West Berkshire care home in-reach team

The aim of this project is to establish a care home in-reach team which will work alongside providers to improve the quality of care delivered to people living with dementia  in residential care homes and nursing homes across West Berkshire.  The team will improve the health, well-being and independence of residents with dementia and provide professional guidance and motivation to care home staff.

The team will comprise two experienced and credible nurses in each of the three local authority areas working in 3-4 homes per locality.  There would be one RGN and one RMN in each locality.  The team will provide proactive specialist assessments for each resident with dementia, reviewing their mental health and physical health needs and their care plans.

Team members will spend most of their time in the homes working alongside staff, reviewing residents, modeling good practice, supporting staff dealing with difficult situations and introducing new tools to assist with the effective management of long term conditions.  They will provide support to carers of the residents and involve residents and their relatives in anticipatory planning for end of life care. Formal training sessions may be delivered but it is envisaged that much of the learning will come about through observation and the adoption of new ways of working. Care home staff will be trained to recognize the early signs of deterioration and advised about measures that can prevent worsening of the condition.  Psycho-social strategies for managing behaviours that are considered challenging will be introduced.

Links to national strategies:

This project would meet at least three objectives from the National Dementia Strategy:

  • Objective 11: Living Well with dementia
  • Objective 12: Improved End of Life care for people with dementia and
  • Objective13:  An informed and effective workforce for people with dementia.

It would also contribute to the national target of reducing inappropriate deaths in hospital by 10{79f878acaa41f375dcd804cc8c058b5459a5482f20a3b9f87269b26c8734749b} (End of Life strategy).

Anticipated outcomes

  • Improved quality of care for the person with dementia in terms of more effective management of physical and mental health conditions as care home staff will have improved skills and      knowledge of dementia.
  • More comprehensive, individualised and effective management plans
  • Carers would be supported and involved more with the plans for the residents.
  • Reduction in number of unplanned hospital admissions for people with dementia
  • Overall reduction in the usage of general and psychiatric hospital services
  • Reduced length of stay would be reduced as acute hospital teams would have the confidence in better Home management and discharge patients earlier.
  • Reduction in the use of medications in general and in particular the use of anti-psychotic medication
  • Improved end of life care – discussion with the  person with dementia and their family to inform decisions about end of life care
  • Self funding scheme as there are cost benefits to the Health economy locally.  This would comprise: reduced use of A&E departments, reduced numbers of admissions (HSJ estimate a cost of £3000/admission), reduced bed stays and reduced use of emergency transport      services (HSJ estimate £145/journey).  Locally there were 777 unplanned admissions from care homes and nursing homes across the West of Berkshire in 2011.  In the first half of 2012 there were 329.

Progress update

A team of very experienced and enthusiastic nurses has been recruited  – they are working well together.

In May the team started working with the first 6 homes spread across the West of Berkshire. In August they moved on to another 6 homes but will maintain contact with the first homes in order to continue to give support and training.

The team has reviewed the mental and physical health of all the residents and given advice re: care and management of their needs. They have linked with family members to ensure they are involved with decisions especially where the resident is no longer able to make decisions for themselves.

Working with the managers and care home staff, training needs have been identified and appropriate training delivered.

The team has built strong links with partner agencies and colleagues who also work in the homes. This includes GPs, community geriatricians, district nurses, CPNs and local authority staff.

With respect to end of life care the team has  now identified a need for advance care plans. It is hoped these will help reduce the number of unplanned admissions.


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