This project aims to esatblish a care home in-reach team which will work alongside providers to improve the quality of care delivered to people with dementia living in residential care homes and nursing homes across West Berkshire.  The team would aim to improve the health, well-being and independence of residents with dementia.

The team would comprise two experienced 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 specialist assessments for each resident with dementia, reviewing their mental health and physical health needs and their care plans.  This team will provide a pro-active service rather than the reactive service currently provided by community mental health services [CMHT(E)s]  and community health staff.   There would be a team manager who would work 50% of their time as a manager and 50% as a clinician.  The team would comprise a total of 6.5 nurses.  They would all be very experienced nurses in order to be credible leaders and motivators.

Team members will spend a high proportion 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.  Staff would be trained to recognize the early signs of deterioration and advised about measures that can prevent the further worsening of the condition.  Psycho-social strategies for managing behaviours that are considered challenging would be introduced and modeled.

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.

Team members would provide support to carers of the residents – an area of work that is often neglected. They would also involve residents and their relatives in anticipatory planning for end of life care.

At a workshop sponsored by the West of Berkshire Dementia Stakeholder’s group a number of bids were discussed and prioritized.  This bid was one of the top 3 bids as the group members felt that improving the quality of care in care homes should be prioritized.  Group members include representatives from the Primary Care Trust (PCT) GPs from the Clinical Commissioning Groups (CCGs) , local authorities, Berkshire Healthcare NHS Foundation trust, voluntary sector groups (e.g. Alzheimer’s Society, Age UK) and the local LINk.

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% (End of Life strategy).

The main outcomes would be improved quality of care for the person with dementia in terms of more effective management of physical and mental health conditions leading to a reduction in the usage of general and psychiatric hospital services. When people with dementia are admitted, the length of stay would be reduced as acute hospital teams would have the confidence in better Home management to discharge patients earlier. This would secure future funding as there would be 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).  Figures show us that 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.

The local CCGs have identified a gap in local services and have indicated that they would welcome a case for future funding being included in next year’s business planning cycle.  Evidence from the first year’s operation would be invaluable to support the case for future funding.

Anticipated outcomes

• Detailed review of the mental and physical health of people with dementia leading to more effective management plans
• Discussion with the person with dementia and their family to inform decisions about end of life care
• Reduction in number of unplanned hospital admissions for people with dementia
• Reduction in the use of medications in general  and in particular the use of anti-psychotic medication
• Improved care for residents as care home staff will have improved skills and knowledge of dementia.
• Opportunity to improve collaboration with community services and CMHTE
• Carers would be supported and involved more with the plans for the residents.

Progress update

We have been successful in recruiting a team of very experienced and enthusiatic nurses who 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.

Work around End of Life care plans was always part of the team’s objectives. They have now identified a need for advance care plans as well. It is hoped these will help reduce the number of unplanned admissions.

The Trust has applied for money from the Winter Pressures fund. This wold be used to add staff to the team for a fixed term. If successful these staff may not be focused only on people with dementia.