Changing social care: an inclusive approach
Case study: BrendonCare – Alton
BrendonCare is a charity with 10 care centres across the South of England. The Alton complex (BCA) was opened in 1997 and provides residential and nursing care for 75 people. It also has day care facilities for the physically and mentally frail. Short–term respite care is available as well as specialist care for those with severe mental frailty. In addition, a smaller complex offers 46 domiciliary flats for older people to live independently with access to nursing and personal support.
In 2006 BCA took part in a pilot project for the Resident Centred Care (RCC) audit tool. The audit was initiated by management as part of a strategy to improve resident centred care. The aim was to assess and help guide the home towards putting a true emphasis on the individual and the outcomes an individual wants for their care. In contrast, at the time, the emphasis was on the process of care. Residents, their relatives and staff were all involved in the RCC audit including being interviewed by the authors of the audit as part of the process. The recommendations from the audit comprised practical suggestions for how to shift the culture and practices of the home to ensure the resident was at the centre of the care. The home continues to look at ways of building on the audit and improving the care they provide.
The next sections review the information gleaned from an interview with the Head of Care focusing on our three key themes: (1) leadership and purpose, (2) employee involvement and (3) stakeholder involvement. Each theme comprises a series of subthemes and we provide relevant examples from BCA as illustrations. Refer to the knowledge review, practice review and analytical reports, Improving Social and Health Care Services, for a full review of the themes. We conclude our case study with a summary of BCA's efforts at evaluating their improvement programme.
The audit process and subsequent improvements made within BCA were started when the Head of Care's recognised that the home's business planning and operations were driven by the process of care and not the resident. Her wish to make changes, together with the support offered by the audit toolkit which acted as a guide to the way forward, drove the improvements. The following section details the role of leadership in the process.
1 Leadership and purpose
Leaders need to establish a clear sense of purpose and ideology to enable change and improvement
The current Head of Care had started working at the home as a senior team leader and became more involved in the annual business planning, especially with care goals and objectives of the home. She realised that the focus at the time was on putting care plans together, with an emphasis on process not outcome for the residents. The care plans were good but often showed little evidence of involvement by the resident. At the time she took over as Head of Care, the National Minimum Standards were emphasising the individual and what individuals wanted from their care. Yet, evidence from the residents care plans seldom demonstrated resident participation in their care plans or choosing what they would like. The Head of Care therefore decided that the whole process needed to change, and she needed to ensure the process and culture recognised and involved the residents as individuals in creating their individual care plans.
However, at the time the Head of Care felt unsure as to how to make the change. She was very clear on what she wanted to achieve but unsure as to how to do it:
I was thinking about it for a long time but quite honestly didn't know which way to go. I knew what I wanted to do but not how to go about doing it.
Leaders create the conditions to enable change and improvement
The Head of Care has become increasingly aware of the need to change throughout her time at BCA and when she took over as Head of Care found herself in a position to be able to instigate the changes. Her lack of a sense of which steps to take first was addressed when she was approached by the authors of the RCC. The authors asked her whether they could use BCA as a pilot for the audit tool. The Head of Care took the opportunity and allowed the RCC access to staff, residents and their relatives to undertake the audit over a period of six months.
A great deal of administrative time was devoted to setting up the audit, for example, gaining consent from residents, their relatives and staff to the interviews taking place and fixing times for the interviews. Crucially, the Head of Care was so convinced of the need and benefit of the audit that she made sure the time was given to doing it properly. On a personal level, the Head of Care spent time one–to–one time with team leaders and residents and in resident and relative group meetings to explain what was happening. Where relatives and residents did not regularly attend the bi–monthly group meetings flyers were given to residents and posted to relatives. Staff were encouraged to spend time with residents and relatives talking about the audit and answering questions. The Head of Care also spent time on the floors of the home to ensure she was accessible to residents and their relatives.
Respond to issues, but do not compromise on direction
The feedback from staff revealed that they felt under resourced in terms of staff numbers and perceived this as a barrier to delivering resident–centred care. The existing dependency tool did not always consistently reflect the number of staff needed to deliver care. Senior management were made aware of this problem and at present the tool is under review. The tool is now being remodelled as it did not adequately reflect the true levels of staff needed to deliver care. However, developing an assessment tool is not a quick or simple process, and the Head of Care was firm that delivering resident–centred care could not be delayed until the tool had been remodelled. Equally, she was clear that in a business with finite resources you need to have a balance and cannot always provide more staff. As such it was important to find ways to help staff deliver resident centred care beyond increasing staff numbers.
Communicate underlying purpose and ensure actions are consistent with this purpose
The purpose of the audit was to help the home to make their aim of resident–centred care a reality and this vision was communicated to staff. The Head of Care made her opinion clear that whilst the home talked a lot about resident–centred care, it was not happening in practice. There was a need to change the mindset of staff and the Head of Care recognised that this was a long–term challenge:
The centre and the focus of all our care must be the residents and I think it's a change of minds that you have to bring about. It doesn't just happen overnight. It takes a long time. I spoke to the staff and said by doing this audit we would be able to see how we could improve our skills and how we could develop our role within this home - caring - not just focusing on the care plans. Saying yes, I'll have a chat with the resident every month and signing off that they are being reviewed isn't enough.
Stakeholders need to be on board with the underlying purpose
You do not see the residents in isolation, you need to look at them holistically and
form relationships with their relatives whenever you can (Head of Care).On the mental health side of the home’s care, communication with residents with severe dementia can be difficult. However, BCA has found many aspect of their care they can engage them in and achieve a person centred approach to care. The Head of Care also believes working with residents’ relatives is a great way forward.
Placing residents at the centre of care means ensuring residents express their true thoughts on the situation of their care. However, it can be difficult to elicit their true feelings:
understanding what residents really believe can be difficult because the residents can often say they don’t want to disturb staff because they are busy or they don’t want to make trouble(Head of Care).
Bringing in an independent body to conduct the audit ensured residents were more likely to express their opinions and enable the team to build a true picture of what needed to change.
Engage employees – give them responsibility
The changes required all staff to deliver resident centred care and each member of staff had to be responsible for ensuring their practices were resident centred. In particular, staff are responsible for drawing up and delivering the care plans. The Head of Care did not believe it was enough that the top management were engaged with residents and relatives at different points the year. Individual care staff and registered nurses all needed to understand and act on the differences involved in delivering resident centred care and deliver it every day.
Establish a structure that allows engagement
Throughout the audit the Head of Care maintained an ongoing dialogue with the auditors. This open dialogue meant the Head of Care was able to feedback findings to staff throughout the process. The auditors also met with staff at the start of the process, through their individual interviews and presented the findings formally to staff at the end of the process. The endorsement of the review at the outset by the Head of Care and the independence of the auditors meant that staff were open and honest in their opinions and engaged in the process. There was some initial cynicism that the process would not be worthwhile, but that appeared to be short lived. The Head of Care also encouraged staff to be part of involving residents and their relatives in the process so that they were ambassadors of it.
Get communication channels right
The Head of Care makes herself visible so residents, staff and relatives are able to approach her. She goes onto the wings every morning, and once a week in the afternoons as well, in order to maintain a visible presence and build up relationships with relatives.
If you’re not visible and not communicating with them on an informal basis they don’t know who to approach and you don’t build up any sort of relationship with them either. I also rely on both my senior team leaders and the registered nurses on each wing to build up good therapeutic relationships(Head of Care).
The Head of Care has also set up regular monthly group meetings with residents and their relatives. However, on one unit residents do not frequently turn up to these meetings. Instead, to inform them about the audit, the Head of Care asked staff to talk to the residents personally, and delivered flyers to their rooms in special containers so they would be easily visible. She also posted information out to relatives’ homes.
The Head of Care maintained a continual dialogue with the auditors throughout the process to obtain feedback and passed this onto staff in their monthly meetings and through the team leaders. At the end of the process the auditors presented their results and recommendations to the Care Centre Manager and Head of Care and team leaders and also to the staff group.
Work with resistance
The Head of Care did not perceive resistance among staff, residents or relatives to the audit or the change of practice in principle. The difficulties emerged mainly from a lack of knowledge of how to incorporate resident centred care into an already busy schedule. The Head of Care worked with staff to identify new ways of managing their tasks to ensure the methods of care changed. She often worked on a one–to–one basis, coaching staff on where they could reduce the time spent on tasks and on how to incorporate resident centred care into the tasks they were doing already.
I think you have to have a balance and say, if you have to care for fifteen residents and most are highly dependent, you’re going to busy in the morning. You’re not going to have time to sit down and you have to ‘work smart’ (to work as a team with good planning of the day and be efficient). You have to have some sort of routine and balance in the morning. You will have time later on in the day to sit down. It’s about finding a balance. Yes, we promote personal–centred care, but you can’t spend half an hour sitting down with somebody talking about their past during a busy time. But you have to have to sit down and talk about these things and reinforce that the resident is the centre. The last thing you want is for your residents to feel rushed. You have to ‘work smartly’ and quickly but not to extent where the resident feels that she’s just a can of baked beans that can be put on the shelf and dusted. You need to be thinking about her needs at that time, talk to her while you’re working.(Head of Care)
The Head of Care also felt it was important to discuss the issues of staffing levels with care staff on a regular basis and maintain an open dialogue:
If you keep communication with your staff open they do have a level of understanding. They might not like it but they do understand. I have always found that if they complain then we sit down and talk about it and see how we can alleviate their burden and make it a little easier for them. Maybe it means instead of doing two baths on Tuesday we ask Mrs Soandso if we might bath her in the afternoon, then you’re not so busy in the mornings. It’s just really communication with your staff. It’s not simple but it’s really important.(Head of Care)
Give staff support to adjust and adapt to improvements
The Head of Care felt that the issues raised in the audit showed that staff were mostly working efficiently but they needed to improve their communication skills. The issues were addressed through supervision meetings with staff and through head office training. Where issues arise, the Head of Care looks at what opportunities exist to coach the employee through the situation either through one to one support or wider training. One particular area that was identified as requiring ongoing training for staff concerned communication around dying.
They get lots of training and support. They know from day one that they are not expected to deal with problems on their own; they are part of a team. If they are upset or have a problem they are reminded they should go straight to their line manager or the senior on duty. So at all times they are supported. But resident– centred care also means employees need support – not only for themselves, but as they need the skills to support the person who is dying as well as the family. It’s a two–way street. It’s not only giving them the support for death, dying and bereavement but they need the skills to deal with the resident and the attitude to support somebody who’s losing somebody they love.(Head of Care)
Staff also have patient–centred mentors to support their development. As part of an initiative from head office, 50 per cent of registered nurses are trained in coaching for resident centred care and the home is working to cascade the resident centred care approach to other categories of staff. The Head of Care is adamant that better education and equipping the employees with the skills they need to be a more professional workforce is essential to having a good approach to delivering resident centred care. Staff are entitled to 36 hours training and six session of supervision per year, so she believes it is relatively easy to fit in the training required. Senior management in head office also provide support, helping to draw up an annual training programme according to training needs.
2 Stakeholder involvement
Service users should be at the heart of change and improvements
One of the key recommendations of the audit concerned communication with residents. Each aspect of the audit brought communication up as an issue in a different way, for example, from the residents’ points of view they felt staff were often rushed. The residents did not feel they wanted to voice their opinions because they felt the care was good but staff were rushed and working too quickly. As such, the Head of Care worked with the audit team and the staff to work out how to address these issues. Ensuring that residents’ perceptions of care were addressed as well as the care itself was central to putting the resident at the centre of care. The Head of Care also extended and developed the role of Activities Coordinator to deliver more one–to–one sessions to take into account individual residents’ likes and dislikes.
Organisations need to work in and with the communities they serve
The community of the home comprises not only the staff and residents but also the families of residents. All stakeholders needed to be on board with the audit and the shift to resident–centred care for the change to take place. In addition the home needs to work with other professionals who provide services to the residents and ensure that all care is resident –centred.
It’s a huge multidisciplinary approach which I think is really good for the home and for any home. When I first came into care in 2003 I don’t think we had that multidisciplinary approach. We’ve got a very good relationship with the two local doctors and you have hospital visits, you review medication and look at patient’s care on a weekly basis. The Gold Standards Framework will also help us collaborate better with the GPs and district nurses so we’re all aiming in the same direction.(Head of Care)
The audit tool provided the Head of Care with a way to understand where the service was providing resident–centred care and where improvements were needed. In the first year following the audit the actions for change focused on delivering resident centred care. However, the process was not simply from A to B, instead the home is now on a continual path of improvement. Subsequently, the home is now registered to include the Liverpool Care Pathways in their end of life care. The next stage will be implementing the Gold Standards Framework.
To evaluate their progress and ensure that improvements are ongoing, the Head of Care and the team leaders conduct audits on a regular basis to ensure new standards are met and that resident–centred care is a reality. Before the audit, on admission, care plans would be drawn up with minimal input from residents or relatives. There was little evidence in the plans that any discussion had taken place. Now, when the care plans are drawn up evidence must be documented that the staff have sat down with the resident and relatives to discuss the care plan. For example, reports will now have comments written in such as ‘I sat down with Mrs Soandso and discussed her likes and dislikes, she says…’. Wherever possible the relative is involved in discussions too. Each care plan is reviewed monthly between staff, residents and relatives. Audits are then conducted by team leaders twice a year for each resident using a patient–centredness structured audit tool. In addition, the Head of Care meets twice a year with residents as part of a structured programme of reviews, though they can always meet on a one–to–one basis with her at any time to discuss issues. Initially these structured reviews were held three times a year but the response was not as good and so meetings were reduced to twice a year to check that residents are happy. In addition, the Head of Care meets twice a year with relatives.
However, irrespective of regular reviews and audits, care plans are reviewed at any point there is a major change in the resident’s situation. The Head of Care also uses the requirement to complete the Care Quality Commission self–assessment each year as an opportunity to review what the service is doing well and what could be done better. She finds the particular emphasis on patient centred care is a good driver to continue finding ways to improve.