The number of people aged over 65 years who require either residential or nursing care is increasing (Bennett et al, 2018). One in seven people, aged 85 years or over, is living permanently in a care home and there are now three times more care-home beds than hospital beds (Care UK, 2017).
According to the British Geriatric Society (BGS) (2016), 75-80% of care-home residents have cognitive impairment, and many also have multiple long-term conditions, functional dependency and frailty. As a result, residents often experience unnecessary yet avoidable admissions to hospital, and suboptimal medication use.
Although GP practices remain responsible for providing most of the health care that care-home residents receive, demand for GPs and logistical difficulties associated with providing care to individuals who may be spread across several homes, means that much nursing care is delivered on a reactive basis.
The Enhanced Health Care Homes (EHCH) model (version 2) will be introduced across England by 2024 (NHS England and NHS Improvement, 2020) in line with the commitment pledged in the NHS Long Term Plan (2019). The EHCH is a move from traditional reactive models of intervention to proactive care, which can be achieved only through a whole-system, collaborative approach. GPs are expected to deliver EHCH through the Network Contract Directed Enhanced Service specification (Care Provider Alliance, 2021).
There are currently 36 000 registered nurses employed by adult social care (Queen's Nursing Institute (QNI), 2021), and they are integral to the EHCH. However, recruitment and retention of nurses in care homes is a challenge. Devi et al (2021) highlighted the importance of having a highly skilled and educated care-home nursing workforce that is able to adapt to change within individual working environments.
Residents' care is becoming more complex and technologically sophisticated, requiring nurses to be equipped with the relevant knowledge. The care-home nursing workforce will need to be developed to meet this challenge, with managers placing a greater focus on prevention, management of long-term conditions and ensuring the capacity to make an urgent response.
New roles
In North Tyneside, the recruitment and retention of nurses in care homes is challenging, with staff frequently moving between care providers. There is also a lack of career structure for nurses working in care homes, which means that experienced nurses are lost from the sector because they choose to move elsewhere for career development.
A unpublished study undertaken by Northumbria University in 2020 in North Tyneside found that nurses in care homes considered that they were often left out of career development opportunities, with new teams frequently brought in to ‘do things’, rather than developing the nurses already working in a home to undertake any new roles and functions.
Mezey et al (2005) recommended that, to improve the quality of nursing care, care homes should employ advanced care practitioners (ACPs). Boyd et al (2019) found that having ACPs in care homes benefits residents, because they offer more immediate access to higher level assessments and decision-making, provide better continuity of care and follow-up.
Recent events, particularly in the context of the COVID-19 pandemic, illustrate the need for care homes to have a highly skilled nursing workforce that is able to provide both urgent and planned care.
North Tyneside Clinical Commissioning Group (CCG), is working in partnership with four large care home providers, to appoint seven ACP trainees as part of the Health Education England (HEE) ACP apprentice scheme.
The ACP competency framework that the trainees will work toward will be the HEE (2017) multiprofessional framework for ACPs in England and the QNI's (2021) standards of education and practice for nurses new to care homes. They will be required to work within the four pillars of clinical practice, namely clinical practice, leadership and management, education, and research.
Skilled practitioners
Caring for residents in care homes is a highly skilled job, requiring an in-depth knowledge of long-term conditions associated with ageing, as well as how to manage complex multiple morbidities and frailty. Care-home practice is diverse, with the need to practise autonomously, utilising assessment and management skills, liaising with many health and social care professionals. Practitioners also need to have a sound working knowledge of relevant legislation relating to care homes. In addition, they need to develop skills in building long-term relationships with residents, relatives and significant others.
The ACP will maintain a person-centred approach to care, which recognises that the care home is the person's home, as well as a place of care. ACPs who work in care homes require emotional intelligence and the use of ‘soft skills’ such as diplomacy, sensitivity, and a heightened awareness that the care home is the individual's home.
The ACPs employed in North Tyneside will have a clear remit to deliver person-centred care. Having ACPs in care homes will give the residents choice and a voice about the care they receive. This will be achieved through listening and shared decision-making, and by ensuring that the nurses are flexible and responsive, moving between the delivery of proactive and reactive care, and ensuring that they are key members of wider multidisciplinary teams.
In supporting this quality improvement innovation, North Tyneside CCG is introducing a new way of working locally with care home providers to enhance the health of residents in care homes. It is also supporting the HEE ACP apprenticeships with a model that promotes career progression and staff development for care home staff that could be replicated nationally.