GP services for older people: a guide for care home managers
Workforce development, standards and regulation - Developing trained, confident care workers
Managers and proprietors should ensure that care staff are trained and supported to be aware of and understand the medical and health needs of residents, and respond appropriately. This has implications for leadership and culture in the care home; raising staff awareness of residents' health needs; and provision of training and staff development opportunities. Staff need the confidence, communication skills and knowledge to initiate and handle the relationship with GPs. Nurses in care homes should be offered joint training with their counterparts employed in the NHS, and the opportunity to obtain practice hours in order to validate specific training. GPs and health care professionals can play a valuable role in training and updating staff, and homes can also contribute to the training of doctors and nursing staff.
Leadership and culture
The provision of good residential or nursing home care is a challenging, demanding and highly skilled job. Yet the staff providing that care are generally undervalued, lacking public recognition, subject to poor pay and conditions and denied the training and development opportunities the job requires. Staff turnover rates are high, although the commitment and motivation of the great majority of care staff are beyond question.
In those homes that offer a good quality of life, support and care to residents, despite the obstacles, the leadership offered by the home manager is crucial. Good managers are able to create a culture and ethos in which staff, residents and relatives are supported, nurtured, motivated and able to maximise their potential. They also tend to be skilled at maintaining good relationships with outside professionals, services and local communities, so that the home has roots in its neighbourhood, is open to contact and influence and avoids becoming isolated.
Increasing staff confidence in relating to GPs
Staff need the confidence, communication skills and knowledge to initiate and handle relationships with GPs. Nurses in care homes should be offered joint training with their counterparts employed in the NHS, and the opportunity to obtain practice hours in order to validate specific training. GPs and health care professionals can play a valuable role in training and updating staff, and homes can also contribute to the training of doctors and nursing staff. Relatives in one study  thought that more information and support could be provided by health specialists already working with the home, including the community pharmacist and GP.
GPs, nurses and relatives report a low level of confidence, knowledge and skills among care home staff, associated with a lack of access to training. This can affect their interactions with GPs, and GPs' or relatives' perceptions of care home staff, as well as being a barrier to partnership working. This can be exacerbated by high turnover among staff.  It has been found that some nurses and other care home workers do not have the confidence, or the knowledge, to influence a GP's decision, and 'go along' with what has been suggested, even if it is to the detriment of the resident and causes harm (such as a medication error). [12, 18, 22] Two studies [18, 22] report that care staff can be reluctant to contact a doctor, especially if there is a poor working relationship with them, or an apparent lack of interest from the GP in visiting the home, so compromising medical care.
Care staff, who provide most of the personal care and have direct day-to-day contact with residents, require a range of skills and knowledge, but their character, values and personal qualities are also critical. Patience, tolerance, empathy, emotional intelligence, curiosity, ingenuity, imagination, flexibility: these are some of the character traits that enrich relationships between staff and residents, and enhance their quality of life. Skills for Care have a number of resources that help to develop these qualities.
Raising staff awareness and expertise
The essential task of improving staff awareness of key issues and maintaining and increasing their professional expertise can be achieved through:
- formal training sessions, off-site or on
- the use by staff groups or individuals of relevant e-learning and Social Care TV materials produced by SCIE and other organisations
- formal and informal supervision and team meetings in the home
- making use of clinician visits to the home to arrange instruction and updating sessions for staff on particular topics.
The CQC's review report 'Health care in care homes'  found that training in a variety of topic areas was provided in care homes. This was both general and specialist, with some variation in the subject areas covered. When looking specifically at nursing and residential homes, most homes (93 per cent) provided training on dementia, but only half (52 per cent) trained staff about stroke. Staff interviews about training attendance during the past 12 months in a range of areas showed, across all care homes, that medicines was the health care area with the highest attendance (59 per cent of all staff interviewed), while a much smaller proportion (36 per cent) had attended training about continence care.
With experience and support, care staff and shift leaders in homes become skilled at picking up the signs that a resident is becoming unwell, or that there has been a worsening of their physical or mental health.
Very rarely have we called a GP out and it's not been needed. We do, particularly our permanent people, we do know them, we do recognise changes, although we're not medically trained, so we're very quick on picking up urine infections. (So we) phone up and say, 'Can we send up a urine sample?' and nine times out of ten it is an infection. So we never get refused or have any problems having a GP out.Care home manager/owner/matron 
Numerous studies and reports note the importance of health care decisions by care home staff because they are with residents all the time. GPs and staff feel that high levels of confidence and skill, along with appropriate judgements in relation to residents, can facilitate relationships with GPs, and increase GP confidence and trust in care staff's work.
In its 'Care Update' (Issue 2: March 2013), the CQC describes a special study it undertook of care home residents with dementia being admitted to hospital. In more than half (78 out of 151) of PCT areas, such people were admitted with 'avoidable conditions' significantly more than people without dementia. The avoidable conditions include urinary infections, dehydration, pressure ulcers, pneumonia and other lower respiratory tract infections, severe malnutrition and fractures. Reviewing the findings, the Alzheimer's Society commented: 'This could firstly be an issue of training. Many care home staff are not adequately trained to work with people with dementia, yet we know that 80 per cent of care home residents have the condition. Without the right training staff are not equipped to support people with dementia, and so they may deteriorate and need hospital care (for example, if they don't have enough to eat or drink). This could also highlight a lack of integrated care. The right services need to be commissioned to provide treatment for avoidable conditions outside of the hospital environment and support care homes in their work.'
Training and other tools for staff development
In an evaluation of the impact of improving the skills of care home staff in 'new roles',  one home thought that 'new role working' had moderately decreased GP workloads. The report discusses whether 'new role' care staff have greater confidence, knowledge and skills, and whether this can benefit the relationship between GPs and staff. One potential downside identified is that if GPs engage less with care home residents as a result of staff taking on 'new roles', ironically staff may end up taking on responsibilities beyond their expertise.
A systematic review  concluded that a facilitator for integrated working between care homes and health services would represent an effective 'bottom-up' approach for health care practitioners (not specifically GPs) to train and support all levels of staff.
Staff in a nursing home considered, in collaborative learning groups and action learning sets, ways they could overcome a lack of partnership working by GPs to implement an end of life pathway. The staff considered how they worded requests to GPs, what assumptions they were making about the GPs, and ways in which they could communicate more explicit options when making decisions about end of life care. The authors of an article written about the study report that this kind of facilitation can make a greater difference than traditional education. 
Code of conduct for care staff
The 'Code of conduct for healthcare support workers and adult social care workers in England'  is another measure designed to improve practice, performance and sensitivity in response to older and disabled residents. It describes the standards of conduct, behaviour and attitude that the public, people who use health and care services and employers should expect. The care worker is responsible for, and has a duty of care to ensure that his or her conduct does not fall below the standards detailed in the 'Code'. If there are people who do not meet these standards, the 'Code' will help to identify them and their support and training needs. Nothing that they do, or omit to do, should harm the safety and wellbeing of people who use health and care services, and the public.
The seven principal elements of the 'Code'
As a healthcare support worker or adult social care worker in England you must:
- Be accountable by making sure you can answer for your actions or omissions.
- Promote and uphold the privacy, dignity, rights, health and wellbeing of people who use health and care services and their carers at all times.
- Work in collaboration with your colleagues to ensure the delivery of high-quality, safe and compassionate health care, care and support.
- Communicate in an open and effective way to promote the health, safety and wellbeing of people who use health and care services and their carers.
- Respect a person's right to confidentiality.
- Strive to improve the quality of health care, care and support through continuing professional development.
- Uphold and promote equality, diversity and inclusion.
Each of the seven elements is broken down in further detail in the 'Code'.
A GP surgery arranged for all their GP trainees to spend time in a care home learning about the care of residents. 
A multidisciplinary GP and secondary care team held regular meetings with care home management teams to develop partnership and pursue opportunities for training. 
In one enhanced service scheme, audit interviews helped the provider of GP local enhanced services and the nursing home manager to identify improvements made in working practices. 
All SCIE resources are free to download, however to access the following downloads you will need a free MySCIE account:
- Evidence review on partnership working between GPs, care home residents and care homes
- GP services for older people: a guide for care home managers
- Improving access to and experience of GP services for older people living in care homes: practice survey