Nottingham Insight

Introduction

According to the Health and Social Care Act 2008 a care home is a place where personal care and accommodation are provided together.  People may live in the service for short or long periods.  For many people, it is their sole place of residence and so it becomes their home, although they do not legally own or rent it.  Both the care that people receive and the premises are regulated.

In addition, in care home services with nursing, qualified nursing care is provided, to ensure that the full needs of the person using the service are met.
There is a difference between older people living in care homes with nursing and those living in care homes without nursing; those residents requiring nursing have higher levels of functional dependence which require more specialist nursing support. 

For the purpose of the JSNA chapter, the use of the term ‘care home’ will encompass both types of home as according to the Martin et al. writing on behalf of the British Geriatric Society, “there is considerable overlap in the case mix and clinical needs of the population, regardless of registration status,” (Martin et al, 2011).

In 2010 there were 376,250 older people in 10,331 care homes in England with the average size being 18.5 places for residential care homes and 46.6 places for nursing homes (CQC, 2010)

The most common types of provision were for older people and people with a learning disability. An estimated 45% of care home places in England are occupied by people who are self-funding rather than being paid for by the state.  In Nottingham City there are 83 care homes with 24% of them being nursing homes and 76% of them being residential accommodation.

In England, 2010 the ownership of care homes was described as 73% independent, 14% voluntary sector, 11% local county and 1% each for NHS and ‘other’ (CQC 2010) In Nottingham the ownership of care homes are 84% privately owned, 7% run by the voluntary sector and 9% run by Nottingham City council.

Care home residents comprise 4% of the UK population aged 65 and over and according to the Office of Fair Trading (2005) the average care home resident is in their mid-80s or older with around 75% women; nearly 20% of those are aged 85 and over. There is a current expectancy that life expectancy is due to increase by 3 years in women from 85 to 88 and four years in men from 82 to 86 years by 2025. (www.gad.gov.uk, June, 2011)

In Nottingham there are 4900 older people aged 85 and over (2% of the total female population and 1% of the total male population in Nottingham respectively are over the age of 85 years). Going forward the number and proportion of those over 85 year olds is expected to increase. Taking this increase into consideration the impact on the future needs of care homes will be need to be reviewed.

It is not only the increase in the number of older people (particularly in the 85+ category) which will contribute to the challenge of care homes but other factors which will put the spotlight on how older people are looked after in care homes.

For example the increasing number of frail/elderly living in care homes with multi co-morbidities, the increasing number of hospital admissions from care homes both appropriate and inappropriate and the increasing pressure placed on the workforce within a care home setting.

In light of the above, Nottingham City Council (NCC) is seeking to implement a number of early interventions which it is anticipated will mitigate some of the demand suggested above.  These early interventions include an expanded assistive technology strategy and an enablement service.  These services will help older people to remain living independently within the community for longer.

Many older people living in care homes have considerable health care needs and are living with multiple co-morbidities. A national census of care home residents undertaken for Bupa by Bowman C, Whistler J and Ellerby M (2003) found that : 

•  More than 50% of residents had dementia, stroke or other neurodegenerative disease.
• Over all 76% of residents required assistance with their mobility or were immobile.
• 78% had at least one form of mental impairment.
• 71% were incontinent.
• 64% were ‘confused’ or ‘forgetful’.

Other health care conditions which are prevalent in the older people residing in care homes are malnutrition, pain associated with arthritis, hip fractures related to falls and hypertension.

In addition many residents within care homes are on multiple medications. The Department of Health, Care Home use of Medicines Study (CHUMS) (2009) found that residents were prescribed an average of 7.2 medicines. In Nottingham the Medicines Management team have been working on intensive medicines management in care homes since Autumn 2008 with the aim of the service to;

• Raise medicines management standards and promote best practice
• Improve governance standards
• Reduce hospital admissions
• Increase patient safety for vulnerable patients across NHS Nottingham City by addressing issues raised by safeguarding events

The workforce of care homes mainly comprises of female staff with many of them being overseas migrants, according to Skills for Care (2010) 80% of the workforce is female with 19% of all workers were born oversees. In addition there is a poor rate of pay for the workforce within care homes and a high turn over of staff.

The needs of older people in relation to falls, dementia and carers are considered elsewhere.

Key issues and gaps

• Number of older people increasing; in particular those over the age 85 years. This is issue will be of particular relevance in Nottingham.
• The number of frail older people in care homes is increasing.
• Poor access to healthcare services and awareness of services particularly for certain community groups.
• The high rates of hospital admissions of older people from care homes. Coupled with this are potentially low rates of admissions from care homes where an admission to secondary care may be appropriate.
• The complex needs and multiple co-morbidities of the residents of care homes which leads to high health care management of the older person and high level of dependence.
• Ensuring the mental health and overall wellbeing of care home residents are taken into consideration.
• Safeguarding of frail/elderly client within a care home is paramount.
• The poor communication between care homes and East Midlands Ambulance Service (EMAS ) in relation to urgency of a call out for example response time in relation for a client who is experiencing a Transient Ischemic Attack (TIA).
• Ensuring there is appropriate communication between staff and residents who have a sensory impairment.
• The complex funding allocation for adult and social care funding for the older person entering into a care home.
• The high level of staff turn over working in a care home, in addition the low pay associated with working within a care home and lack of structured training for health care assistants.
• Communication barriers between the NHS, Health and Social Care and the care home.
• The sharing of health and social care records, NHS records with all relevant parties to gain a comprehensive picture of the older person.
• The lack of formal end of life planning/palliative care within care homes.
• There is an increased likelihood of being admitted into a care home if the older person comes from a deprived area.
• The increased risk and higher rate of abuse of older people living in a care home.
• The lack of formal structured training for health care assistants working within a care home.
• The lack of a Comprehensive Geriatric Assessment for all older people at the point of admission to a care home.

Recommendations for consideration by commissioners

• Develop a robust data dash board to report on key care home issues for example pressure ulcer incidence and prevalence in care homes related to hospital admissions.
• To ensure each older person undergoes a Comprehensive Geriatric Assessment at the point of admission to a care home.
• Support the implementation of advance end of life planning within each care home using a recognised framework for delivery for example the Gold Standard Framework.
• Continue to conduct a medicine management review of polypharmacy.
• Conduct a review of the care home workforce to ensure there are enough qualified staff to meet the needs of the care home residents and the appropriate skills mix of registered nurses to health care assistants.
• To incorporate ethnicity data into monitoring of care home residents.
• Continue to build on the Care Home LES following on from the results of the evaluation.
• Further develop a comprehensive medicines management service/specification into all commissioned care home services and contracts.
• Develop a jointly commissioned arrangement between the Nottingham City Clinical Commissioning Group and Nottingham City Council with regards to enabling a sustainable pharmaceutical infrastructure to reduce clinical and corporate risk and improve safety for care home residents.
• Development of a multi-disciplinary care homes team

Mary Orhewere, Consultant in Public Health Medicine, mary.orhewere@nottinghamcity.nhs.uk 
Sarah Quilty, Public Health Development Manager, sarah.quilty@nottinghamcity.nhs.uk Ellyn Dryden, Public Health Development Manager, ellyn.dryden@nottinghamcity.nhs.uk 
Simon Down, Lead Commissioning Manager, Nottingham City Council
simon.down@nottinghamcity.gov.uk