resident s family. Further advice on implementation may be obtained form Adult Services Commissioning unit. Recording Use MAF 1 to record new Assessment, Support Plan for the Review and attach the completed Mental Health Dependency profile sheet. For new placements, complete the Panel Report (Within the MAF1), MHP form (Appendix 2) and MHP Dependency profile sheet and submit to Team Manager for sign off. Send the Panel Report in the usual way and fax MHP form and MH Dependency profile sheet to the Business Support Officer Panel on Any disregards need to be decided at this stage and not to be determined by Finance. For existing Placements that are to be upgraded, there is no need to submit to a Panel Report. Complete the MHP form and submit to the Team Manager for signature then fax to the Business Support Officer Panel who will record on Swift. Panel decisions will be input by the Business Support Officer, Panel. The case will be picked up at District to be followed up with the Purchasing/Review process. Purchase Orders should reflect or be amended to reflect, the MHP fee. ESCR Documents should be indexed in accordance with the ESCR indexing instructions found in the Net-it area of the Adult Care Intranet Site. Page 21 of 40

22 DEPENDENCY PROFILE appendix 1 Name : Room : Criteria Score Care Independent Mainly 1, Low Dependency Residential Home Mainly 2,3, Medium Dependency Residential Home Mainly 3,4, High Dependency EMI Nursing Home Mainly 4, Total Dependency Specialised Unit Medical Supervision Clinical Diagnosis Drugs Speech & Communication Memory Orientation Mood Sociability Tolerance Cognitive Ability Co-operation Sleep Safety Total Score Date of Assessment Date: Page 22 of 40

23 Medical Supervision Memory Tolerance Safety Under GP management only 1 Retains 1 Within appropriate range.. 1 Wanders by day, needs guidance.. 1 Seen by psychiatrist intermittently.. 2 Slightly forgetful 2 Occasionally verbally aggressive/abusive. 2 Restless liable to fall out of chair/bed. 2 Under active treatment by 3 Forgets past events.. 3 Frequently verbally aggressive/abusive 3 Trying to walk out/nocturnal wandering. 3 psychiatrist Post hospital discharge. 4 Forgets present events. 4 Occasionally physically aggressive/abusive. 4 Risks of 4 Admission request by Mental Health Team burns/scalds 5 Cannot remember most things 5 Consistently physically aggressive. 5 Major risks fire, destruction of property.. 5 Clinical Diagnosis Orientation Cognitive Ability Confusion/disorientation/anxiety/neurosis.. 1 Complete. 1 Responds to all verbal stimuli.. 1 Mild to moderate dementia 2 Orientated in familiar surroundings. 2 Responds to direct stimuli only 2 Severe 3 Misidentifies people only.. 3 Responds only with prompting. 3 dementia/alzheimer s Confirmed psychotic illness requiring active 4 Cannot find way round.. 4 Needs physical and verbal prompting. 4 monitoring Other progressive neurological pathology.. 5 Completely lost 5 No response 5 Anxiolytic/Neuroleptic & Hypnotic Drugs Mood Co-operation None.. 1 Within appropriate range.. 1 Actively co-operative, no disruptive behaviour. 1 Occasional dose.. 2 Occasionally low or elated 2 Some mild or intermittent irritability or restlessness 2 Minimal regular dose.. 3 Regular fluctuations in mood 3 Pushing, interfering, pestering, marked over activity/ agitation. 3 Moderate regular 4 Frequent fluctuations (daily/hourly). 4 Persistent, threatening, seriously over activity. 4 dose Large regular dose.. 5 Constantly low or elated 5 Serious physical attacks, intimidation, obscene behaviour 5 Speech & Communication Sociability Sleep Fully comprehensive.. 1 Initiates and accepts social contact 1 Regular 1 pattern Occasional difficulty 2 Accepts contact only. 2 Occasionally 2 Understood by certain 3 Avoids social contact, physical & verbal 3 Irregular pattern PRN. 3 people Unable to express verbally 4 Resists all contact.. 4 Consistently disturbed am/pm reversal.. 4 Unable to express physically. 5 Totally mute and inactive.. 5 Irregular high dose sedative. 5 Page 23 of 40

24 Mental Health Premiums Appendix 2 PIN Name Residential Home Address Date admitted to Placement Name of Assessor Locality Office Date of previous Panel meeting Previous Panel decision Date of request for Mental Health Premium Date of Review for Mental Health Premium Date agreed by Team Manager Comments Signature of Team Manager Date Signature of Chair of Panel Date PLEASE INCLUDE MENTAL HEALTH PREMIUM DEPENDECY TOOL WITH THIS REQUEST AND SEND BOTH TO FAX EXT

25 Older People in Borough Care Homes (Poor / Adequate) LAMA 2009/10 Including CQC Quality Ratings APPENDIX VI CARE HOME OP10 OP12 OP13 OP14 OP15 OP16 OP18 OP19 OP26 OP27 OP28 OP29 OP3 OP30 OP31 OP33 OP35 OP38 OP6 OP7 OP8 OP9 CQC LAMA rating 4878 Adeq 4881 Adeq Adeq Adeq Adeq Adeq Poor Adeq Adeq Adeq Adeq Poor Adeq Adeq Adeq Poor Good Adeq Good Not meeting standard with major shortfalls Meeting standard Not meeting standard with minor shortfalls Exceeding standard 25

26 OLDER PEOPLE KEY NATIONAL MINIMUM STANDARDS Standard OP10 OP12 OP13 OP14 OP15 OP16 OP18 OP19 OP26 OP27 OP28 OP29 OP3 OP30 OP31 OP33 OP35 OP38 OP6 OP7 OP8 OP9 Descriptor Privacy & Dignity Social contact and activities Community contact Autonomy & Choice Meals & meal times Complaints Protection Premises Hygiene & Infection Control Staff complement Qualifications Recruitment Needs assessment Staff training Day-to-day operations Quality Assurance Service use money Safe working practices Intermediate Care Service user plan Healthcare Medication 26

27 APPENDIX VII Care Quality Commission 16 essential standards that most directly relate to the quality and safety of care Outcome 1 (Regulation 17): Respecting and involving people who use services Outcome 2 (Regulation 18): Consent to care and treatment Outcome 4 (Regulation 9): Care and welfare of people who use services Outcome 5 (Regulation 14): Meeting nutritional needs Outcome 6 (Regulation 24): Cooperating with other providers Outcome 7 (Regulation 11): Safeguarding people who use services from abuse Outcome 8 (Regulation 12): Cleanliness and infection control Outcome 9 (Regulation 13): Management of medicines Outcome 10 (Regulation 15): Safety and suitability of premises Outcome 11 (Regulation 16): Safety, availability and suitability of equipment Outcome 12 (Regulation 21): Requirements relating to workers Outcome 13 (Regulation 22): Staffing Outcome 14 (Regulation 23): Supporting workers Outcome 16 (Regulation 10): Assessing and monitoring the quality of service provision Outcome 17 (Regulation 19): Complaints Outcome 21 (Regulation 20): Records 27

28 APPENDIX VIII Outcome Evidence (Provider Compliance Assessment) Respecting and involving people who use the services People understand the care and treatment choices available to them. They can express their view and are involved in making decisions about their care. They have their privacy, dignity and independence respected, and have their views and experiences taken into account in the way in which the service is delivered. Date Details of Evidence Document? Visual? Other (please Specify Location of Evidence state) Signed statement held in care plan documentation explaining care and treatment choices (see form XY10). In care plan documentation for each and every service user. Care plans are situated in Care plans agreed by Named Nurse and Service User care plans signed by both parties to show agreement. In care plan documentation for each and every service user (as above) Minutes from regular Service User meetings. Notice on Notice Board advertising next Service User meeting Both forms of evidence are on the Notice Board in the main foyer to the left of the front door as you enter Privacy Policy policy number SHC 11/06C In policies and procedures folders on the third shelf down in the Home Manager s office. USB Audio policy On USB memory stick labelled Policies and Procedures SHC 2011 taped in policy folder as above Audio policy disc situated in top right hand drawer of Registered Nurses desk in Nurses 28

29 disc office Knock and await answer before entering notices On Service users doors Care plans are person- centred and concentrate on how to optimise what the person can do and how we can assist them to do this, rather than what a problem is perceived to be and how we can do it for them. In care plan documentation for each and every resident location as above Results from bi annual survey relating to privacy and dignity highlight that 99% of respondents feel their privacy and dignity is respected at all times and 1% say it is respected most of the time. Survey responses received are in the bi annual audit response file in the 3 rd drawer down of the grey filing cabinet in the manager s office. Graphed analysis of responses on notice board to right of window in service user meeting room 29

30 Appendix IX Positive Assurance Framework Quality & Safety Committee 14 th October 2011 Positive Assurance Framework for Care Homes (Nursing) Agenda item No: TITLE OF REPORT: PURPOSE OF REPORT: REPORT PRESENTED BY: Positive Assurance Framework for Care Homes (Nursing) To update the committee on the implementation of the Positive Assurance Framework Hilary Walker, Director of Quality KEY POINTS: A Positive Assurance Framework has been developed and agreed The 18 nursing homes across Dudley have agreed to submit a data set on a monthly basis Work has started to agree a process for analysis and review of the data Further work is planned to maximise the impact of the Positive Assurance Framework RECOMMENDATION : Committee members are asked to note the content of the report 30

31 NHS Dudley strategic direction To help and encourage people be as healthy as possible To make sure health services meet the needs of the local people To raise the quality of services NHS Dudley goals View of the Professional Executive Committee or clinical lead(s) View of patients, carers or the public and the extent of their involvement Implications on resources Legal implications Implications on quality and safety Assurance framework number Risk register number Implications on health inequalities Equality impact assessment Indicate how the outcome of the EIA has influenced the development of the content and recommended outcomes in this report Publication Required If the report is accepted by the board does this require the report/strategy to be published as a separate document from the Board Papers on the Trust website and Publications scheme? Tackling Obesity Reducing Alcohol Misuse Improving Mental Health and Wellbeing Providing Systematic and Targeted Prevention Care at the Appropriate Setting Improving our Urgent Care Services Managing Long Term Conditions Improving Patient Safety and Outcomes Improving Patient Experience Championing Innovation and Excellence Enabling NA NA NA NA Works to mitigate the risk of quality failures in care homes NA NA NA 31

32 Introduction NHS Dudley is committed to commissioning high quality care from Nursing Homes for Dudley residents. Over recent years a small number of high profile events have prompted a review of the approach used to monitor and drive up quality. Dudley Metropolitan Borough Council (DMBC) and NHS Dudley are natural partners in the pursuit for high quality care in the care home sector and we have worked together to review current arrangements, plan an improved way forward and start to implement those plans. This paper provides a summary of the issues and a progress report in relation to the development and implementation of a Positive Assurance Framework for care homes. Background While both NHS Dudley and DMBC have processes to monitor against the standards defined in contracts held with Nursing Homes, concerns about quality of care are not always identified in a timely way and are often raised outside these processes through: Safeguarding referrals Complaints Care Quality Commission (CQC) inspections Learning from recent events such as the closure of Grange Park and Alexandra House Nursing Homes has identified that: Information sharing is not sophisticated enough to ensure that all parties have a common understanding of the status of a home and any current quality issues identified While monitoring the care delivered for individuals is important, this approach does not reliably facilitate the recognition of systemic or process failures NHS Dudley and DMBC anticipate they would be better able to support a home with quality issues to improve if they are aware of problems early Therefore work has been undertaken to implement a more pro-active approach through the development of a Positive Assurance Framework (PAF). The concept is for Nursing Homes to self assess against an agreed set of key performance indicators or metrics and submit that data on predetermined dates to the PCT and Local Authority. Progress to date Positive Assurance Framework meetings have been established since September Scheduled to take place monthly, these meetings have been chaired by Mike Marshall, Head of Commissioning at DMBC and with a multiagency membership including representatives from the care home sector and LINks. A data set to enable assessment of quality has been developed and agreed by all parties involved. It is recognised that the data set is likely to evolve as regular submission and analysis of the data identifies that which is most valuable and that which is less so. The data set spans the dimensions of quality including safety, effectiveness, experience and workforce. (Appendix 1) 32

33 A senior nurse from the PCT has met with all 18 Nursing Homes within Dudley and all have agreed to provide the data on a monthly basis. It is acknowledged that the independent sector need the opportunity to review and respond to its own data before submission to the PCT and DMBC, therefore data will be submitted on the 20 th of each month for the previous month. A member of the Informatics Team at the PCT is engaged with the project and is working to develop the analytical possibilities. Undoubtedly there will be trends and correlations that emerge, but it will be important to treat early data as a baseline. Any comparisons between homes need to be treated with caution. It is expected that early data is likely to lead us to ask more questions rather than to think it provides us with answers. 13/18 homes have started to submit data with the remaining homes due to submit for the first time this month. Summarised below are anonymised examples of what the data submitted so far suggests. 1) Number of residents prescribed anti-psychotic medication Number of residents prescribed anti-psychotic medication who have had their medication reviewed within the last 6 months June July Aug The excerpt above might suggest that through completion of the data set, it was recognised that reviews of residents prescribed anti-psychotic medication were overdue and that this has since been addressed. 2) Total number of residents receiving continence aids i.e. pads Total number of residents who have received a continence review by the home this month? June July Aug The excerpt above might suggest that through completion of the data set, it was recognised that continence reviews were not up to date and prompted work to address the issue. However it might indicate that process within the home is to conduct continence reviews quarterly. It will be necessary to ask the question to understand what the data is telling us. 33

34 3) June July Aug Total number of residents with a diagnosis of dementia 13 Total number of staff who have completed dementia training 0 The excerpt above prompts a question about staff being suitably trained for the care they need to deliver. 4) Number of bed rails in situ 29 Number of bed rails in situ 3 The above data from 2 homes with the same number of residents, both caring for significant numbers of residents with dementia may have different approaches to keeping their residents safe. This would be worth exploring to understand further and share best practice. 5) Number of 999 calls from the home (Ambulance) Number of 999 calls resulting in residents attending the emergency department Number of 999 calls resulting in residents being admitted into a hospital bed While this home has made five 999 calls in the past 3 months, it would appear that these were appropriate. Should this level of calls persist further work might be required to: Seek assurance that staff are not failing to recognise deteriorating residents and that they are seeking interventions in a timely way Understand the level of involvement from Primary Care clinicians Identify the details of individual residents involved and seek the perspective of the ambulance service / hospital with regards to the appropriateness of the referral 6) 34

35 How many resident discussions or discussions with residents family have taken place this month to establish if the resident is happy and satisfied with the care home/care received How many residents have responded to a satisfaction survey within the last 6 months? 0 0 Number of complaints (both verbal and written) received this month 1 1 With 28 residents currently in this home, this data might prompt a question with regards to the homes approach to seeking feedback from their residents. 7) June July Total number of hours covered by external agency for care assistant grade Total number of hours covered by internal bank for care assistant grade 0 0 Total number of sickness hours for Care Assistant Grade Number of injuries that required clinical assessment and/or intervention 0 1 Number of falls this month Number of residents who have lost either; more than 5% of body weight has lost more than 2 kilos or who's BMI has decreased to 18.5 or lower within this monthly period 5 4 If the template has been correctly completed there are questions to be raised with this home. It appears that there are a high number of Care Assistant hours lost to sickness and not covered through temporary staffing arrangements. Within the same period a number of safety incidents could be related to insufficient staffing. However it could also be that agency staff were employed but there is an omission in the data. Next steps 35

36 At the next Positive Assurance Framework meeting this month samples of the data received will be shared and debated. A process for the regular review of data and planned response will need to be agreed with Local Authority colleagues in particular. Giles Tinsley, Care Home Lead at the SHA will also be joining this meeting. He has expressed interest in the work as he is leading efforts to agree a common data set for care homes for both residential and nursing across the West Midlands. An appointment, Jane Atkinson, has been made to the Lead Nursing for Quality & Safety post. She will take the lead on continued implementation and development of this work. It is not yet known when she is starting in post but it is anticipated that it may not be until Jan Until this time Chris Badger, Quality Analyst will work to ensure data continues to be received and analysed. Planned next steps include: The return of data to care homes in graphical format so that they can share their performance and progress with their teams. Reporting progress back to West Midlands Care Association, the representative body for Dudley Care Homes Share progress with Dudley Clinical Commissioning Group Negotiate with care homes the format of a data summary document that could be shared with the CQC proactively on a regular basis Support Local Authority colleagues roll out the PAF to the residential sector, recognising some adjustments to the data set are likely to be required. Consider whether a future payment structure could be aligned to the PAF. Hilary Walker Director of Quality 6 th October