How to provide Outstanding care

Care home providers WCS Care, Colten Care, Birtley House, Stow Healthcare and Anchor share how they achieve Outstanding care with CHP. 

CHP: We have the full range of care home properties represented here today, from period conversions to modern purpose-built. What are the key ingredients for an outstanding care home environment?

Simon Whalley (SW), Owner, Birtley House: Every care home is a bit different. We are at the luxury end of the market. We are in 48 acres. We have lovely grounds. You cannot see another property from the building. We are surrounded by woods and fields and cows and sheep. It’s a very old house, which has its disadvantages in terms of conversion. There’s been something on our site since 1231. That history is quite nice. The residents love sharing that. Because we have the grounds and the space, we make it available to the community. We bring the community in. It’s a fundamental part of good care to be wholly engaged with the community around you. You have got to make sure that residents and staff all feel proud of where they are. We have something like 10,000 people through our site each year. We have our Sculpture Gardens event that lasts for a month and attracts thousands of people. We really build up a whole range of things that people can be proud of. That’s key for staff and residents. They have got to feel part of one organisation that they are proud of it together. That’s fundamental to our approach.

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CHP: Does having an old building hamper you from providing the type of technology that is required in a modern care setting?

SW: You have to invest more. WiFi is hard with big thick walls but we are moving ahead with technology. Clearly technology in terms of access to information is advancing really well but frustratingly it’s a bit piecemeal and people are coming up with all sorts of solutions which are not always compatible. We have a basic system that is working in all of the care planning and we are now going to connect that up so people can actually see what’s happening on screen in a much wider sense for family and residents and staff. We are looking to connect up to the ambulance service more freely. It’s a slow process. We are now connected with our pharmacy and we are able to audit the medicines administration more reliably.

CHP: Ruth, you have a similar property model in terms of period home conversions.

Ruth French (RF), Operations Director, Stow Healthcare: All of ours are period properties and are Grade II listed buildings. We share lots of the same challenges and advantages as Birtley House. Like you Simon, we are working very hard to bring the community into the home. Our latest innovation has been a new toddler group which has been set up in one of the homes on a monthly basis. We have lots of events that are open to the community. There’s a scope to use the properties to really open up to the community and create some excitement. We are all in the position where no-one in the ideal world would ever to want to move into a care facility. Our challenge is encouraging people to come and see the environment before we even need to think about care. At the point then when people do need it they will maybe think back and remember when they heard a fantastic music recital or whatever and that was the thing that made them engaged with the home. It’s so hard to get people over that threshold and feel positive about the home. If you can do that and get people to think in advance, rather than be in that crisis situation where they have to find a bed, then you really have started to meet some of the challenges.

One of the other issues we have had is the size of some of the gardens which are quite vast in some cases. They are beautiful in terms of the views but we have to create some smaller parts particularly for people who are living with dementia where they can feel more secure but can also have that little bit more independence rather than feel that staff are constantly hovering.

We have been creating sensory courtyard gardens over the last four years which have really enhanced the environment that we are offering.

We have similar issues around technology and thick walls as Birtley but we have the advantage as many of us round the table of being a smaller, more agile organisation in terms of being able to introduce technology. 

Ruth FrenchCHP: Elaine, you are coming at care provision from the other angle of being able to create your own homes. How does that help in creating a caring environment?

Elaine Farrer (EF), Operations Director, Colten Care: We are very fortunate in having a sister company that is our own building company so we can sit literally with a blank piece of paper and change our design as the building progresses. We have taken a lot of time for our new build that will open in Poole in the spring of next year by going back to our last new build that opened in Chichester a couple of years ago and sitting down with residents and saying ‘honestly, have we got this right?’. We received some really interesting feedback. It’s their home and we want to make sure it feels like a home and not like a hotel. We have taken a lot of time to make sure we have engaged with as many interested parties as we can so that the home integrates well into the local community. It’s important our residents feel part of the local community from day one. We want to create a positive first impression so when you come into the care home as part of a community event you see first-hand what an amazing building it is with wonderful facilities and a feeling of home. We all know what a difficult journey it is to find a care home, often at short notice, and what to look for if you haven’t had the opportunity to step inside one before.

CHP: Your designs are also very sensitive to blending in with the surrounding area, Elaine.

EF: Very much so. Some of that is done because of the very challenging planning application process. There’s lot of things that we look to do where the planner has gone ‘no’, so we have had to find a compromise. The last thing you want is for your care home to stand out for all the wrong reasons. You want to blend in from a building point of view. I can remember when I first started and I went to our home in Sherborne and I couldn’t find it. It had been designed to look like several cottages facing the main road. It looked so unlike a care home. It’s such a different experience and blends in so well with the local community and that’s important.

Christine Asbury (CA), CEO, WCS Care: Of our 13 homes, only two are new builds. The remainder were inherited from the local authority. Of our six Outstandings, only one is a new build and the other five are very old stock that really are ageing. The first thing to say in relation to being Outstanding is that it’s not the environment that’s the important thing. However, being Outstanding isn’t what drives us and what drives us is our values and ambitions and the experience of our residents. With our new builds we have been on a journey and we learnt some things on our first new build which we have transferred to our second new build, which has a fantastic environment that has been designed to enable us to be able to deliver the care that we want to deliver, which is all about every day being well-lived for our residents. We have been able to cascade it back to some of our other homes.

More and more we are focusing on our residents being independent and active and having lots of opportunities within the environment to do things that they have always done, such as going to the shop or to the cinema or playing table tennis. A lot of that we are able to cascade back to our other homes because they don’t require a lot of space or a new build.

The other thing we are really focusing on now, and you see it in the design of the building that is coming out of the ground now, is having enough outdoor time. We are convinced that being outside is a really important part of well-being. We have set a target of 90 minutes a week of outdoor time for all our residents. We have a statistic that the average time spent outside a care home is four minutes, which is probably going to the ambulance and back. Last summer we achieved something like 59 minutes for half of our residents a week so we are building towards our target. We have designed a building in our next home which means you will have to go outside once you leave your front door to get anywhere else in the care home. We also have two-seater bikes at five of our homes now and have been able to build bike tracks around the homes.

CHP: Has the cascading back from your new homes to your older stock been particularly challenging in any way, Christine?

CA: Yes there has been a challenge in terms of space. We would like households to be self-contained units in terms of being domestic so you come out of them in order to do activities you want to do. That’s harder in an older home. You can’t have a cooking kitchen in an older home because of fire regulations. Meal time experience is more traditional and more conventional. We only have shops in our two new builds at the moment. We are trying to find ways of introducing them in our older homes. We have been able to introduce cafes into most of our homes. It gives people living with dementia who may not know where they want to go a sense of purpose when they arrive at a destination.

CHP: Are any of your older homes approaching the end of their lives, Christine?

CA: I think most of them are. We are looking to get the maximum life out of them or to redevelop them. The one we are building at the moment is a redevelopment so we have demolished the old style building, but we can’t do it all at once.

Christine Asbury

EF: We are fortunate that our homes are of newer stock compared to many care home providers with opportunities for our residents, families, staff and visitors to access outside space. We are using outdoor space more. We are encouraging our staff to take the view that it’s fine for our residents to go outdoors even if it’s raining. We want people to be able to feel the wind and rain on their cheeks. It’s all about living well and doing what is normal. We have been spending a lot of our time making our gardens even more accessible this spring.

We have been positioning bird feeders where our residents can see them. We have hedgehog holes and compost heaps and bug houses and have planned out interesting garden routes around our homes so people can take a map and have a look around the garden stopping off at places of interest and reading or looking at various plants. We have been making our own jams and chutneys from produce grown in the garden. We grow our own vegetables and the residents enjoy helping the gardeners where possible.

Rob Martin (RM), Head of Care Quality, Anchor: There needs to be a provision for easy access to outdoor space. We have some buildings that are 20 or 30 years old which have still achieved Outstanding despite some design issues of the period and the fact that back when they were built we didn’t consider the importance of outdoor space in the way we do now.

Two of our most recent Outstanding rated homes are typical of the design environment of the 1970s and 1980s. We have made provision to compensate for this. What we have done to overcome that challenge is just to acknowledge that those limitations are there and put additional staffing in to compensate and also make some changes through good planning to improve the layout and landscape in the way that we deliver services. At one time those that were less able bodied would live on the upper floors and those with good mobility would take the ground floor. Some of our planning approach is now to reverse that to give those with greatest need the closest access to outdoor space, this ensures that all people using our services can enjoy the outdoor space equally.

CHP: Having access to sunlight in the winter months is a big challenge.

CA: We have just done a pilot in our first new build, Drovers House in Rugby, into circadian rhythm lighting. It’s been quite transformational with residents and we are installing that into our new build that is going up at the moment. If it works for astronauts and in education then surely it is going to be beneficial for people with dementia? We have installed it into one household and some of the communal areas of Drovers House such as the cafes and public areas. It creates a really bright and uplifting environment. It gives you white light earlier in the day and gradually transforms into light that mimics candle light in the evening. It starts to reset your natural body rhythms. We have seen some real transformations. People who really didn’t engage have started to engage and come and eat meals with other people and go to communal areas. We have seen a lot less agitation.

 SW: We do a lot of work with young people with learning difficulties who work in our gardens and grounds. Our residents realise that they are people they can help and so we have a lot of interaction. We have school children who come in for wood carving and have helped residents to try this out too. We have groups who use our land for bee keeping training. They produce honey which our residents love. We have a whole range of people working in wood and stone who share what they create with residents and have taught our residents how to carve. We have willow weaving and charcoal making sessions and fishing activities. You can’t do some of these things without assessing risk. There’s antagonism to risk in the whole system but sometimes people just have to enjoy things.

 CHP: How do you go about establishing a caring culture in your homes?

 SW: Good care has to be exemplary from the top down but what we are really trying to do is encourage leadership from the bottom up. Ultimately, it’s vitally important that all staff feel that they are supporting each other rather than getting something for themselves. If we are not sharing ideas then the whole thing just collapses. It’s about sharing ideas with the staff and encouraging them to come forward with ideas and demonstrating leadership and feeling that they are contributing. That makes the culture work.

Simon Whalley

RF: We are just going through our annual staff surveys and every year communication has come up as an issue. One of the innovations we have introduced at a home we have just acquired is the Pulse Group, which includes meeting with a member of every department every week and asking them what their issues are. We are now spreading it out to our other homes and are getting some really encouraging feedback. We had suggestions boxes in our homes for a really long time and felt they were not really working. We morphed that into a ‘you said, we did board’ and still felt that wasn’t working effectively. We have now created a very public log of every suggestion that comes in so anyone who comes into the home can read every suggestion that’s been made and if we have done something about it what that was and if we could not why that was and if we are able to do it differently in the future. It has become much more of a virtuous circle and we are getting a lot more suggestions through because people are seeing that we are doing something about them.

RM: We have found ‘you said, we did’ boards to be really effective and a really good way in communicating directly with residents and family members.

CA: Maintaining care quality is all down to culture. The most important point for us is that people share the same passions and the same set of values. We introduced our values about five years ago. What really excited staff about them was that it was validating what they were doing anyway, it was just finding a set of words that we could all use to share about those values. It was not using all that jargon about person centre care because that’s quite alienating to everybody. Why wouldn’t it be person-centred care? What sort of care would it be if it’s not person centred? I don’t even know why we are discussing that. It’s about showing leadership through all parts of the organisation and one of our values is we talk about the ‘standard you walk past is the standard you accept’ and that’s so powerful for everybody because they just get it. That really has a massive impact.

CHP: Most of your staff were already there at the homes you acquired from local authorities when you brought those values in, Christine?

CA: I did a lot of the initial sessions and the people who came along to them were nervous about what they were going to have to learn but actually they left thinking ‘this is what we actually do’ because we talk about ‘play’, ‘make someone’s day’, ‘be there’, ‘choose your attitude’ and ‘the standard you walk past’. It’s all very easy, accessible language that means something to people. A good carer will be doing that anyway.

RF: There were a couple of things we spent a lot of time looking at last year. It is challenging to recruit nurses for all nursing homes across the country. We have got some quite isolated homes that people have to be able to drive to, which rules out a lot of people who arrive in the UK from foreign countries any way. We don’t have the resources to head off to Croatia, Portugal and Italy and bring bus loads back and it’s not how we want to do it any way. We have tried a different, two-pronged approach. We approached the local university which has a nursing course and said we would like to host a recruitment evening for your nurses who are going to be leaving in the next cohort. We recruited three nurses from that event who have all now started with us and are doing their preceptorship and are delighted about the choice they’ve made. They are earning a lot more than they would in the NHS. Their training programme, which we have put together for them, has been extremely comprehensive. These were all carers who went into nursing because they were working in a care home and liked it and thought ‘I think I can be a nurse’, so this environment is a lot more familiar to them than a hospital would be. As part of that programme, because we are working much more closely with the university, we are now introducing student nurses into our homes for the first time. We are also having paramedics and physiotherapists on placement.

The other thing we have been doing is upskilling our senior carers. We inherited senior carers from some of the homes we bought. They had a title which didn’t necessarily mean they had any extra responsibilities. We wanted to do away with the title and we invited people to go through an application process to be a care home assistant practitioner (CHAP). We have developed a comprehensive, in-house programme. Now, rather than bring in an agency nurse when one of our two nurses goes on holiday, we can have one nurse supported by two assistant practitioners. They can deal with the medication and simple wound dressing. The nurse’s skills can be far more focused on the poorliest residents in the homes and not having to do endless drug rounds. We are able to offer career progression for our care staff when before we were losing our senior carers to the bigger companies who were saying come and be a team leader or a unit manager. We are giving something different and I hope that’s really going to benefit our residents moving forward and help with our recruitment. We are now fully recruited for nurses across all our homes which is a very different position to what we were in a year ago. I think the nurses have been really impressed by the professionalism of the CHAPs who have been working alongside them. Frankly, the error rate amongst the CHAPs is always lower than amongst the nurses because they are much more careful.

SW: We have done the same in terms of promoting carers. On the whole we have given more administrative than medical support to nurses because we found our nurses were getting very upset if somebody was taking on their drug responsibilities. It’s a slightly tough area we have to be careful about. We have also appointed an external nurse to do our auditing, which is less threatening for our staff.

EF: We have done something very similar with our senior care leads. We have strong links with Bournemouth University and student nurse placements. We have 32 mentors across our 20 homes. The students bring such energy into the home. We have been taking first year students and have now been accepted to take third years and we have attended several recruitment days at the University which have been very successful. When you sit and think about all the responsibility nurses have in care homes, it’s phenomenal. There’s a whole misunderstanding about nurses in care homes not being good enough to work in the NHS and them winding down for retirement. This is simply not the case. We have seen strong career paths with newly qualified nurses who have gone on to do great things. One of our last home manager appointments is someone who joined us at the beginning of her nurse career. That’s the sort of succession planning story that sets care homes apart from other nurse career streams.

Elaine Farrer

SW: We have one Clinical Lead nurse who started with us as a 17-year-old carer from Zimbabwe some 18 years ago. It is amazing to see the opportunities that are now there which weren’t there in the old days.

 EF: We have a clinical excellence day that we host every year for about 100 of our nurses. They come along for an interactive day to improve clinical practice and to visit various trade stands, including from The Royal College of Nursing and Bournemouth University. We have presentations and workshops throughout the day about striving towards clinical excellence. It’s one way that we as an organisation show how much we value our nurses as individuals and how they can make the lives of our residents so much better. We celebrate Nurses Day and all of our nurses get an individual thank you card. We have just celebrated our first Colten Champions awards ceremony with 140 employees participating in a black tie gala event. We had 800 nominations from residents, colleagues, relatives and professionals for the 12 award categories. Our teams had an amazing night to remember.

SW: We have a staff fund which are residents contribute to and we give it out at Christmas. We do that on the basis of hours worked throughout the year rather than seniority. We also have a bonus structure which is done on a seniority basis.

RM: Our challenge is having a dispersed workforce of well over 7,000 colleagues that we want to engage with. We think about offering a career pathway for people by starting with apprenticeships. We have just won a Skills for Care apprenticeship of the year award. We also offer our My Futures development programme that supports our colleagues to develop their career to the next level.

Around 18 months ago we introduced facebook’s Workplace for all of our staff. That has been phenomenal as a communication tool. We have around 3,500 people actively engaged on it. People can talk directly to their chief executive, whether they are the cleaner, the manager, or the care worker. It’s become a great means of sharing ideas. We have groups where frontline staff can post about how their day is going or post great activities and events that are going on. We have groups specific to care events, conferences and pets in our homes.

We have found we are much more engaged with our workforce and are sharing ideas all of the time. We run all of our conferences live so the whole of our workforce can see them. We have a ‘leaders live’ session every month where groups of leaders come together and people can ask questions.

Rob Martin

CA: We use Workplace. We have set up a group called ‘a window into Christine’s world’ where people can see what I am doing. It’s about sharing and transparency and making sure people feel involved.

CHP: Can I wrap up by asking each of you how you are using technology to provide better care?

SW: We work with a Canadian care planning system called Medicare. We were one of the first in the south of England to adopt it. It’s working pretty well and has been extended out to provide support on emar. The next stage is looking at its interactive capabilities so that everyone can get into it within the context of the right security so that residents can communicate with their families.

We are also developing our Virtual Care Home initiative in order to reach out to the community where we can take people from hospital and get them to the stage where they can return home but not feel abandoned. The NHS Trust has asked us about the potential of having a step-down ward in our local hospital where they can do the medical side but can’t do the social care. Finding new ways of getting those sort of things working is really the way we have got to go and technology is going to be a key part of that process.

RM: We break technology up into three areas: safety, engagement and efficiency. From a safety perspective, we are designing homes with PIR lighting and full technology capability. From an engagement perspective, we are ensuring we have WiFi in all areas of all our homes, we have iPads in every care home that can be utilised by residents, we are also experimenting with VR technology for people who are not able to experience moments that they would have in the past such as walking along the beach or through the countryside. In terms of efficiency, we are using technology in the back of house to run care homes much more cost effectively through things such as moving to online food ordering.

CA: We have the reputation of using lots of technology but I would much rather people focus on the creativity of the care we are delivering. We are always looking at what will improve the experience of our residents and staff and the residents’ families, and technology may be the answer to that but innovations such as our side-by-side bike are not technology. So for example, we have introduced thumb-print door access because it makes it easier for people to get in and out of locked doors.

RF: Many more of our staff are integrated as a result of the technology we have introduced. We have expanded our tablet systems from our nurses and carers to our ancillary staff over the past 12 months so that they feel much more part of the team.

EF: We have used technology primarily from a clinical outcomes perspective. Traditionally, our Clinical Leads would complete audits four weeks retrospectively which would have to be in on a given day and the data was then analysed and reported on. Not the most timely nor efficient way of working. We now have responsive electronic data reporting supported by our two Clinical Managers who support the homes where necessary. Data analysis is now simple, quick and easy to do and makes sure that we are dealing with incidents in the timeliest way possible.