Search results

Concerns about quality and standards of care in the nursing and residential home sector have exercised policymakers, managers and practitioners in both Australia and the UK for some years. While Australia is a relatively young country, demographically speaking, it has in place a coherent ‘aged care’ policy. The UK on the other hand, with its rapidly ageing profile, has only recently made a serious policy commitment to the health and social care agenda for older people. Australia therefore has several years of experience to be shared with the UK when it comes to policy and practice of quality improvement. In particular, there are valuable lessons to be learnt from Australia's national outcome standards and monitoring system for care homes, and its more recent introduction of a care homes accreditation system. Apart from identifying any issues associated with the implementation of such approaches to quality improvement, it is important to establish whether they have an impact on the quality of care and life of older residents. As the UK moves to implementing national minimum standards in 2002, lessons from Australia are timely and may help inform best practice and policy in long‐term care in the future.

The purpose of this paper is to trace the history of official policy on the regulation of care homes in respect of end of life care and to contrast this with the results of research on this important theme, not least in terms of what is required to support care home staff in relation to dying residents and their relatives. A central concern is to argue for the open recognition that care homes now cater primarily for frail people towards the end of their lives. Good end of life care and a good death could become a positive “selling point”. The author concludes that the system of regulation has broadly failed to address a good death or good end of life care in a residential home. Death talk should no longer need to be avoided in care homes. The research suggests that appropriate support for care home staff in relation to dying residents needs careful identification and investment. A cultural shift is required.

Following a review of policy documents on regulation and standards of care in residential homes and a subsequent review of the research literature on death and dying in care homes, the paper illuminates the contrast between the ambitious aims in policy documents with very varied practice in everyday care of frail residents.

The recent systems of regulation have broadly failed to address a good death or good end of life care in residential homes. Open acknowledgement of death and dying should not be avoided in care homes. Appropriate support for care home staff in relation to dying residents needs careful identification and investment.

The focus of this paper is to contrast official policy with everyday practice. Whilst policy documents suggest recognition of the importance of dignity and respect from dying residents, the research literature indicates great variation in the practice of everyday care.

This paper highlights the need for researchers to work across disciplinary boundaries in order to capture the complexity that care practitioners have to engage with everyday in care home settings. Drawing on findings from a literature review on the complexity of loss in continuing care institutions for older people, the case is made for less victim blaming and more appreciative approaches to research. The way this thinking informed the development of a further literature review on quality of life in care homes (My Home Life) is discussed. Findings from this second study are shared by illustrating key messages with quotes from older residents, relatives and staff living, visiting and working in care homes. These best practice messages focus on: transition into a care home; working to help residents maintain their identity; creating community within care homes; shared decision‐making; health and health services; end‐of‐life care; keeping the workforce fit for purpose, and promoting positive culture. The importance of collaborative working in both research and practice is discussed. The paper is likely to be of interest to all those concerned with improving and developing evidence‐based practice in the care home sector, including users and service providers, managers, commissioners and inspectors, policy‐makers, researchers and teachers.

In this chapter, I examine stories that foster care youth tell to legislatures, courts, policymakers, and the public to influence policy decisions. The stories told by these children are analogized to victim truth testimony, analyzed as a therapeutic, procedural, and developmental process, and examined as a catalyst for systemic accountability and change. Youth stories take different forms and appear in different media: testimony in legislatures, courts, research surveys or studies; opinion editorials and interviews in newspapers or blog posts; digital stories on YouTube; and artistic expression. Lawyers often serve as conduits for youth storytelling, translating their clients’ stories to the public. Organized advocacy by youth also informs and animates policy development. One recent example fosters youth organizing to promote “normalcy” in child welfare practices in Florida, and in related federal legislation.

Key to successfully addressing the ongoing transitions being experienced in the care home sector is a transformation of the workforce. This is required in order to respond appropriately to the increasing dependency of older people moving into care homes. This article considers the policy framework surrounding the provision of care services in England and reviews the relevant research into the workforce and the changes needed if the sector is to meet the needs of vulnerable older people living in care homes. Building on present policy and practice, consideration is given to how this change could be achieved.

Serious Case Reviews (SCRs, now Safeguarding Adults Reviews (SARs)) may be held at local level in England when a vulnerable adult dies or is harmed, and abuse or neglect is suspected, and there is cause for concern about multi-agency safeguarding practice. There has been no analysis of SCRs focussing on pressure ulcers. The purpose of this paper is to present findings from a documentary analysis of SCRs/SARs to investigate what recommendations are made about pressure ulcer prevention and treatment in a care home setting in the context of safeguarding. This analysis is presented in cognisance of the prevalence and risks of pressure ulcers among care home residents; and debates about the interface of care quality and safeguarding systems.

Identification of SCRs and SARs from England where the person who died or who was harmed had a pressure ulcer or its synonym. Narrative and textual analysis of documents summarising the reports was used to explore the Reviews’ observations and recommendations. The main themes were identified.

The authors located 18 relevant SCRs and 1 SAR covering pressure ulcer care in a care home setting. Most of these inquiries into practice, service communications and the events leading up to the death or harm of care home residents with pressure ulcers observed that there were failings in the care home, but also in the wider health and care systems. Overall, the reports reveal specific failings in multi-agency communication and in quality of care. Pressure ulcers featured in several SCRs, but it is problems and inadequacies with care and treatment that moved them to the safeguarding arena. The value of examining pressure ulcers as a key line of inquiry is that they are “visible” in the system, with consensus about what they are, how to measure them and what constitutes optimal care and treatment. In the new Care Act 2014 context they may continue to feature in safeguarding enquiries and investigations as they may be possible symptoms of system failures.

Reviews vary in content, structure and accessibility making it hard to compare their approach, findings and recommendations. There are risks in drawing too many conclusions from the corpus of Reviews since these are not published in full and contexts have subsequently changed. However, this is the first analysis of these documents to take pressure ulcers as the focus and it offers valuable insights into care home practices amid other systems and professional activity.

This analysis highlights that it is not inevitably poor quality care in a care home that gives rise to pressure ulcers among residents. Several SCRs note problems in wider communications with healthcare providers and their engagement. Nonetheless, poor care quality and negligence were reported in some cases. Various policies have commented on the potential overlap between the raising of concerns about poor quality care and about safeguarding. These were highlighted prior to the Care Act 2014 although current policy views problems with pressure ulcers more as care quality and clinical concerns.

The value of this documentary analysis is that it rests on real case examples and scrutiny at local level. Future research could consider the findings of SARs, similar documents from the rest of the UK, and international perspectives.

The value of having a set of documents about adult safeguarding is that they lend themselves to analysis and comparison. This first analysis to focus on pressure ulcers addresses wider considerations related to safeguarding policy and practice.

Current provision of health and social care for older people reflects a dysfunctional historic legacy of separatism, one with increasingly unacceptable consequences for the quality and cost‐effectiveness of the care provided. However, there is now detailed and encouraging comparative evidence to support the view that more integrated care ‐ delivered jointly, promptly and flexibly to meet the changing clinical and dependency needs of frailer older people at home ‐ can minimise unnecessary use of more costly and less preferable care elsewhere, and thus reduce the overall costs of late‐life care while improving its quality. This paper considers the background to the widely prevailing culture of separatism, presents quantitative evidence of the current postcode lottery in care, describes examples of current good practice, considers some options on functional and structural integration, and speculates on policy that might deliver better and more cost‐effective care for an ageing population at a time of impending stringency in the funding of public services.

Local serious case reviews (SCRs) (now Safeguarding Adults Reviews (SARs)) may be held in England when a vulnerable adult dies or is harmed or at risk of being so, and local agencies may not have responded to the abuse or neglect. The purpose of this paper is to present findings from a documentary analysis of these reviews to ascertain what recommendations are made about pressure ulcer prevention and treatment at home, setting these in the context of safeguarding, and assessing what lessons may be learned by considering them as a group. This analysis is presented at a time of increased interest of the risks of pressure ulcers among frail and very ill populations; and debates about the interface of neglect and safeguarding systems.

Identification of SCRs from England where the person who died or who was harmed had been suffering from pressure ulcers or their synonyms in their home; termed home acquired pressure ulcers. Narrative and textual analysis of documents summarising the reports was undertaken to explore the reviews’ observations and recommendations. The main circumstances, recommendations and common themes were identified.

The authors located 18 relevant SCRs, one of which was a case summary and two SARs covering pressure ulcers that had been acquired or worsened when the individual was living at home. Most of these inquired into the individual’s circumstances, their acceptance of care and support, the actions of others in their family or professionals, and the events leading up to the death or harm. Failures to have followed guidance were noted among professionals, and problems within wider health and care systems were identified. Recommendations include calls for greater training on pressure ulcers for home care workers, but also greater risk communication and better adherence to clinical guidelines. A small number focus on neglect by family members, others on self-neglect, including some vulnerable adults’ lack of capacity to care for themselves or to access help. In some SCRs the presence of a pressure ulcer is only mentioned circumstantially.

The value of this documentary analysis is that it draws on case examples and scrutiny at local level. Future research could consider the related findings of SARs as they emerge, similar documents from the rest of the UK, and international perspectives

This analysis highlights the multitude of complex social and health situations that gives rise to pressure ulcers among people living at home. Several SCRs observe problems in the wider communications with and between health and care providers. Nonetheless poor care quality and negligence are reported in some SCRs. Cases of self-neglect give rise to challenging practice situations. While practices and policies about poor quality care and safeguarding in the form of prevention of wilful neglect are emerging, they often relate to hospital and care home settings. Preventing and treating pressure ulcers may be part of safeguarding in its broadest sense but raises the question of whether training, expertise and support on this subject or wider self-neglect and neglect by others are sufficiently robust for home care workers and community-based professionals.

The value of having a set of SCRs is that they lend themselves to analysis and comparison. This analysis is the first to focus on home acquired pressure ulcers and to address wider considerations related to safeguarding policy and practice. Pressure ulcers feature in several SCRs either as contextual information about the vulnerable adults’ health-status or as indications of poor care. The potential value of examining home acquired pressure ulcers as a key line of enquiry is that they are “visible” in the system, with consensus about what they are, how to measure them and what is optimal care and treatment. In the new Care Act 2014 context, they may still feature in safeguarding inquiries as symptoms of failings in systems or of personal culpability for poor care. Learning from them may be of interest to other parts of the UK.

The training of care staff in care homes for older people is important to ensure the maintenance of evidence‐based and effective care. Moreover, training can assist in changing attitudes and promoting improved quality care for residents.To this end the Allied Health Professional (AHP) Care Homes Training Team provides training to care staff throughout the greater Glasgow area. This study sought to elicit service user views and opinions about the team's current provision to assist in informing prospective developments and enhancing future performance. Many of the responses discussed training in general in care homes and so should be of interest to all AHPs and others with an interest in care homes. Ten semi‐structured interviews were undertaken with home management staff, which were thematically analysed. The response rate was 100%. 648 care staff had received training from the team in the ten care homes. However, only 36% of these staff remained employed by the homes at the time of the study. Therefore, only the remaining staff received postal semi‐structured questionnaires. The response rate was 14% for these staff. A range of service users' opinions and views were elicited.Topics covered included: induction training, career progression through training, training records, team training and support provision, changes implemented as a result of training, barriers to implementing training, structure/times/content and delivery of training sessions, training gaps, information and training for managers and appropriate topics for training. Feedback was extremely positive but the study raised wider implications for older people's care in care homes, which merit further research and debate.

This paper reports on an action research study that aimed to collaboratively develop a complementary therapy care intervention to augment palliative care choices available to nursing home residents with advanced dementia.

An action research design was adopted that consisted of a series of action cycles involving collaborative exploration, problem-solving planning, development and evidence gathering. A combination of mixed methods was used when gaining data at the different stages, including face to face delivered questionnaires, observational notes, focus groups, and the objective measure of the Neuropsychiatric Inventory adapted for Nursing Homes (NPI-NH).

Care home staff and relatives considered the use of Complementary Therapy to be a helpful intervention promoting that it can reduce a sense of loneliness and provide companionship for residents experiencing distress. Analysis of NPI-NH scores showed a reduction in presenting neuropsychiatric behaviours associated with stress and distress.

Differing levels of participant group engagement may affect this study’s findings as it was noted that care home staff provided a fuller contribution to the project in comparison to relatives.

Implementation guidance is needed when implementing complementary therapy within the nursing home practice to promote consistency and successful integration of an intervention that is not provided as routine care.

The findings of this study are encouraging and demonstrate the acceptability of complementary therapies to residents with advanced dementia, where positive impacts on otherwise difficult to address dementia symptoms related to stress and distress are highlighted.