Tool developed to help care home residents and their carers to be involved in improving safety

A first-of-its kind questionnaire has been developed to gather the experiences of care home residents and family members on the safety of their care, allowing their voices to be heard. The Resident Measure of Safety (RMOS), has been designed by residents and carers alongside health and care home staff with researchers at the National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre.

The RMOS is a questionnaire that encourages care home residents and their family members to be actively involved in their safety. Staff in care homes can use the feedback gathered by the RMOS to develop specific solutions tailored to the issues raised.

Drs Natasha Tyler, Sally Giles and Maria Panagioti worked on the study and talk about development of the questionnaire and its impact below.

Developing the RMOS

We identified some useful previous research in this area and pulled this together with similar staff-focussed questionnaires that already exist. We then worked with a group of residents, carers, healthcare and care home staff to help create a new questionnaire. They helped us with the design and content to ensure the RMOS includes the most important questions and is easy to understand and use.

How the RMOS is different

There are some care home safety questionnaires in use. However, they are designed from the point of view of professionals. The RMOS is the first questionnaire of its kind where feedback is collected from residents in care homes, and their family members.

This is important as the experiences of residents and their family members are valuable when looking at making improvements to safety. The RMOS allows them to comment when things actually happen allowing professionals to take action quickly. It also introduces a standardised approach to safety.

We believe that the RMOS has the potential to be used during standardised assessments, such as Care Quality Commission assessments, as a way for residents and their carers to voice their safety concerns.

Our next step will be to assess the RMOS on a larger scale to see how well each element of the questionnaire works. We believe that, if used regularly the RMOS will create safety improvements inspired by the voice of residents and family members.

Want to know more?

If you want to know more, you can read our research paper about the development of the RMOS: or email Natasha Tyler.

The first review of transitional care interventions between hospitals and care homes has been conducted by researchers at the GM PSTRC

Research has revealed that older people living in care homes who are allocated to interventions that support the move between a care home and a hospital or emergency department are almost two times less likely to be readmitted.

Here, the authors of the paper, ‘Transitional Care Interventions for Older Residents of Long-term Care Facilities: A Systematic Review and Meta-analysis’, along with a member of the centre’s public engagement group, share their thoughts on the study and its findings.

The transition between hospital and care home is a challenging time for many older people and previous research has shown that patient safety issues are more common at points of transition.

Therefore, we identified the need to carry out research to improve patient safety in this area. Our study involved a systematic review which gathered together data reported in previous research. We then used a type of analysis known as meta-analysis to understand the association between interventions that support transitions between care settings, and various outcomes for care home residents and care home staff. Some examples of these interventions include post-discharge support and outreach services.

Transitional care interventions associated with improved outcomes

We discovered that for care home residents who were allocated to a transitional care intervention, there were fewer readmissions and their length of stay in the emergency department was shorter.

However, we discovered that the content of these interventions varied. The studies didn’t always measure the same outcomes, making it difficult to directly compare the results across studies. Therefore, a standardised set of outcomes that are agreed by patients, staff and health and care systems would strengthen future research.

We also found that the quality of communication and referral processes between care providers, as well as engagement with primary care is likely to influence the effect of transitional care interventions.

Input from people with lived experience

The study was supported by three public contributors with experience of caring for family members, preparing for a move to or already living in care homes. The public contributors provided feedback on the design of the research and on the studies that were included in the review. They agreed with our finding that more clarity is needed regarding staff roles, training and ability, in order to support transitions to and from different care settings.

Public contributor Mr Manoj Mistry said: ”We were involved from the beginning of the study, we questioned everything that was presented to us by the researchers on the basis of our ‘lived experience’ of having family members in care homes etc, which then led to refinements, further discussions and consensus. This study has been a good example of genuine collaboration and co-production between an established team of researchers and public contributors, adding more validity to the findings”.

Implications of the research

Dr Maria Panagioti, lead of the GM PSTRC’s Safer Care Systems and Transitions theme and an author of this study, said: “As this is the first review of transitional interventions in care homes, we believe our findings have the potential to improve patient safety in this area, especially since the emergence of COVID-19.”

The research identified 15 studies of transitional care interventions, 10 of which were set in Australia, but none had been carried out in the UK.  

Dr Panagioti continued: “There is a striking lack of investment in transitional care interventions across most countries, and the high human and financial costs mean such investment is urgently needed.”

The research “Transitional Care Interventions for Older Residents of Long-term Care Facilities: A Systematic Review and Meta-analysis” was published in the journal JAMA Network Open and was funded by the National Institute for Health and Care Research School for Primary Care Research (NIHR SPCR), with support from staff within the National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC).

Research into Infection Prevention Control in care homes reveals how to make improvements post COVID-19

A new study investigated measures used to control infection in care homes for older people. It involved analysing data and previous research from 2007 to 2020, before the COVID-19 pandemic, in a bid to understand the reasons how viruses spread and identify how to influence this both now and into the future.

The research ‘Beyond the control of the care home: A meta-ethnography of qualitative studies of Infection Prevention and Control in residential and nursing homes for older people‘ was published in the journal Health Expectations, and is funded by the National Institute for Health Research Greater Manchester Patient Safety Translational Research Centre (NIHR GM PSTRC). The Centre is a partnership between The University of Manchester and Salford Royal NHS Foundation Trust. 

Dr Maria Panagioti, lead of the GM PSTRC’s Safer Care Systems and Transitions Theme and an author of this study, said: “In England, Government policy around the discharge of patients from hospitals into care homes has been used to explain how COVID-19 spreads though care homes.  

“However, we believe this is only part of the story as less attention has been given to investigating the role Infection Prevention and Control played. In conducting this research we’ve analysed a large number of studies to identify some of the reasons why Infection Prevention and Control might not always be effective in stopping COVID in its tracks and how this can be improved to make healthcare safer in care homes for older people.” 

The research identified that one of the challenges faced by care homes is uncovering how an outbreak begins.  Then, once an infection begins to spread, identifying who is responsible for the necessary control measures is not always easy. High staff turnover was also found to be an additional challenge. The need to bring in external health care professionals such as GPs to diagnose or treat an infection effects Infection Prevention and Control (IPC).  

Researchers concluded that training staff repeatedly could support them in ensuring IPC is effectively practiced across care homes as this would help to, overcome one of the key reasons why IPC in care homes has not been as effective as it could have been, i.e. high staff turnover. However, the success of this measure depends upon managerial commitment and organisational improvements being made within care homes.  

Dr Panagioti, continued: “Our research has identified how important it is to understand the unique challenges care homes face regarding IPC. We believe repetitive staff training in IPC is key in helping to improve safety for care home residents and we look forward to seeing these recommendations being acted upon.” 

An experienced public contributor, who is an informal carer, was involved in the research, and said: ‘‘Having previously inspected acute hospital inpatient and mental health inpatient wards for their condition and cleanliness as a Public Member throughout Northwest England, and previously having family members / family friends admitted into care homes, I was genuinely interested in assisting with this much needed research study.

“The findings from this study on effective Infection Prevention and Control in care home settings if adhered to by owners, managers and the staff working within care homes, should make a positive difference to the safety and welfare of care home residents by reducing the risks of any potential infections that may originate and then spread. A particular strength of the study was that the voice of those with lived experience of care homes and their family members/ family carers was both listened to and incorporated into the recommendations.”

Research is underway to improve safety for older people when they’re transferred between hospitals and care homes – researchers need your help

The COVID-19 pandemic has highlighted the challenges faced when arranging transfers into or out of hospital, for people living in care homes. Making transfers safer has been a focus for researchers at the GM PSTRC. Researchers are looking for members of the public in Salford and Manchester to take part in a 45-60 minute interview either online or over the phone.

Here, Dr Gavin Daker-White, researcher in the centre’s Safer Care Systems and Transitions theme talks about the research and explains why members of the public are being encouraged to get involved with the research, what it entails and what impact this may have.

“For some time we’ve been focused on patient safety in residential care and nursing homes for older people, aged 65 years or over. Our work happened to coincide with the COVID-19 pandemic and highlighted its importance.

“We started work designing the study and to ensure it could be as useful as possible we worked with researchers from one of the centre’s other theme’s which focuses on marginalised groups and patients and carers. With them we carried out a number of literature reviews to find out what had already been uncovered in this area of research.

“Our research team have also been working with partners at Salford Royal NHS Foundation Trust and the Advancing Quality Alliance, an NHS care quality improvement organisation to design this study.

“Central to this research is finding out what can go right or wrong when residents from care homes are transferred to or from hospital, and how this could be made safer. We’d like to interview:

1. Care home residents
2. Members of their families
3. Care home and hospital staff

“The success of this important research relies upon members of the public taking the time to share their experiences of the transition between hospital and care home. Once we know what works and what doesn’t then we can look at making the transition safer. Ultimately, those who take part in the study will support our mission to ensure that older people in care homes are not harmed while being transferred to and from hospitals. It’s also about ensuring staff at care homes and hospitals are properly equipped to manage these transfers safely.    

“The information gathered in this study will be used to trial a new way of managing the hospital transfers (also known as “handovers”) of people living in care homes in Salford and in Greater Manchester. This innovative ‘handover’ scheme will allow care home residents and their formal and informal carers to decide together which belongings and documentation will be transferred during their transition. We will work together with Salford Royal NHS Foundation Trust in collaboration with AQuA (Advancing Quality Alliance) to successfully deliver this innovative handover scheme.”

The study is underway now, and interviews will be completed by July 2021, so if you’re interested in getting involved please get in touch with Gavin Daker-White as soon as you can.

Opinion piece: New COVID-19 government guidelines for care homes: Residents deserve better

by Victoria Moore

Context:

Victoria is a PhD student at the GM PSTRC whose research focuses primarily on how regulators respond to patient safety incidents linked to the hospital discharge process within the English NHS. Within this system, regulators share the same primary purpose, established through legislation, of protecting the public. Victoria is examining how effectively this aim is achieved within the context of hospital discharges.

This particular piece of guidance caught her eye because of the discharge-element. From a regulatory perspective, doctors should not be discharging patients to settings that put patients at risk. Victoria sees challenges in, and problems with, adherence to this guidance, especially in the context of COVID-19 guidance, and she wanted to address this through her blog post below.

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On 2 April 2020 the government issued new guidelines for care homes regarding the admission of patients during the COVID-19 pandemic. It is an incredibly complex situation, particularly because of the vulnerability of care home residents. As a researcher who looks at safety at transitions of care, I believe the question we should all be asking, after reading the guidelines is: Are there any other solutions which could work better at keeping all patients safer and comfortable?

The guidance has not been welcomed  by some care home managers, primarily because there is a general belief that it puts residents and staff at risk.

The main concerns being voiced are:

1. The challenges of providing intimate care while socially distancing as per the guidance.
2. The practicalities of isolating suspected positive cases as, according to the guidance, those with symptoms should be isolated in a single room with a single bathroom. If this isn’t possible then they should be moved to a room with another resident who also has symptoms.
3. Capping testing to a maximum of five residents if a care home has one resident with symptoms. This is seen as not meeting demand or need  when agency staff who provide care throughout multiple care homes may transmit COVID-19.

In addition, there are concerns around admissions to care homes. The guidance says that admissions may either follow discharge from hospital, or come from a home setting and that a negative [COVID-19] test is not required prior to transfers / admissions into the care home.

One care manager, speaking about two hospitalised residents due to be discharged without testing, said she would give notice to both residents so they wouldn’t be returning to their own care home. This would allow her to reduce the risk of exposing the other residents to the virus.

It could be argued that this approach is based on utilitarian grounds. By refusing to care for those two patients, the care manager may safeguard the lives of many other residents, when keeping this highly vulnerable population as safe as possible is a priority. But this must also be balanced with the rights and interests of the patients due to be discharged from hospital. Those people also deserve compassionate and ongoing care.

In addition, by refusing to accept patients who haven’t been tested for COVID-19, there is a possibility that a much-needed hospital bed would not available for another patient in need. It is also recognised generally that frail patients should not be kept in hospital longer than is needed due to the risk to their own health.

There is no easy solution to these problems. These circumstances require a careful balancing of the hugely varied issues at play. Importantly, the current guidance does not account for the complex nature of caring for older people in a care home setting, keeping all residents safe while ensuring those who do have the virus receive the best possible care in the most appropriate setting. This must all be seen within the context of the availability or otherwise of personal protective equipment (PPE).

It is recognised by everyone that vulnerable people cannot simply be turned out on the streets because their care home, which is their home, refuses to accept them due to the risk to all the other residents it cares for. The valid safety concerns of those who manage care homes must be listened to before guidance unintentionally permits a virus to sweep through a care home.

Some of the solutions that could be investigated could be using hotel rooms as temporary accommodation to allow symptomatic care home residents to isolate properly, with appropriate care (depending on social care workforce availability), before returning to their usual residence. Or might it be possible to ask if any family members would be willing and able to provide a temporary sanctuary for the recovery of their loved ones, with support from visiting carers? Of course, this may not always be possible depending upon the specific needs of the person in question, but there may be instances where this would be a workable approach.

In the long-term, continued efforts to join up health and social care may help to ensure better preparedness for times of crisis. The consequences of failing to do so are too high a price for our most vulnerable to pay.

Update: On 15 April the government announced that people will be tested prior to being admitted into care homes, and isolated until results come back. It remains unclear where these people will be isolated whilst awaiting results, and how care homes will subsequently be able to appropriately isolate and care for those who have tested positive.