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Residential & Nursing care provision

Introduction

Population ageing is a 'game changer' for health and social care services. While many people remain well, engaged and active well into later life, report high levels of happiness and continue to make a major contribution to local communities - as carers or volunteers, for instance - increasing age also brings an increasing chance of long-term medical conditions, frailty, dementia, disability, dependence or social isolation.

We can do much to prevent these problems or to help people live well with them, to retain their independence and keep out of hospital. But, in the end, we must also be realistic in acknowledging that older people often do need residential, nursing social care or rehabilitation after a spell of illness; that they will sometimes move into nursing or residential homes; and that support, choice and control towards the end of life are as important to them as they are to younger people with terminal illness.

When older people are not able to live at home safely, there are a range of housing options available to support their health and social care needs. Residential care and nursing homes offer accommodation needs and personal care and support for people who may not be able to live independently.

What do we know?

Nationally, spend on older people is 52% (HSCIC 2014/15) of Adult Social Care's gross budget (£10 billion out of a total £19.2 billion spend). Within the budget for supporting older people, residential and home care are the areas with the highest level of spend. However, the greatest numbers of people are supported through domiciliary care.

Older People's Residential Care Homes provide accommodation and care on either a short or long term basis. Reading Borough Council has 36 registered care homes within the Borough;

14 are registered to provide services for older people. There are 5 homes in Reading that care for people with Dementia (1 of which is owned by the council), providing 149 beds.

Nursing homes provide the same assistance with personal care as residential care homes, but the staff are nurse trained and higher levels of support are given to service users, providing 24 hour care for more complex health needs and frail elderly who may not be able to care for themselves. As well as nursing care, many homes offer rehabilitation services, a range of therapies and specialist care; including for dementia and cancer. Reading has 5 nursing homes and the council has placements in 143 of the 383 available beds.

In Reading people are supported to remain in their own homes as long as possible. The NHS Five Year Forward View published October 2014 sets out a new shared vision for the future of the NHS based around the new models of care. Under this new care model there will be a greater partnership with care home providers to develop new shared models of care and support, including medical reviews, medication reviews and rehabilitation services. This has been achieved through establishing Vanguard sites. This is one of the first steps in supporting the improvement and integration of services.

The frail elderly make up 2% of our population but account for 28% of health and care spending in Berks West.

Facts, Figures, Trends

National

On 31st March 2014 there were 213,000 supported residents in England. This is a reduction of 2,000 people on 2013's figures. The overall number of supported residents has fallen by 22% since 2004.

78% of supported residents were aged 65 and over in 2014. Almost half (42%) of supported residents in registered accommodation were aged 85 and over, compared to 24% aged 75 to 84 and 11% aged 65 to 74. The age distribution of supported residents has remained relatively unchanged from 2008-09.

For supported residents aged 65 and over, 65% were in independent residential care, 30% were in independent nursing care and 4% were in council staffed homes in 2014. The percentage of clients in council staffed homes fell by 5% points from 2009 to 2014.

Permanent admissions to residential and nursing care homes are measured in the Adult Social Care Outcomes Framework. They are shown as the number of council- supported permanent admissions of adults to residential and nursing care, excluding transfers between residential and nursing care (aged 65 and over), as a rate per 100,000 of the population aged 65 and over.

In 2013/14 there were 65,000 admissions into residential and nursing care in England, which was a decline of 4% on 2012/13 figures. 93% of these admissions were for people aged 65 and over, which equated to 651 admissions per 100,000 population aged 65 and over.

(Source: Health & Social Care Information Centre (2014); Community Care Statistics, Social Services Activity - England 2013/14)

Local

Around 800 people per 100,000 of the population living in the Borough were permanently admitted to a residential or nursing home in 2011/12, as shown in Figure 1. This is a higher rate than both the national and regional average. Data from 2014/15 is shown in figure 1 below. (Note - there are plans to reduce by 20% for the next two years to bring in line with statistical neighbours).

Figure 1: Permanent admissions of older people to residential and nursing care homes per 100,000 population. Comparison with South East local authorities.

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Source: Health and Social Care Information Centre

Source: NASCIS.

Figure 2: Number of weeks spent in a care setting in the Reading Borough (2014/15)

Number of weeks spent in care

Nursing care

9,573

Own provision

1,397

Residential care provided by others

17,421

Source: National Adult Social Care Information Centre.

Current activity & services

The Council commissions services with more than 100 providers of residential and nursing care across the country. Within the Reading Borough there are 14 residential homes caring for older people and 5 nursing homes providing a total of 781 beds for people aged 65 and over. The average cost of a residential placement to the council is £682.59 per week and the average cost of a nursing placement is £707.04 per week (excluding Registered Nursing Care Contribution).

There is currently sufficient capacity within the market to cater for the council's needs through till 2030 especially taking into account reduction in care home placements the Council intends to make each year and the effect the additional extra care housing will have on the care home market once all of the schemes are completed.

However, it is clear that the beds being offered in the borough, outside of the council's block contracts are not being offered to us at cost effective rates. Therefore, it may be necessary in the future to develop new nursing provision, not to meet capacity needs, but to mitigate the risk of market failure in this sector and provide additional secured capacity at a very good below market rate.

The Better Care Fund 2015/16 Care Home Programme has focused on delivering training and education and has seen a reduction of 72 (20%) in non-elective admissions compared to 2014/15.

The 2016/17 programme will be revised as a single programme which takes into account the work undertaken to date and integrates various work streams across Health and Social Care into a coordinated approach. The 2016/17 project will be delivered through a revised project group that will oversee the delivery of the objectives though 4 work streams that will focus more on collaborative working directly with key stakeholders, in particular the Care Home staff and Local Authorities in the delivery of the following.

  • A proactive and reactive support to care homes through the Care Home support team and the Rapid Response and treatment team. A tailored programme of training for care home staff will be delivered proactively and will help them to support residents to remain within their home as long as possible. This will be achieved through targeted training for UTI, pneumonia, falls and dementia using various models of delivery including train the trainer.
  • Continued support from the Rapid Response team and on-going evaluation of the impact of the service supporting the care of residents in the home avoiding the need for hospital admission.
  • Protocols and standards that are supported by all providers and focus on the delivery of quality social and health care and reducing the impact of any necessary interventions outside the care home, particularly length of stay in secondary care. The development of protocols, standards and ESD that support the care of patients in the care home will be in collaboration with partners.
  • A model of care through GP practices that provides and consistent and collaborative approach to care within care homes. Looking at new models of care that potentially reduces the number of practices involved in each care home. This work stream will also include the support to medicines management to ensure review of process to ensure increased efficiency and therefore realisation of the KPIs
  • A supportive health and Social care process for the monitoring of Care Home performance through collaborative working with all providers delivering aligned processes across Berkshire west.

The combined work of these work streams will contribute to the predicted delivery of a 45% reduction of NEL admissions and a 50% reduction in the use of the South Central ambulance service. The percentage reduction was arrived at by comparing the outcomes of best practice examples of similar schemes undertaken by similar health economies that, like Berkshire West, are in the top quartile for NEL performance.

National & Local Strategies (Current best practices)

The main legal duties of the Local Authority are legislated through the Care Act 2014. Part 1 of the Act focuses on the Adult Social Care reform. Section 2 (1) places a duty on local authorities to provide or arrange services that reduce and help delay the development of the need for support from people with care needs and their informal carers. Residential and nursing care providers are required to comply with the Care Standards Act 2000. This Act enforced all care homes to be registered and regulated; introducing minimum standards for care services that take place. There have been several updates in terms of supplementary policy for residential and nursing services, including the Health and Social Care Act 2008 and the Care Quality Commission (Registration) Regulations 2009. Nationally all residential and nursing homes have to comply with Essential Standards of Quality and Safety and 28 specific outcomes that people who use the services have the right to expect from the service provider.

Reading is developing an older people's commissioning strategy, which will focus on 4 core themes:

  • To ensure older people stay healthy and independent for longer.
  • To ensure that all older people are safe and respected both in the community and when receiving support.
  • To ensure that older people have choice and control over the services they receive and have access to the right information in order to make decisions.
  • To ensure high quality services in health and social care through robust quality monitoring

What is this telling us?

In Reading there is a Quality and Performance Monitoring Team who support local service providers to meet and exceed the national standards for the benefit of all residents. All new service providers for council funded services go through a series of checks before a placement is confirmed. Advice and support is available for those who do not come through social care processes to have to have their needs met. Our Quality and Performance Monitoring Team's work with the Reading care home providers has given us a better understanding of the services operating in our Borough. Through the sharing of best practice and lessons learnt they have been able to improve the quality of services provided to all residents and to enable care homes to exceed the national standards or to become compliant with the Care Quality Commission again as quickly as possible should they fall below minimum standards.

Their work with providers has enabled the Council to address issues before they become complaints or safeguarding cases. Following the introduction of our Quality and performance monitoring team we have seen a reduction in complaints and our safeguarding and quality concerns are now resolved faster and investigated more thoroughly than they have been in previous years. The Clinical Commissioning Group (CCG) funded Care Home Support Service (currently provided by Berkshire Healthcare Foundation Trust) aims to deliver improved outcomes for people with dementia living in residential and nursing homes.

The multi-disciplinary provider team works closely with care home staff to:

  • Deliver improved quality of life for people with dementia living in residential and nursing homes.
  • Improve the skills of the care home staff by building their confidence and professionalism.
  • Improve communication with people with dementia, and involvement of Carers. This will include their involvement with anticipatory planning for end of life care.
  • To ensure referral to an appropriate clinician / service.

The service will provide individual assessments for older people in care homes to review their physical and mental needs and care plan, thus providing a pro-active rather than reactive service.

What are the unmet needs/ service gaps?

Reading is a small urban Borough with only 5 nursing homes. A needs analysis conducted for the Reading area shows that there are a sufficient number of nursing dementia beds within the Borough to cater for expected population increases through to 2030. However, the provision is held by 2 homes in the Borough with more than 75% of the available beds being held in one home. Should this home close, or should placements need to be suspended for any reason, the Council and many of its partner organisations would find themselves severely short of nursing dementia beds. Future consideration may be given to the building of new facilities to provide alternative nursing dementia provision and to provide additional competition in to the current market (See Dementia module for further information).

One nursing home within the Borough is in the process of transforming from an older persons nursing home to a home that deals with younger people (40-55 years old) with a physical disability. The loss of 18% of the available nursing beds for the over 65 has put pressure on the Council to continue to meet placement demand. Future consideration may be given to the building of new facilities to provide additional nursing provision and to provide additional competition in to the current market.

Whilst the home mentioned above is transitioning to cater for people with a physical disability, they have a significant waiting list of private clients and the Council struggles to make age appropriate placements for people with a physical disability when this home is full.

The Council commissions services for a wide variety of people with varying health and social care needs. Nationally, one area with increasing need is bariatric care for people who are obese. Being obese is now recognised as being one of the World's most significant and increasing health problems (World Health Organization). Whilst Reading Borough does not get many people with bariatric needs requiring residential/nursing care at this point, the current market does not cope well with bariatric care. It is often the case that whilst a care home can meet the personal care needs they often lack the necessary equipment and in some cases the additional staff to cater for bariatric care adequately. This is currently seen as a specialism by care home providers, rather than a normal service to be provided for.

  • End of Life Care,
  • Housing and Homelessness.
  • Excess Winter Deaths.
  • Carers.
  • Mental Health.
  • Dementia

Way forward

For 2016/17-2020/21 an overarching programme will be developed with Reading in line with the outputs from the Frail Elderly Programme providing an opportunity for Health and Social Care to work together, to address a wider range of aims and objectives that addresses the responsibilities both have to residents within the Care homes setting and to enable those homes most in need of support to be supported. This provides an opportunity for Health and Social Care, working together to meet the requirements within:

  1. Quality Care for older people with urgent and emergency care needs produced by the British Geriatric Society1 in June 2012.
  2. Care Act, 2014
  3. The NHS England Five Year Forward View, October 2014.
  4. The Berkshire West 10 FEP programme recommendations and implementation plan
  5. Older People in Care Homes. NICE, Local Government Brief 25, February 2015
  6. Safer, faster, better: good practice in delivering urgent and emergency care, August 2015
  7. Transition Between inpatient hospital settings and community or care home settings for adults with social care needs, NICE CG 27, December 2015

Some of the most vulnerable people in our society are reliant on care and extra support to help them lead better more comfortable lives. The care and support they receive can be the difference between a life that is fulfilling and active and one which is unnecessarily limiting.

The Quality Care for older people with urgent and emergency care needs produced by the British Geriatric Society in June 2012 and Safer, faster, better: good practice in delivering urgent and emergency care, August 2015, describe the overarching national objectives for the care of people resident within care homes.

The Older People in Care Homes, Local Government Briefing, February 2015 and the Care Act, 2014 outline the responsibilities Local Authorities have towards care home residents, as commissioners and their statutory duties to safeguard residents and ensure their wellbeing. This applies regardless of whether they run the homes themselves or a resident pays their own fees. The key within these is to emphasise the importance of 'people maintaining their independence as much as possible and for as long as possible'. Over the next few years There will be fundamental changes to the way care is delivered and paid for. These changes will mean that users of the service and their carers are in control of their own care and support. The Adult Social care Outcomes Framework (ASCOF) is the tool used to measure performance against this ambition and the four domains link into the overall work described

References:

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