MDS – latest research · (RNCC) tool was introduced in 2001 to determine the amount of NHS-funded registered nursing care that residents in care homes need. • This study evaluated

MDS – latest research

MDS – latest researchReviewing the RNCC tool, flexible skills mix, andthe specialist nurse project

Chrysa Apps, Phillip Borkett, Margaret Cook, Peter Cox, Val Ellis,Jan Gilbert, Jan Reed and Bill Watson

The Joseph Rowntree Foundation has supported this project as part of its programme of research andinnovative development projects, which it hopes will be of value to policy makers, practitioners and serviceusers. The facts presented and views expressed in this report are, however, those of the authors and notnecessarily those of the Foundation.

Joseph Rowntree FoundationThe Homestead40 Water EndYork YO30 6WPWebsite: www. jrf.org.uk

The Registered Nursing Care Contribution tool: © University of Northumbria 2003Flexible skills mix: © Elmfield Centre for Education and Phillip Borkett 2003The specialist nurse: © Joseph Rowntree Foundation 2003

First published 2003 by the Joseph Rowntree Foundation

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Contents

List of Figures and Tables vi

PART I: THE REGISTERED NURSING CARE CONTRIBUTION TOOL: AN EVALUATION OF USE 1Jan Reed, Bill Watson and Margaret Cook

1 Summary 32 Introduction 43 Background 44 The study 85 Results 146 Summary of findings 217 Implications: the way forward for implementation 228 Implications for future research 239 Conclusion 23References 23Appendix 1: Example of an MDS assessment form 25Appendix 2: Example of an EASY-Care assessment sheet 30Appendix 3: Letter to home manager 37Appendix 4: RNCC documentation and guidance 38Appendix 5: Letter to care home staff and information sheet 41Appendix 6: Residents’ letter and information sheet 44Appendix 7: Examples of care plans 47Appendix 8: Manual handling profile 53Appendix 9: Anonymised patient record 55

PART II: FLEXIBLE SKILLS MIX: A MODEL OF STAFFING FOR A NEW CARE DEVELOPMENT 59Phillip Borkett and Jan Gilbert

1 Background 612 Emerging factors 613 Issues considered by the group 624 Towards a staffing model for Bedford Court 655 The model 66References 67Appendix 1: Staffing calculations for Bedford Court 68Appendix 2: Nurse monitoring activity over a 24-hour period 70

PART III: THE SPECIALIST NURSE PROJECT: ENHANCING THE QUALITY OF RESIDENTS’ CARE 77Val Ellis, Chrysa Apps and Peter Cox

1 Background 792 Project aim 793 Implementing the project 804 Dementia awareness group 875 Education 886 Conclusion/points arising 887 Acknowledgements 89

Figures

Part I

1 Schematic diagram of the project design 112 Location of participating care homes 12Part II

3 Nursing activity, 22.00–23.00 724 Nursing activity, 23.00–midnight 725 Nursing activity, midnight–01.00 726 Nursing activity, 01.00–05.30 737 Nursing activity, 05.30–07.30 738 Nursing activity, 07.30–11.00 749 Nursing activity, 11.00–15.00 7410 Nursing activity, 15.00–18.00 7511 Nursing activity, 18.00–21.30 75Part III

12 Cognitive performance scales: Lamel Beeches, April 2002 8213 Cognitive performance scales: Red Lodge, April 2002 8214 Cognitive performance scales: The Oaks, April 2002 82

Tables

Part I

1 Overview of participating care homes 132 Residents’ characteristics 143 Number of residents allocated to each RNCC category by each rater 154 Percentage agreement between MDS RUG-III and each nurse rater for each RNCC band 155 Rater pairs in order of strength of agreement 166 Nurse rater pairs in order of strength of agreement 177 Analysis by gender 178 Analysis by age 189 Analysis by number of recorded conditions 18Part II

10 Allocation of staff resources at Bedford Court 6411 Staffing calculations for Bedford Court: Lower overall dependency 6812 Staffing calculations for Bedford Court: Higher overall dependency 69

List of Figures and Tables

PART IThe Registered Nursing Care Contribution tool

An evaluation of use

Jan Reed, Bill Watson and Margaret Cook

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Part I

1 Summary

• The Registered Nursing Care Contribution(RNCC) tool was introduced in 2001 todetermine the amount of NHS-funded registerednursing care that residents in care homes need.

• This study evaluated the initial implementationof the RNCC tool by comparing it to the resultsof evaluation using the Minimum Data Set(MDS) tool.

• 186 care home residents were assessed andallocated to an RNCC band both by nurse ratersand by the MDS RUG-III tool.

• RNCC assessment was carried out by fivedifferent raters: the care home staff, an externalcare home expert, the nurse researcher, a nursingconsultant in the care of older people (a sub-setof the sample) and the official RNCC rater(where available).

• Both the MDS RUG-III and nurse assessmentplaced the majority of residents in the mediumband. All of the nurse raters placed substantiallyfewer residents in the high band compared withthe MDS RUG-III allocation.

• The level of agreement between assessments wascalculated both as a percentage of agreement,expressing the number of times the raters agreerelative to the total number of assessmentsmade, and as the strength of agreement,measured using Cohen’s Kappa coefficient.

• The percentage and strength of agreementbetween the MDS RUG-III and the nurse raterswere generally low.

• There was a relationship between the knowledgebase of the nurse rater and their level ofagreement with MDS RUG-III. Those nurseraters with knowledge and experience of thecontext of care, i.e. the care home staff and theexternal care home expert, had a higher level ofagreement with MDS RUG-III than did those

nurse raters with more general knowledge ofcare for older people.

• The percentage and strength of agreementbetween the five nurse raters were low.

• The variability across nurse raters was lower,and therefore agreement was higher overall, forpeople with greater than median age. Neitherthe respondent’s gender nor the number ofrecorded medical conditions had a statisticallysignificant consistent effect on agreementbetween raters.

• The study found that the level of agreementbetween raters’ RNCC allocations was notassociated with the resulting degree of financialagreement.

• The care home staff reported difficulty in somecases in discriminating between the low andmedium bands, with some residents apparentlyfalling somewhere between the two bands. Theydid not report any problems assigning residentsbetween the medium and the high bands.

• Experience of the care home environment wouldseem to be essential if assessments are to reflectthe type and amount of care given in thisspecialised setting. The study suggests, then,that RNCC raters should have some experienceof working in this environment.

• Differences between raters may have manydifferent explanations, not least because of theunstructured nature of the RNCC tool itself.With multiple factors in play it is likely thatthere will be variations between raters, but itmust be remembered that any rater who isdifferent is as likely to be more as less accurate indeterminations. Difference per se is notnecessarily an indicator of inaccuracy, andwithout a benchmark to work to evaluatingraters according to difference from others is not avalid process. Developing such benchmarks isnecessary if monitoring is to be effective.

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MDS – latest research: the RNCC tool

• This study took place at an early point in theimplementation of the RNCC tool. As such, itsfindings form the basis for a larger study with amore diverse group of care homes. A larger andlater study would be able to explore issues aboutgender, age and disability to a greater degree,and also to collect more data on officialbandings.

2 Introduction

This report presents the findings from a studyundertaken by the Centre for Care of Older Peopleat Northumbria University to investigate the use ofthe Registered Nursing Care Contribution (RNCC)tool introduced by the government in October 2001.This tool was designed to assist in calculating thetype and amount of care residents of care homesrequired from a registered nurse. From thisdetermination, or banding into a high, medium orlow RNCC category, the cost of registered nursingcare to be paid for by the NHS would be calculated.The RNCC tool is an attempt to address some ofthe anomalies of funding and provision which havearisen in the care home sector through its long andcomplex history, and this report makes acontribution to these efforts in the way that it caninform the evaluation and development of theRNCC tool.

3 Background

The care home sector has a long and chequeredhistory, with many forms of provision and manydifferent management frameworks. Historians ofthe care home have variously traced its antecedentsback to medieval monasteries, Elizabethanworkhouses, Second World War evacuation policiesand pre-NHS maternity homes (Means and Smith,1985). These different histories mean that, whileprovision may have changed in response tochanging societies, much of the current structure ofprovision bears the marks of former initiatives and

developments. There are, however, some aspects ofthe care home sector which seem to be a constantmatter for debate and dispute.

One such aspect is the debate about how todetermine the type of care and support needed byolder people in care homes. There is a concern toensure that older people receive the right amountof care and support, with access to staff who haveappropriate skills, in order that they can maintainquality of life and independence. This concern alsoexists against a backdrop of other issues, such asthe ways in which care will be managed andresourced in a mixed economy of welfareprovision, where some people will fund their owncare but others may need state help with finance.The provision of care also reflects a mixed economyof welfare, in that some care homes are privatelyrun for profit, others are run by voluntary sectornot-for-profit agencies, and others are run by thestate (i.e. local authority homes).

The situation is made more complex by theorganisation of care home provision, which is madeup of two types of facility, each with differentstructures and histories. One type of provision hasbeen the residential care home for those who werethought to need social support and assistance withdaily living. Local authorities were central inproviding residential care until relatively recently,and entry into them was sometimes simply amatter of being eligible for housing benefit ratherthan because of any assessed need (Richards, 1996).Since the 1990 NHS Community Care Act, thissituation has changed somewhat, with newresidents who are not funding their own carehaving their care needs assessed and a care plandeveloped by their care manager (from the socialservices department concerned). Alongside thisneeds assessment was an assessment of ability tocontribute towards the cost of care, with capital,savings and property being taken into account andany shortfall being taken up by the local authority.Residential homes were inspected and registeredby social services departments who would stipulate

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Part I

standards and procedures which the homes had tocomply with. Because of this dual responsibility, forregulating residential care homes and fundingplaces in them, local authorities have developedcontracting or commissioning processes, wherebyresidential homes entered into a contract with localauthorities to meet certain standards at specifiedcosts. While this went some way towardsguaranteeing standards and levels of provisionwithin budgets, it meant that individuals couldpotentially be restricted in their choice of home toone that had a contract with the local authority.

The local authority has also had theresponsibility of supporting people receivingnursing care in the other form of care home – thenursing home. Again there would be an assessmentof need and ability to contribute towards the cost ofcare for those who were not self-funding, and thisis where some of the anomalies became mostevident. The issue of assessment of nursing need bysocial services staff, who did not necessarily havehealthcare experience, became increasing disputed,leading to strategies for carrying out more jointassessments with healthcare staff (Burgner, 1996).The problems were, however, compounded by thefact that health authorities regulated nursinghomes, including having responsibility forinspection and registration, so staff employed bylocal authorities had little involvement in settingstandards or procedures.

Recent changes and developments

The 1990 NHS and Community Care Act began tochange this situation in some ways, as indicatedabove. Local authorities were required to establishcare management processes, which would meanthat individuals would be assessed to determinethe type of support they needed, and a ‘carepackage’ would be created which would, for some,involve a move to care homes. The role of caremanager, however, was a complex one, and onewhich raised many questions about the expertise

needed to make these assessments (Stanley et al.,1999).

There was also an increased awareness that theresidential care/nursing home split in care was notalways in the best interest of residents. Residentsoften had to move if their needs changed, in orderto comply with registration regulations. Thisdisrupted many relationships and friendships andgave rise to the stress of relocation (Reed et al.,1998). More flexibility was introduced into thesystem with the creation of ‘dual-registration’status for care homes, which meant that they couldaccommodate people with a range of needs. Theprecise mechanisms of registration and inspection,however, were complex, and resulted in the settingup of joint inspection units, involving health andsocial services staff, and more recently the NationalCare Standards Agency, to oversee the process(Department of Health, 2000a).

During the 1990s there was also a decrease inNHS hospital beds for those needing long-term orcontinuing care (Department of Health, 2000b). AsNHS hospitals focused more on acute care, patientswere often discharged to care homes for continuingcare and rehabilitation, where they became liable topay fees for care. This understandably caused someprotest as the effects of the anomaly were morefully realised, for example where people had to selltheir homes to pay for care which would have beenprovided free in an NHS hospital. This was aparticular point raised by the Royal Commission onLong Term Care, which reported in 2000, and it wassuggested that a distinction could be made betweenhealth and social care elements of care costs,although the Commission was divided on thepracticalities and principles of doing this.

In an attempt to resolve this situation, the NHSPlan (Department of Health, 2000c) accepted thatregistered nursing care should be free of charge tothe recipient in all settings, including care homes.Nursing care has been defined by the Health andSocial Care Act 2001 as:

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services provided by a registered nurse and involvingeither the provision of care or the planning,supervision or delegation of the provision of care,other than any services which, having regard to theirnature and the circumstances in which they areprovided, do not need to be provided by a registerednurse.

Clearly this statement is open to a range ofinterpretations, and does not constitute anunequivocal definition of nursing care. Thedifferences between nursing or health care andsocial care have long been a subject of debate, withlittle agreement being arrived at. Dalley (2000), forexample, has described the successive attempts todraw and redraw boundaries between health andsocial care, and pointed to the differences indefinitions, professional ideologies, policies andsystems which have made attempts to integratecare so difficult. Defining need, then, and drawingthe line between nursing and social care is fraughtwith difficulties. The government has thereforedeveloped two other initiatives to clarify andstandardise the process of determining need forcare and support, the single assessment process(SAP) and the Registered Nursing CareContribution (RNCC) tool. These aim to ensure thatolder people receive the amount and type of carethat they need, in a cost-effective way.

Single assessment process

The first initiative is the development of the singleassessment process, where health and social careagencies are required to develop a co-ordinatedsystem for assessment through four levels:

• contact assessment, including the collectionof basic personal information

• overview assessment

• in-depth assessment

• comprehensive old-age assessment.

This process is still in its early implementationphase, having commenced in April 2002 with localagencies determining their own procedures andprocesses. The Department of Health did notspecify an assessment tool, but encouraged localagencies to build on current practice and negotiatea process and mechanisms that were acceptable toeveryone. A list of criteria which processes shouldmeet was given in the guidelines forimplementation published by the Department ofHealth (2001a), along with an indication of theimplications for the agencies and staff who wouldbe involved. This could include GP surgeries,hospitals, community care services and drop-incentres, to name but a few of the varied agenciesthat might be involved in the assessment of olderpeople. The intention is that assessments should beco-ordinated and communicated between agenciesto avoid duplication and to ensure effective referraland response systems. In the words of the guidancedocument:

the single assessment process should ensure thatthe scale and depth of assessment is kept inproportion to older people’s needs, agencies do notduplicate each other’s assessments, andprofessionals contribute to assessments in the mosteffective way. The single assessment process alsoprovides information to support the determination ofthe Registered Nursing Care Contribution forresidents in care homes which provide nursing care.(Department of Health, 2001a, p. 1)

The significance of the single assessmentprocess for this study is therefore twofold. Itindicates the general policy move towardsintegration of health and social services, and theincreasing sharing of information which providesthe backdrop for the RNCC development. Second,it indicates that the process will be linked to RNCCdetermination in that the information collected willbe used as part of the RNCC determinationprocess.

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Part I

Registered Nursing Care Contribution (RNCC)

determination

The second initiative is the development of theRNCC tool, to be used to assess the amount ofnursing care that an older person needs and whichthe NHS will fund. This was launched on 1 October2001 and was used to assess the level of nursingcare that individuals need for the purposes ofdetermining the fees that will be paid by the NHSto care homes, rather than by the older peoplethemselves. This was extended to includereimbursement to local authorities in April 2002.The draft supplementary guidance on NHS-fundednursing care, published by the Department ofHealth on 20 December 2002, states that the reasonfor the introduction of NHS-funded nursing carefor people in care homes providing nursing care‘was to ensure that this group of people had accessto National Health Service funding and services onthe same basis as others receiving NHS nursingcare in other settings, either at home or inresidential accommodation’. It points out that thisalso includes equipment and continence services,and that these new processes of funding also givethe NHS ‘a stake in commissioning services for thisgroup of people’. In accordance with this interest,lead nurses in Primary Care Trusts (PCTs) arerequired to audit the outcomes and use of theRNCC tool, and to ensure that there are a ‘sufficientnumber and range of nurses trained in the use ofthe RNCC tool within the Trust’ (Department ofHealth, 2002, p. 1).

The RNCC tool is supported by a practice guideand workbook, which describes the process thatraters should go through to arrive at an RNCCdetermination (Department of Health, 2001b). It isanticipated that for new residents, the applicationof the RNCC tool will have been preceded by ajoint assessment, under the auspices of the singleassessment process, so indications for nursing careneed should have already been established andrecorded in the care plan. This care plan shouldincorporate all types of assessment, including

specialist assessments, and provide information‘indicating the intensity, instability, predictabilityand complexity of problems’ (Department ofHealth, 2001b, section 2.9). From the information inthe care plan, the RNCC determination can beapplied – ‘The RNCC draws heavily on allassessment information to determine the mostappropriate level of registered nursing input’(section 2.11). In addition, the nurse undertakingthe determination will use ‘professional knowledgeand observations of the patient in reaching adecision’ (section 2.14). The guidance also goes onto say that this should be an individualised process,and not ‘a bureaucratic paper exercise’, and that themore familiar the nurse is with the patient, ‘theeasier it is to accurately determine individual needsfor registered nursing care’ (section 2.14).

Using the RNCC tool, people are allocated intoone of three Registered Nursing Care Contribution‘bands’: low, medium or high. They are defined asshown in the box.

The High Band

People with high needs for registered nursingcare will have complex needs that requirefrequent mechanical, technical and/ortherapeutic interventions. They will needfrequent intervention and re-assessment by aregistered nurse throughout a 24 hour period,and their physical/mental health state will beunstable and/or unpredictable.

The Medium Band

People whose needs for registered nursing careare judged to be in the medium banding mayhave multiple care needs. They will require theintervention of a registered nurse on at least adaily basis, and may need access to a nurse atany time. However, their condition (includingphysical, behavioural and psychosocial needs)is stable and predictable, and likely to remainso if treatment and care regimes continue.

continued overleaf

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The allocation of a person into the bands isdetermined by two factors:

• the type of care the person needs – i.e.whether a registered nurse needs to deliversome or all of the care

• the requirement for monitoring andoverview – i.e. the extent to which theperson’s condition is stable and predictable.

People who need substantial registered nursinginput and whose condition is unstable and requiresconstant monitoring and rapid response aretherefore placed in the high band of nursing care,while those who are more stable are placed inlower bands. The lowest banding indicates peoplewho do not need to be in a care home whichprovides nursing care – that is, community nursescould provide their nursing needs in the same waythat they provide for people living in their ownhomes or residential homes.

Implications for research

The RNCC, therefore, is not so much a needsassessment tool as a costing and workforce-planning tool. In order for it to do this jobeffectively and accurately it needs to have a soundbasis and to be compatible with other tools whichassess the level of support that an older person

needs for other purposes, for example careplanning or staff management. The use of threebroad bands, for example, needs to be compatiblewith the categories developed by other tools thathave gone through processes of validation. When itwas introduced in 2001 it only covered those carehome residents who were self-funding (42,000came into this category in the first year). It has beenexpanded, and from April 2003 the RNCCdetermination will be applied to all other carehome residents (Department of Health, 2002, p. 1).

At the end of the inception period, then, it istimely to explore the progress of the RNCC tool.The audit data collected by lead nurses will detailthe number of determinations made, the appealsagainst determinations that have been made andthe final banding agreed on. It has also beensuggested that lead nurses collect data on thedeterminations made by each individual rater andthat a process of peer review and shared learning isset up (see the website created by the Departmentof Health: www.doh.gov.uk/jointunit/nhsfundednursingcare). It is not clear how and ifthis audit data will be shared or acted on, and thisis included in a wider review of the RNCC processcommissioned by the Department of Health. Thisstudy, then, has focused on the specific questionsarising about the validity and reliability of theRNCC tool rather than issues about the processesof its implementation.

4 The study

This project was commissioned by the JosephRowntree Foundation to explore the results ofassessment obtained by the RNCC tool. The studywas designed to do this by comparing RNCCresults with those obtained by the Minimum DataSet (MDS) and the EASY-Care tools, developed forcontact assessment. Both of these are establishedand well-validated tools, and so the rationalebehind the study was that by comparingassessments resulting from the use of these

The Low Band

The low band of need for nursing care willapply to people who are self-funding whosecare needs can be met with minimalregistered nurse input. Assessment willindicate that their needs could normally bemet in another setting (such as at home or in acare home that does not provide nursing care,with support from the district nurse), but theyhave chosen to place themselves in a nursinghome. (Department of Health, 2001b, sections3.8–3.10; italics in original)

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Part I

well-validated tools, the validity of the RNCC toolcould be judged. There are of course other toolsavailable that have undergone similar processes ofvalidation, but MDS and EASY-Care offered thestudy some advantages. First, the MDS tool hashad extensive internal validation, and hasdeveloped to provide, through the ResourceUtilisation Groups (RUGs) element, parallels to theRNCC assessment. EASY-Care has a similarinternational development, and is designed for easeof use with minimum training – it can also be usedas a self-assessment tool. For both tools the need fortraining, which was beyond the capacity of thestudy to provide, was obviated, for MDS by thepossibility of accessing care homes already usingthe tool, and for EASY-Care because of its ease ofuse.

The validity of a tool is dependent on its abilityto help the user to identify key phenomena andtranslate them into measures, scores or scaleswhich are consistent and accurate. There are issues,then, about the use of tools, which involveconsideration of the type and nature of theinformation that the user has to collect in order tocomplete an assessment – how observable,unambiguous, stable and relevant this is. There arealso issues about the way in which the tool helpsthe user to arrive at consistent results, and differentusers to arrive at similar results – issues ofreliability. The tool should allow the same user toreach similar conclusions each time the tool is used,and for different users to have agreement. If thisdoes not happen, then the tool is nothing more thanan impressionistic and variable indicator ofwhatever it claims to assess.

The process of checking the validity andreliability of tools, then, is a vital process, and oftena lengthy one. Repeated studies are often needed tocheck the consistency and integrity of a tool underdifferent circumstances and with differentpopulations of raters and assessed. This study doesnot attempt to do this for the RNCC tool –resources and timescale would not allow this, so

the strategy chosen was to run the RNCC toolalongside MDS and where possible EASY-Care, onthe same population of residents, to provide anindication of the robustness of the tool. Because theRNCC tool could be used by a number of differentindividuals with different qualifications, RNCCgradings from a number of different individuals forthe same residents were also collected. Because anyvariations in grading have potential financialimplications, for the resident (if self-funding), thecare home, and the health and social services,scores have also been translated into fundinglevels.

The Minimum Data Set (MDS)

The MDS was originally developed in the USA as aresult of an understanding that accurate assessmentis fundamental to identifying the care needs ofolder people so that high quality care can beplanned and delivered. An example of an MDSassessment sheet is given in Appendix 1. The MDScollects the minimum amount of data necessary tobe comprehensive and reliable. Possible problemsand risk factors, collectively referred to as ResidentAssessment Protocols (RAPs), are identified in theassessment. These signify current problems, thehigh risk of developing new problems or the needfor rehabilitation. All individuals are different andhave a diversity of requirements, however MDSgroups people according to how much resourcethey require. These are known as ResourceUtilisation Groups (RUGs). The RUG-III systemgroups individuals into 44 categories within sevenhierarchical levels (reduced physical function;behavioural problems; impaired cognition;clinically complex; special care; extensive care;rehabilitation). If an individual qualifies for morethan one group he or she is placed in the mostresource-intensive one. Using the RUG-IIIcategories the MDS software produces threecategories: low, standard and enhanced nursingcare. These equate to the RNCC bands. Thereliability and validity of the RUG-III system have

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been established in several international studies(Schneider et al., 1988; Ljunggren et al., 1992; Fries et

al., 1994; Ikegami et al., 1994; Carpenter et al., 1995;Carrillo et al., 1996; Carpenter et al., 1997; Bjorkgrenet al. 1999).

EASY-Care

EASY-Care was developed from an EU-fundedstudy to support integrated assessment in healthand social care needs of older people in Europe. Itis currently used in 18 countries worldwide, and anexample of the assessment form is given inAppendix 2. It is designed to give a broad pictureof the older person’s needs in order to assist thepractitioners to improve the care they can providefor the older person. EASY-Care was developed toelicit the views of the older person during aconsultation between them and a practitioner.Work on the validity and reliability of EASY-Care isextensive (http://www.shef.ac.uk/sisa/easycare/html/reference/refset.html), and it was one of thetools identified on the Department of Health’swebsite as meeting all the criteria for the singleassessment process. (See the website for details:http://www.doh.gov.uk/scg/sap/toolsandscales/toolsandscales260902.pdf.)

The project’s intention was to include an EASY-Care assessment for all residents in the study inorder to provide some indication of thecorrespondence of RNCC ratings with self-assessedneed. Because EASY-Care relies on self-reporting,however, it proved difficult to recruit adequatenumbers to the study to allow comparisons with theRNCC tool to be made. EASY-Care requiresrespondents to be able to participate in a discussionof their needs and the frailty of the sample was suchthat few residents were identified as being able toparticipate. The EASY-Care data collected in thestudy are therefore not included in the results of thisstudy. The problems that we had in using EASY-Care, however, do have a bearing on this study inthe way that they indicate the frailty of those in carehomes who are in need of nursing care. With such a

frail population, who may be unable to express andcommunicate need, careful observation andassessment become even more important.

Aims of the study

The aims of this study were therefore:

• to establish the strength of agreementbetween the RNCC bandings derived fromMDS RUG-III assessments and those of arange of nurse raters for older adultsreceiving nursing care in a care home

• to establish the inter-rater reliability of theRNCC assessment tool when used bydifferent nurse raters

• to explore the views of the raters regardingtheir experience of using the RNCCassessment tool.

Timescale

The study was carried out in 2002, with datacollection beginning in February 2002 and endingin August 2002. As the previous discussion hasindicated, this was early in the implementation ofthe RNCC tool, and only a few residents, who wereself-funding, had had an official RNCCdetermination. While conducting the research atthis early stage in development runs the risk ofhitting ‘teething’ problems, it does have the benefitof identifying ways forward at an early stage ofimplementation.

Project design

The project was designed to explore how the RNCCassessments, completed by multiple nurse raters,compare with the three bandings derived from theMDS RUG-III (Figure 1). Multiple nurse raters wereused in the study in order to cover the potentialrange and experience of raters who could beemployed to carry out determinations. Each nurserater brought a different clinical knowledge base tothe project:

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Part I

• The care home registered nurses (A) hadboth knowledge of the care homeenvironment and in-depth knowledge of theresidents’ care needs.

• The nurse researcher (B) employed on thestudy possessed general nursing knowledge.

• The external care home expert (C) hadknowledge of the care home environmentbut no detailed knowledge of the residentsinvolved in the study.

• A nurse consultant (D) had expertknowledge of care of older people.

• Official RNCC (E) bandings were alsocollected on those residents who hadundergone RNCC assessment but where theraters’ knowledge background was unknown.

Raters B, C and D were single individuals, inorder to minimise the impact of individualvariations within each rater group, while the nursesin group A were a range of individuals withknowledge of the residents and the care home

sector. Because of the way in which staff wereallocated to residents in these homes, these werethe nurses with most contact with the residents.Raters in group E were not identifiable in the study,and may have been a number of individuals. Eachnurse rater with the exception of those in group E,for obvious reasons, was interviewed on thecompletion of the RNCC bandings to elicit theirviews regarding the RNCC tool.

Sampling

Because the study required homes which had alreadybecome familiar with MDS, the Joseph RowntreeFoundation was used to identify care homes usingMDS software for inclusion in the study. Six carehomes were recruited on the basis that:

• they provided care for a range of residents withdiffering physical and/or mental health needs

• they were competent in the use of the MDSassessment tool to assess their residents’nursing care needs

• they were willing to participate in the project.

Figure 1 Schematic diagram of the project design

Care home staff A Nurse researcher B

EASY-Care

Official RNCCbander E

External carehome expert C Nurse consultant D

MDSRNCC Assessment

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Following the initial contact between each carehome manager and the nurse researcher (Appendix3), information and guidelines regarding the RNCCtool (Appendix 4) and the project (Appendix 5)were sent to inform the care home staff of theproject. Negotiations between the researcher andthe care home manager were conducted to establishthe best method of informing each resident withinthe care home about the background of the projectand to allow any resident the means of refusing tobe part of the project. Different approaches wereemployed in different care homes, ranging fromcontacting the residents individually to supplyingthe necessary information and allowing the staffwithin the home to display and/or explain theproject to the residents and/or their families(Appendix 6). Table 1 gives a brief description ofeach of the participating care homes in the study.

The overall total number of residents within theparticipating care homes in the study was 296 witha high proportion of nursing care residents (218:73.6 per cent). The total number of residents classedas residential was 58 (19.8 per cent) with theremaining 20 (6.7 per cent) of residents identified aselderly mentally infirm (EMI). However, of the six

care homes in the study only one had separateprovision for the care of the EMI with theremaining five homes integrating these residentswithin their nursing and/or residential care bedsdepending upon each resident’s care needs. Two ofthe six care homes in the study were managed bycharitable organisations whilst the remaining fourhomes were privately owned by large care homeorganisations. The locations of the homes provideda geographical spread from the North East to theSouth West of England (Figure 2).

Residents’ characteristics

The total number of care home residents in theproject was 186 with a high proportion of females(142). Residents’ age ranged from 54 to 102 years,with the majority (141: 76 per cent) of residentsaged 80 years or more (see Table 2). Co-morbidityranged from one lady having no reported illness toresidents with ten reported illnesses. Manyresidents had illnesses covering as many as sixdifferent physiological systems, highlighting thecomplexity of the healthcare problems experiencedby these residents.

Figure 2 Location of participating care homes

Care home 230 RNCC / 11 EASY-Care




Care home 516 RNCC

Care home 621 RNCC

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Part I

Table 1 Overview of participating care homes

Total Number of Number of Number of elderlyCare home ID and brief number of nursing care residential mentally infirmdescription of setting residents residents residents residents (EMI)

1 Large purpose-built, continuing careretirement community managed bya charitable organisation, whichincludes a central care centre that isdual registered 41 14 27

2 Large charitable organisation witha mixture of old and new purpose-built properties that are dualregistered. Also has one ‘intermediatecare bed’ and 7 respite beds plus 90units of sheltered housing 61 54 7

3 Large purpose-built 60-bedded carehome, comprising 3 floors that aremanaged as single units. EMIresidents are cared for in a single unit.The care home is part of a privatelyowned care home organisation 60 40 20

4 Large Jacobean hall converted to acare home. Part of a large privatelyowned organisation 67 64 3

5 Small care home that is part of theprivate organisation which includescare home 4. Dual registered and cantake EMI residents but they are notcared for in a separate unit and arecounted in the nursing/residentialresidents depending upon their care needs 21 21

6 Medium-sized purpose-built dualregistered home, which is part of theprivate organisation that includeshomes 4 and 5. Dual registered; cantake EMI residents but again theseresidents are counted in nursing/residential residents depending upontheir care needs 46 25 21

296 218 58 20

14


Of the 186 residents, the majority (116: 62.4 percent) were funded by their local authority whilst 69(37.1 per cent) were self-funding. The NHS fundedthe remaining one resident.

Process

Registered nurses using the RNCC tool assessed186 care home residents within their respective carehomes according to the guidance criteria suppliedwith the RNCC tool (see Appendix 4).

Data were also extracted from care plans foreach of the 186 residents with each data setincluding information on the following:

• personal details including age, gender, dateof birth, past medical history, currentcondition

• nursing care plan

• nursing notes

• structured assessments such as pressure risk,nutrition, risk of falls and moving andhandling

• current medication.

Each anonymised data set (see Appendix 7 foran example) was used by the nurse researcher (B),the external care home expert (C), and the nurseconsultant (D) to allocate residents into RNCCbands. Official RNCC bandings (n=51) were alsocollected on those residents who had undergoneRNCC assessments. The nurse consultant was onlygiven a sub-set of 45 residents to assess, comprisingrandom samples of 15 assessments taken from theMDS RUG-III low, medium and high bands. Thetotal number of official RNCC assessments is low

because of the period of the study, when only self-funding residents had RNCC assessments made.The official RNCC assessments were only availableon those residents who had undergone assessmentprior to or during the period of the project.

This produced a maximum of five RNCCassessments for each resident, which werecompared with each other and with the ratingobtained through the MDS software. Only the carehome staff and the official RNCC raters hadknowledge of the residents’ identity. None of thedata sets used by the researcher, the external carehome expert and the nurse consultant containedany means of identifying any particular resident.

On completion of the RNCC assessments, allregistered nurse raters were interviewed to exploretheir experiences and views on using the RNCCtool.

5 Results

The total assessments carried out by each rater andthe categories of the assessment are given in Table 3below. As can be seen from this table each raterplaced the majority of residents in the mediumband. The MDS RUG-III assessment placed 57.6 percent of residents in the medium band.Proportionately, three of the other raters placedsubstantially more residents in this band (carehome staff, external care home expert and officialrater) whilst the researcher and the nurseconsultant placed the same or slightly fewerresidents in the medium band. Conversely, all ofthe nurse raters placed substantially fewerresidents in the high band compared with the MDSRUG-III allocation.

Table 2 Residents’ characteristics

Number of residents 186Gender Male 44 (24%) Female 142 (76%)Mean age (Range) 85 years (54–102 years)Mean number of reported illnesses (Range) 3 (0–10)

15

Part I

This is also reflected in Table 4, which shows thepercentage of agreement between MDS RUG-IIIand each nurse rater for each RNCC band. Thepercentage of agreement is markedly lower in thehigh band, compared with both the low or mediumbands, for all raters except the nurse consultant, inwhose case the agreement is equal across eachRNCC band.

Level and strength of agreement between RNCC

and MDS RUG-III

As stated earlier the RNCC banding derived fromthe MDS RUG-III was used as a benchmark tocompare the RNCC assessments completed by thedifferent nurse raters. Inter-rater reliability is anestimate of the degree to which two or moreindependent raters are consistent in theirjudgements. The assessment of inter-rater reliabilityis particularly important in the development of astandard measuring instrument which will be usedby a variety of raters in a variety of situations.There are several methods of assessing inter-raterreliability. This project measured inter-raterreliability using two methods.

The level of agreement, using percentage ofagreement, expresses reliability in terms of thenumber of times the raters agree relative to the totalnumber of assessments made. Percentage ofagreement is the most frequently used measure ofinter-rater reliability and the most appropriatewhen there are few distinct categories. The overallpercentage of agreement between the RNCCbanding derived from MDS RUG-III assessmentsand those of the range of nurse raters rangedbetween a high of 60.66 per cent (external carehome expert) and a low of 40 per cent (nurseconsultant) (Table 5).

The strength of agreement was measured usingCohen’s Kappa coefficient, which measures theproportion of scores which fall into the samecategory. Kappa can vary between 0 (no agreement)and 1 (perfect agreement). The strength rangedfrom poor agreement (0.1) between MDS and thenurse consultant to only a fair agreement (0.263)between MDS and the external care home expert.

Table 5 shows the agreement between the MDSRUG-III and each of the nurse raters’ allocation ofresidents into RNCC bands in rank order, with both

Table 3 Number of residents allocated to each RNCC category by each rater

Assessments by Low Medium High Total

MDS RUG-III 31 106 47 184Care home 26 123 37 186Researcher 71 107 8 186External care home expert 36 130 19 185Nurse consultant 7 24 14 45Official 10 36 5 51

Table 4 Percentage agreement between MDS RUG-III and each nurse rater for each RNCC band

Low Medium High

Care home 54.84 71.70 27.66External care home expert 64.52 78.30 17.39Researcher 80.65 62.26 6.38Nurse consultant 40.00 40.00 40.00Official rater 71.43 78.57 6.25

16


Kappa coefficient and overall percentage ofagreement plus the degree of financial difference.The external care home expert rater, whorepresented knowledge of the care homeenvironment but no detailed knowledge of theresidents involved in the study, achieved thehighest level of agreement with the MDS RUG-IIIallocation. However, with a Kappa coefficient of0.263 and an overall percentage of agreement of60.66 per cent, this still represents only moderateagreement. The next highest agreement is with thecare home staff. The two highest-ranking raters,therefore, share knowledge of the care homeenvironment, whilst the lower-ranking raters didnot possess such knowledge. In broad terms,however, there is little difference in the level ofagreement between all the nurse raters, with four ofthe five achieving overall percentages of agreementwithin 10 per cent of one another.

The degree of financial equivalence betweenMDS RUG-III and each of the nurse raters is alsoshown in the above table. This indicates thedifference between the financial consequences ofthe MDS RUG-III allocation of residents into RNCCbands compared with each of the nurse raters’allocation. For example, where the cost derivedfrom the MDS RUG-III allocation is £13,675.00 (£35for residents allocated into the low band, £70 forresidents allocated into the medium band and £110for residents allocated into the high band) and thecost derived from the care home staff’s allocation is£13,445.00, the financial difference is £230.00. A

negative figure indicates that the nurse rater’s costwas higher than the MDS RUG-III cost. It is notablethat the rank order of nurse raters in the table isdifferent in relation to financial difference to that oflevel and strength of agreement. This indicates thatthere is poor correlation between the strength andlevel of agreement and the financial consequences.High agreement between raters does not lead tofinancial equivalence. It is likely that this is due tothe funding structure of the RNCC tool and thatfinancial equivalence stems more from agreementspecifically in the high band than from overallagreement. As was noted above, the nurse raterswere conservative in their allocation to the highband relative to MDS RUG-III.

Level and strength of agreement between the

different nurse raters

Table 6 shows the strength and level of agreementand the financial difference between the nurseraters. The strongest agreement was between thenurse researcher and the external care home expert.However, with a Kappa of 0.437 and an overalllevel of agreement of 70.81 per cent this stillrepresents only a moderate agreement.Interestingly, the two raters with the greatestdegree of knowledge of the care homeenvironment, the care home staff and the externalcare home expert, achieved an even lower strengthof agreement. Again, as with Table 4, there is noassociation between the agreement among ratersand the financial outcomes of the assessment.

Table 5 Rater pairs in order of strength of agreement

Kappa Significance Overall % FinancialRater 1 Rater 2 coefficient level of agreement difference

MDS Care home 0.218 0.001 57.61 £230.00MDS External care home expert 0.263 0.001 60.66 £1,295.00MDS Researcher 0.173 0.001 51.09 £2,965.00MDS Nurse consultant 0.100 0.315 40.00 –£240.00MDS Official rater 0.187 0.144 54.90 £545.00

17

Part I

Table 6 Nurse rater pairs in order of strength of agreement

Kappa Significance Overall % FinancialRater 1 Rater 2 coefficient level of agreement difference

Care home External care home expert 0.281 0.001 64.86 £1,070.00

Care home Researcher 0.152 0.002 52.69 £2,735.00Care home Nurse consultant 0.218 0.032 53.33 –£495.00Care home Official rater 0.199 0.034 54.90 £435.00External care Nurse consultant home expert 0.348 0.001 60.00 –£565.00External care Official rater home expert 0.244 0.025 66.00 –£35.00Researcher External care

home expert 0.437 0.001 70.81 –£1,665.00Researcher Nurse consultant 0.185 0.045 46.67 –£855.00

Table 7 Analysis by gender

Male FemaleKappa Significance Overall % Kappa Significance Overall %

Rater 1 Rater 2 coefficient level of agreement coefficient level of agreement

MDS Care home 0.029 0.799 39.53 0.029 0.799 63.12MDS External care home expert 0.378 0.001 62.79 0.210 0.001 60.00MDS Researcher 0.192 0.037 48.84 0.164 0.004 51.77MDS Nurse consultant 0.000 1.000 40.00 0.088 0.432 40.00MDS Official rater 0.000 1.000 57.14 0.243 0.023 54.05

Subgroup analysis

As shown above, there was poor to moderateagreement between the nurse raters overall. Inorder to understand this overall pattern in greaterdetail, analysis of the agreement, accounting forresidents’ age, gender and co-morbidity, wascarried out. Measurement of co-morbidity wasbased upon the number of illnesses recordedwithin each resident’s nursing notes and care plan.

Table 7 gives the agreement between MDSRUG-III and each nurse rater for males and femalesseparately. The table shows that the gender of theresident has little overall impact on the strengthand level of agreement between raters. There is nota substantial difference in the Kappa coefficientvalues for any rater pair across resident gender. The

greatest difference is with the MDS RUG-III andexternal care home expert pair, where Kappa ismarginally higher for men than for women,indicating that this pair agree slightly more for menthan they do for women. However, even for thispair the difference does not change the overallmagnitude of the agreement: it is still onlymoderate. It is a similar picture for the percentageof agreement values, with only one rater pairvarying in their agreement with resident gender.The MDS RUG-III and care home pair had aconsiderably higher overall percentage ofagreement when assessing female residents (63.12per cent) compared to when they were assessingmale residents (39.53 per cent).

18


Table 8 shows the agreement between MDSRUG-III and each nurse rater across resident age.The median age (85 years) was used as the cut-offpoint to create two groups: residents aged underthe median point and residents aged over themedian point. There was a little more variability inagreement across this factor compared with gender.For two of the rater pairs, MDS RUG-III with theresearcher and the official rater, there was a changein the Kappa coefficient such that the strength ofagreement was statistically significant for thoseover median age but not for those under medianage. This indicates that, for these rater pairs,agreement was greater for older people than foryounger people. Equally, for four of the five raterpairs their overall percentage of agreement wasgreater for older people that for younger people.MDS RUG-III with the nurse consultant was theexception to this, where there was only a marginalreduction in overall strength of agreement acrossincrease in age.

Again, with the third factor, number of recordedmedical conditions, there were some changes inagreement for specific rater pairs. Here, as withage, the number of conditions was split at themedian value to create two groups: those residentswith fewer than median conditions and those withgreater than median conditions.

There was a change in the Kappa coefficientsuch as to affect the statistical significance of thestrength of agreement for only two rater pairs:MDS RUG-III with the care home and with theofficial rater. For both of these rater pairs thestrength of agreement was higher for those peoplewith fewer recorded medical conditions. This wasreflected in the change in the overall percentage ofagreement (see Table 9).

Whilst there were differences in agreementbetween specific rater pairs for each of these threeresident factors, it was difficult to see from thisanalysis whether they had a consistent or overalleffect on agreement between raters. To test this

Table 8 Analysis by age

Aged under 85 years Aged 85 years and overKappa Significance Overall % Kappa Significance Overall %


MDS Care home 0.105 0.247 50.63 0.270 0.099 62.86MDS External care home expert 0.058 0.471 49.37 0.402 0.082 69.23MDS Researcher 0.019 0.783 41.77 0.275 0.001 58.10MDS Nurse consultant 0.069 0.666 43.48 0.094 0.453 36.36MDS Official rater 0.057 0.661 51.85 0.335 0.014 58.33

Table 9 Analysis by number of recorded conditions

3 or fewer illnesses More than 3 illnessesKappa Significance Overall % Kappa Significance Overall %


MDS Care home 0.303 0.001 63.87 0.076 0.394 46.15MDS Researcher 0.145 0.012 49.58 0.232 0.006 53.85MDS External care home expert 0.220 0.000 61.34 0.314 0.000 59.38MDS Nurse consultant 0.026 0.841 36.67 0.259 0.073 46.67MDS Official rater 0.306 0.013 66.67 0.022 0.880 38.10

19

Part I

further the variability in the difference betweenMDS RUG-III and each rater (V) was calculatedusing the following means:

VRm Rn

n=

−( )2

where Rm is the MDS RUG-III classification, Rn

is each nurse raters’ classification, and n is thenumber of classifications in the data set.

This analysis showed that the variability acrossnurse raters was lower, and therefore agreementwas higher overall, for people with greater thanmedian age (t=2.25, d.f.=184, p=0.026). Neither therespondent’s gender nor the number of recordedmedical conditions had a statistically significantconsistent effect on agreement between raters.

Analysis of raters’ interviews

On completion of the RNCC assessment, 13 carehome registered nurses and three external nurseraters were interviewed using semi-structuredquestions to elicit their views and experiences ofusing the RNCC tool. Using content analysis thedata were classified in terms of recurrent issuesarising from them.

Knowledge of the RNCC tool prior to

commencement of the project

Responses ranged from no knowledge (threemembers of care home staff) to fully aware of thetool (nurse consultant with knowledge of care ofolder people). The external care home expertreported that they had asked their ‘newlyappointed care home manager about it and wastold that it is to do with area manager and higherup’. They felt that this remark suggested it was nottheir place to know about it but they felt that thismanager should have known more about theRNCC assessment. Remarks made by the nurseswithin the care homes participating in the studyrevealed that some had knowledge of the RNCCassessment tool whilst others stated they weretotally unaware of it prior to the project. All the

nurses reported it was the first time they had usedthe RNCC assessment tool and that they needed toread the instructions a number of times in order tounderstand the terminology, with one nurse statingthat ‘the terminology needs to be simplified’.

Raters’ views regarding conducting the RNCC

assessment

The care home staff continued to state that oncethey understood the terminology they felt it waseasy to use especially as they knew the residentswell. The raters whose assessment was basedpurely on the documentation had specific issues; allfelt that it was difficult to complete the assessmentwithout seeing the person because thedocumentation was limited. They had to rely upontheir individual clinical expertise to mentally buildup a picture of the resident’s needs and reportedthat they relied upon the daily communicationsheets for indications of whether the resident’snursing care needs were being met and to judgewhether the resident’s physical and mental statewas stable/unstable and/or predicable/unpredictable. All three raters thought the carehome’s use of assessment scales such as pressurerisk assessment and risk assessment scales assistedin building up the picture of the resident but thatthese did not necessarily indicate the person’s careneeds and were not always reflected in theresident’s care plans. The external care home expertfelt that the majority of residents within themajority of care home settings had stable andpredictable care needs. The nurse researcher foundcompletion of the RNCC assessment difficult attimes mainly owing to the lack of knowledgeregarding the difference between residential andnursing care homes. Questions such as ‘doresidential care homes have a registered nurse onduty?’ and ‘do residents in a residential settingundergo any formal assessment regarding any careneeds?’ were asked as ways of developing a betterunderstanding of the care home sector.

20


Comments relating to contact with the official

RNCC raters

The majority of the nurses within the residents’care homes reported that it should be easy for an‘outsider’ to complete the RNCC assessment if theresident’s care plan was kept up to date. However,they acknowledged that this was not always thecase and some care plans were incomplete. It wasalso acknowledged that the official RNCC rater didhave access to both the residents and the nursesinvolved in their care and did not have to relysolely upon what was documented.

The external care home expert stated that ‘Ihave had no contact with an official RNCC raterwithin my care home’. The nurse consultant wasfully aware of the background of the official RNCCraters within her clinical area and stated that ‘theirbackground is of experienced community nurses ofG grade level with experience of the area’s rapidresponse team’.

Identified problem areas

Nurses from the care homes reported difficulty inassigning some residents into the low and mediumbands, with these residents apparently fallingsomewhere between the two. They did not reportany problems assigning residents between themedium and the high bands. Some nurses felt thattheir experience of accompanying the officialRNCC rater during their visits to the care homehad helped them to complete the RNCCassessments for the project.

All three raters who relied upon thedocumentation to make the RNCC assessmentsreported that the main problems arose because ofthe variation of format and information within theresidents’ documentation. Some of thedocumentation was inadequate with somecompleting a variety of assessments but thenidentifying problems which were not reflected inthe care plans. The raters also found it difficultbecause of their lack of contact with the resident

being assessed. The nurse researcher had a problemwith one data set which had large sections ofinformation missing, making it impossible to buildup a picture of the resident’s nursing care needs,and in this case a ‘guesstimate’ was made as to theRNCC banding. The nurse researcher also noted aspecific problem concerning those residents whosuffered from cognitive problems and required asafe environment but who were self-caringregarding their activities of daily living. Theseresidents may have required prompting andguiding with certain activities but there appearedto be no obvious need for a registered nurse otherthan for supervision.

The nurse consultant also felt thedocumentation was not wholly accurate but foundthe drugs charts a source of information whichwent further than informing which drugs wereprescribed – for example, if the resident wasprescribed skin preparations, pain relief, aperientsetc., this indicated that they had some conditionwhich required daily monitoring and therefore sheplaced them into the medium band rather than alow band. The nurse consultant was aware that shehad not placed many residents into a low band.This was, she argued, due to the fact that whilstsome residents did not appear to require theintervention of a registered nurse over 24 hoursthey had complex needs. If their care was carriedout correctly then they wouldn’t have anyproblems but if it wasn’t then things could go verywrong and their condition could deterioratemarkedly. These residents were therefore placedinto the medium band instead of the low band. Thenurse consultant also argued that residents withmental health problems were unpredictable andtherefore she felt obliged to place them into thehigh band whereas in reality they may fit into themedium or low band with the right intervention.She also felt that older people suffering fromdementia required care by a registered mentalnurse.

21

Part I

Suggestions for the future

The majority of the nurses from the residents’ carehome felt that their in-depth knowledge of theindividual resident’s nursing needs was required toassess the resident’s RNCC banding and that theyshould be the people doing the RNCCdeterminations. The staff also felt that the RNCCassessment did not take into account the amount oftime they spent on other aspects of care such ascare planning, training of healthcare workers,motivating and talking to depressed residents, toname a few. The nurse researcher acknowledgedtheir lack of experience and knowledge of the carehome environment and felt that it was important tounderstand the context of where the care was beingdelivered in order to place the resident into theappropriate band. The external care home expertbelieves that the official RNCC rater needs to be anurse experienced in the care of the older personbut did not feel that a community nursingbackground was a prerequisite. They continued toexpand on this by saying ‘it is entirely differentnursing someone in a care home setting than justcalling into someone’s home for a short period ofcare’. The nurse consultant stated that the RNCCassessment is very flexible and in their opinion itneeded to be so but they thought that a fourth bandwas needed, their suggestion being that themedium band be split into two.

6 Summary of findings

The agreement between the MDS RUG-III and thenurse raters’ allocation to RNCC bands was low.Lack of agreement was particularly high forallocation to the RNCC high band, where,compared with the MDS RUG-III, nurse raters wereconservative. Moreover, the lack of agreement wasnot uniform across all raters. In fact there weresubstantial variations between the raters’ strengthof agreement with MDS, and this difference may berelated to the background and knowledge of the

raters. Those raters with knowledge of the contextof care appear to have a stronger agreement withMDS than those without this form of knowledge.An interesting finding is that the external carehome expert’s ratings had greater agreement withthe MDS score than the resident’s own care homestaff’s ratings, whilst those of the nurse consultanthad the least agreement with MDS. This suggeststhat knowledge and understanding of the contextof care is of greater relevance to the rating processthan knowledge and understanding of olderpeople, either in a personal or a general sense.

The findings, which show differences betweenraters’ levels of agreement with MDS, indicate thatagreement levels are not consistent, againsuggesting problems with reliability. If differenceswere consistent across different raters, this could beinterpreted as evidence that the MDS and RNCCwould produce consistently different ratings, butthe variation between raters indicates that this ismore likely an indication that the RNCC tool itselfis open to inconsistency. This lack of agreement wasonly partially explained by residents’characteristics, in that there was greater agreementfor people with greater than median age, butgender or number of illnesses had no impact. Onaverage, however, men were banded higher thanwomen and younger people were banded higherthan older people but the number of illnesses didnot relate to the mean banding.

This study also found a low level of agreementbetween the nurse raters themselves, although thefindings suggest that the nurse raters agree withone another slightly more strongly than they agreewith MDS RUG-III bandings. This further suggeststhat the lack of agreement stems from thecharacteristics of the RNCC tool. Compared withthe MDS, the RNCC tool is loosely structured. Thisallows for professional judgement and local andindividual conditions to be reflected indeterminations; however, it also allows moreflexibility and therefore inconsistency in ratings.

22


7 Implications: the way forward for

implementation

The study points to some important considerationswhich must be made when implementing theRNCC process, given that the tool seems prone toinconsistencies and variations between raters.

Resourcing RNCC raters

The raters who were interviewed felt that residentcontact was important in completing an RNCCassessment. This was partly because of thevariability of documentation and the standards ofrecording, but also because they felt that theknowledge built up over time would give a betterpicture of the resident – interestingly, some ratersmade use of the daily records to gain someunderstanding of residents’ needs, rather than justassessment sheets. This suggests that RNCCbanding may be a labour-intensive activity, if ratersare to be able to spend enough time with residents.Some findings, however, suggest that spendingtime with the residents does not guarantee accurateassessment, e.g. the finding that care home raterswere less in agreement with MDS ratings than theexternal care home expert.

Recruiting RNCC raters

As the study has shown, a nursing qualification onits own will not give results close to the MDS, evenif the nurse has considerable expertise in the care ofolder people (for example, the nurse consultant inthe study). Experience of the care homeenvironment would seem to be essential ifassessments are to reflect the type and amount ofcare given in this specialised setting. The studysuggests that RNCC raters should have someexperience of working in this environment.

Training of RNCC raters and the support and

resources they will have, particularly the time

they will have to access information

While access to the single assessment processresults will help the RNCC assessment, this processis itself in an early developmental stage and maynot provide enough reliable information tosubstantially aid RNCC determination. It is likely,then, that raters will have to access care homerecords and meet residents in order to arrive at acomprehensive understanding of their needs. Thisprocess will take time for each resident assessed,which may pose problems if too much emphasis isplaced on speedy RNCC determinations. Theremay also be some implications for training forRNCC raters in the use of the tool, and the supportmechanisms suggested by the guidance documents,including peer group discussions, may go someway to ensuring reliability. The content of trainingand the most appropriate delivery modes, however,is something which will need careful planning andevaluation as more is known about the issuesfacing RNCC raters.

Monitoring of assessments

The lead nurse has responsibility for recording andmonitoring RNCC determinations and identifyingany differences between raters. This studysuggests, however, that differences between ratersmay have many different explanations, not leastbecause of the unstructured nature of the RNCCtool itself. Background and experience also seem toaffect determinations and so any monitoring willhave to take this into account. With such factors inplay, it is likely that there will be variationsbetween raters, but it must be remembered that anyrater who is different is as likely to be more as lessaccurate in determinations. Difference per se is notnecessarily an indicator of inaccuracy, and withouta benchmark to work to, evaluation of ratersaccording to difference from others is not a validprocess. Developing such benchmarks is necessaryif monitoring is to be effective.

23

Part I

8 Implications for future research

The study was designed to capture the use of theRNCC tool at an early stage of implementation. Assuch it emphasised rapid data collection fromspecific settings, rather than a large study whichmay have been more inclusive but, because itwould have been complex to carry out, would havefailed to reflect the initial experiences and practices.Because of this focus, the study does not addresslater developments in the RNCC tool and, while itcan give some early messages, does not followdevelopments over time. A longitudinal study iscertainly worth carrying out to track the processesinvolved as raters, care homes, older people andtheir families become more used to the process.

The findings of the study could also form thebasis for a larger study with a more diverse groupof care homes. A larger and later study would beable to explore issues about gender, age anddisability to a greater degree, and also to collectmore data on official bandings. As this study tookplace at an early point of implementation, this wasnot possible as official banding was in its infancyand not fully operational in all of the areas for allresidents. Evaluating official ratings against MDSand/or against other raters would indicate whetherthe RNCC tool in use was consistent and reliable.

There is also a need for more exploratoryresearch about the experiences of those raters usingthe tool and the reactions of care home staff to thisuse. This study was able to collect some data onthis, but the timing and scope of the study meantthat this could only be indicative of some of theexperiences and that issues could not be exploredsystematically or over time. Further work would beable to provide some insights into changingresponses to the RNCC and the development ofstrategies and processes for RNCC determination.

9 Conclusion

The RNCC tool is an attempt to recognise and costthe nursing care input to people in care homes, andto ensure that this care, like other NHS provision, isfree at the point of delivery. As such it represents anattempt to operationalise long-standing debatesabout differences between nursing and other formsof care, the role of the nurse and the needs of olderpeople in a way that is user-friendly. These aims arelaudable, but the process of achieving them iscomplex and it is to be expected that it would bedifficult.

The aims of the RNCC tool are not simplytheoretical, however, and it has potentially asignificant impact on the way needs are assessedand care resourced. In particular this impact will befelt by care homes, whose provision needs to beresourced, and by health and social services whosebudgets will be affected by RNCC determinations.It is important then, to develop the RNCC tool insuch a way that everyone is comfortable with andconfident about its use and application. This study,then, makes a contribution to this goal, by pointingout some of the lessons to be learned from the earlydays of implementation.

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NHS: Long-term Planning for Hospitals and Related

Services: Consultation Document on the Findings of the

National Beds Inquiry. London: Department ofHealth (http://www.doh.gov.uk/nationalbeds.htm)

Department of Health (2000c) The NHS Plan,Command Paper 4818–1. London: The StationeryOffice

Department of Health (2001a) The Single Assessment

Process: Guidance for Local Implementation. London:Department of Health

Department of Health (2001b) NHS Funded Nursing

Care – Practice Guide and Workbook. London:Department of Health

Department of Health (2002) Consultation on Draft

Supplementary Guidance on NHS Funded Nursing

Care. London: Department of Health (http://www.doh.gov.uk/jointunit/nhsfundednursingcare/guidanceconsult1202.htm)

Fries, B.E., Schneider, D.P., Foley, W.J., Gavazzi, M.,Burke, R. and Cornelius, E. (1994) ‘Refining a case-mix measure for nursing homes: ResourceUtilization Groups (RUG-III)’, Medical Care, Vol. 32,No. 7, pp. 665–8

Health and Social Care Act 2001 (http://www.legislation.hmso.gov.uk/acts/acts2001/20010015.htm)

Ikegami, N., Fries, B.E., Takagi, Y., Ikeda, S. and Ibe,T. (1994) ‘Applying RUG-III in Japanese long-termcare facilities’, Gerontologist, Vol. 34, pp. 628–39

Ljunggren, G., Fries, B.E. and Winblad, U. (1992)‘International validation and reliability testing of apatient classification system for long-term care’,European Journal of Gerontology, Vol. 1, pp. 372–83

Means, R. and Smith, R. (1985) The Development of

Welfare Services for Elderly People. London: CroomHelm

Reed, J., Payton, V.R. and Bond, S. (1998) ‘Settlingin and moving on: transience and older people incare homes’, Social Policy and Administration, Vol. 32,No. 2, pp. 151–65

Richards, M. (1996) Community Care for Older People:

Rights, Remedies and Finances. Bristol: Jordans

Royal Commission on Long Term Care (1999) With

Respect to Old Age: Long Term Care – Rights and

Responsibilities, Cm 4192-I. London: The StationeryOffice (http://www.official-documents.co.uk/document/cm41/4192/4192.htm)

Schneider, D.P., Fries, B.E., Foley, W.F., Desmond,M. and Gormley, W.F. (1988) ‘Case mix for carehome payment: Resource Utilisation Groups,version II’, Health Care Financing Review, AnnualSupplement, pp. 39–51

Stanley, D., Reed, J. and Brown, S. (1999) ‘Olderpeople, care management and interprofessionalpractice’, Journal of Interprofessional Care, Vol. 13,No. 3, pp. 229–37

25

Part I

Appendix 1: Example of an MDS assessment form

26


27

Part I

28


29

Part I

30


Appendix 2: Example of an EASY-Care assessment sheet

31

Part I

32


33

Part I

34


35

Part I

36


37

Part I

Appendix 3: Letter to home manager

38


Appendix 4: RNCC documentation and guidance

The Registered Nursing Care Contribution: definitions for use

Highly complex: Physical and mental needs are highly complex; mechanical/technical and/or therapeuticintervention are needed frequently, including frequent reassessment over a 24-hour period.

Medium complexity: Physical and mental needs are moderately complex; mechanical/technical and/ortherapeutic assistance are needed regularly or intermittently. The interventions require regular reassessment.

At risk: Abilities are compromised or absent most or all of the time; sensory loss is multiple; self-image islow. Frequent reassessment of risk is needed.

Minimal risk: Abilities present most of the time, but there is a need for regular reassessment of risk.

Unpredictable: How the patient responds to their health or disease processes/disorder or to any internal orexternal triggers cannot be anticipated with certainty, and there is a requirement for ongoing assessment,care planning, intervention and review.

Predictable: How the patient responds to their health or disease processes/disorder or to any internal orexternal triggers can be anticipated with some certainty through established interventions and regularlyreviewed care plans.

Unstable: A fluctuating disease process/disorder, and/or emotional, physical, behavioural and psychosocialconditions, resulting in an alternating health state and requiring frequent or regular intervention ortreatment.

Stable: Health or disease process/disorder, including emotional, physical, behavioural and psychosocialneeds, is in a steady state, and is likely to remain so if correct treatment/care regimes continue.

• Remember that care from a registered nurse includes time spent in direct contact with the patient, butalso that spent in planning, supervising and monitoring care delivered by someone else – who mayor may not be a registered nurse.

• It is essential to consider each person holistically in order to determine the full range of needsidentified from the assessment. Think carefully about each category of physical and mental need andreflect on whether a need in one field is likely to impact on another, thereby increasing the patient’soverall dependency and their requirement for care by a registered nurse.

• Consider the stability, predictability, risk and complexity of needs, and the patient’s requirements forcare and reassessment by a registered nurse against each of these dimensions. Take full account of thechanges that can occur over a period of a week or a number of weeks, rather than attempting to makea judgement as a snapshot of a particular time. If the person is currently stable, but is oftenunpredictable, this should be reflected in the determination.

• Using the information presented by the assessment and care plans, and using your professional skilland judgement, write a description of the registered nursing input required. Include all the relevantdetails to enable you to draw a conclusion concerning the appropriate level of registered nursingsupport that offers the ‘best fit’ for this person, and to demonstrate the reasons for your decision.

39

Part I

• The decision you make should be based on the patient’s current and anticipated health status.Review and reassessment will be undertaken three months following placement and at least annuallythereafter, or when there is a significant change in the patient’s health status.

• You must support your decision about the band of need for registered nursing care with a rationalebased on the evidence and information available to you and drawing on your professionalknowledge, skills and experience. You should express this rationale as clearly as you can, and avoidusing jargon if possible, making clear the key aspects of need that informed your decision.

Determining care from a registered nurse

The form reproduced below should be used to record the determination of registered nursing care for theperson in one of three bandings: high, medium or low, within the framework of stability, predictability, risk

and complexity. In making this determination, a holistic approach should be followed and considerationgiven to the totality of information gained from the domains of the single assessment and the care plan,which will also have addressed the key dimensions of instability, predictability, intensity, risk andcomplexity of needs. This information should be used by the designated NHS nurses alongside theirprofessional skills, knowledge and observations of the individual concerned, to inform the determination ofregistered nursing care needs within a nursing home setting. In evaluating all assessment information, fullaccount must be taken of the prognosis of people’s conditions and the likely outcomes if help were not tobe provided, or was provided in different ways. Attention should be paid to the full range of a person’sproblems, and not just those for which a nursing response is immediately obvious.

Professional judgement and an understanding of what is meant by terms such as stability, predictabilityand risk are essential in applying the RNCC tool. There will be different permutations in differentsituations. There can sometimes be unpredictability within a generally stable state. In making thedetermination of banding, designated nurses need to think about which offers the ‘best fit’ in matching theneeds of the patient. The judgement about stability or unpredictability should not be made as a snapshot ata moment in time, but should take full account of what is known about the person’s condition and theirusual behaviour over the course of a week or a number of weeks.

The high band

People with high needs for registered nursing care will have complex needs that require frequent mechanical,technical and/or therapeutic interventions. They will need frequent intervention and reassessment by a registerednurse throughout a 24-hour period, and their physical/mental health state will be unstable and/or unpredictable.

The medium band

People whose needs for registered nursing care are judged to be in the medium banding may have multiplecare needs. They will require the intervention of a registered nurse on at least a daily basis, and may needaccess to a nurse at any time. However, their condition (including physical, behavioural and psychosocialneeds) is stable and predictable, and likely to remain so if treatment and care regimes continue.

The low band

The low band of need for nursing care will apply to people who are self-funding whose care needs can be met withminimal registered nurse input. Assessment will indicate that their needs could normally be met in anothersetting (such as at home, or in a care home that does not provide nursing care, with support from the districtnurse), but they have chosen to place themselves in a nursing home. (Department of Health, 2001b, p. 14)

40


Resident’s ID number:

Band Decision (Tick relevant box) Rationale

HighUnstable and or unpredictable,at riskComplex needs (Needs frequentregistered nursing interventionover 24 hours)

MediumStable and/or predictable, minimalrisk (Needs daily intervention bya registered nurse and may needaccess to a nurse at any time)

LowSelf-selected placement, care couldbe provided in another settingwith minimal registered nurseintervention

41

Part I

Appendix 5: Letter to care home staff and information sheet

42


43

Part I

44


Appendix 6: Residents’ letter and information sheet

45

Part I

46


47

Part I

Appendix 7: Examples of Care Plans

48


49

Part I

50


51

Part I

52


53

Part I

Appendix 8: Manual Handling Profile

54


55

Part I

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TE O

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larly

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its

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ee s

hop

for m

eals

with

his

wife

Appendix 9: Anonymised patient record

56


DAT

ED

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AIN

NO.

P RO

BLEM

I NTE

RVEN

TIO

NS I

GN

ATU

RE

20.12

.20

01

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, 16

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57

Part I

DAT

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NO.

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RE

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p.

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John

Sm

ith

PART IIFlexible skills mix

A model of staffing for a new care development

Phillip Borkett and Jan Gilbert

61

Part II

1 Background

The project was designed to consider a model ofstaffing for Bedford Court, the new mixeddevelopment in Leeds. This will be registered bythe Care Standards Commission (CSC) as a ‘singlehome’ without the former labels of nursing/residential. It therefore provides scope for somemore flexible and creative thinking about thedeployment of staff and the link between residentneed and staffing mix/levels.

An advisory group was formed in September2001. Membership included registration andinspection officers from Leeds health and socialservices (incorporated into Care StandardsCommission in April 2002). Other members weredrawn from external care providers and JosephRowntree Foundation (JRF) staff. The group waschaired by the Director of Care Services andfacilitated by an external consultant. The task of thegroup was to consider a model for the care needs ofresidents using the Minimum Data Set (MDS)Resident Assessment Instrument and the HomeCare version to ascertain the care needs ofresidents. This is in turn related to the mix of staffwho are required to plan and deliver care at theappropriate level.

The resulting model is to consider the types ofqualifications that would be required to deliver safeand person-centred care. The project had links withother strands of JRF work including thedevelopment of the nurse practitioner role, theimplications of single assessment and thecontinuing development of MDS.

Construction work on Bedford Court began inspring 2002. The development comprises 34 singleen-suite rooms, four double close-care apartments(registration for 42) and ten bungalows. There willbe flexibility to use the accommodation to meetspecialist needs in the future. It is expected thatthere will be integration between the care homeand bungalows from the outset.

The project has been informed by researchcarried out by Dr Iain Carpenter who has been

looking at the use of MDS to identify nursing carein UK nursing homes (Carpenter and Perry, 2001).Part of the study involved a workload analysis ofJRF homes. A further independent study of nursingtime as related to resident dependency in JRFhomes was undertaken in September 2002 forcomparison (Appendix 2). Contact has beenestablished with the Residential Forum (RF) whichhas been commissioned by the Department ofHealth to develop a formula for non-nursing stafflevels in residential care. Finally, there has beenconsiderable input from analyses of MDS data forexisting JRF homes and discussions between theproject consultant and home managers.

It was agreed that the project aims were todevelop a model for the staffing of a ‘single carehome’ which:

• ensures that residents have access to staffwho are appropriately skilled to deliver theassessed care which will ensure theirmaximum quality of life

• establishes a link between residentdependency and staff establishment

• ensures that staff are deployed efficiently soas to utilise the skills, qualification andexperience of each individual for their ownand the home’s benefit

• meets the requirements of the CareStandards Commission whilst offering aflexible and responsive approach

• meets JRF financial requirements bydelivering a cost-effective, quality service.

2 Emerging factors

The project has been undertaken at a time ofchange and is seeking to take advantage of freshthinking and new approaches to the registration,inspection and delivery of care for older people.Some of the most relevant issues are listed below inorder to give an appropriate context.

62

MDS – latest research: flexible skills mix

The Care Standards Act, regulations, minimum

standards and Commission

Since the project started the foundationaldocuments have been finalised and CSC staffingput in place. The project has considered therelevant sections of regulation and minimumstandards. Recent months have seen the relaxationby government of some proposed standards asexemplified in a letter from Jacqui Smith, Ministerof State, to Ann Parker, Chair of CSC, which statesinter alia, ‘Essentially the Department is keen toensure that your activities lead to the raising ofstandards, but that initially a pragmatic but timedapproach is taken with regard to compliance’(National Care Standards Commission, 2002).

Recruitment of staff

This continues to be a problem across all care andhealth sectors. The Joseph Rowntree Foundation’sexperience is that the recruitment of professionalstaff, especially nurses, has proven particularlydifficult in the Yorkshire region with both LamelBeeches and Hartrigg Oaks having unfilledregistered general nurse (RGN) vacancies.

Single care home

To date, there has been no guidance forthcoming onthe way in which a home that provides bothnursing and residential care will be regarded byregistration and inspection staff. There have beendevelopments on the single assessment processwith detailed guidance issued by the Departmentof Health (DoH) along with identification of anumber of suggested assessment tools (includingMDS). The link between single assessment and asingle registration is of crucial importance but it isstill not clear how individual homes will beexpected to specify the specific client groups theywill care for. The most recent definitive paper onthis subject was published by Malcolm Johnsonand Lesley Hoyes for JRF in November 1996. Thisargued for a model which included ‘A level andmix of staffing in each home dependent upon the

assessed levels of need of residents’ (Johnson andHoyes, 1996, p. 3).

MDS

The Joseph Rowntree Foundation’s experience ofusing MDS is evolving; all homes are nowcompleting assessments and these are being used toestablish the appropriate Resource UtilisationGroup (RUG) and case-mix index. The Home Careversion is being piloted at Red Lodge. As a generalrule, this work is showing that MDS provides auseful tool to plan and monitor the care ofindividuals and the way in which resources aredeployed between residents of differing abilities.

Refinements are ongoing in order to establishthe most appropriate definitions of nursing andresidential care. A recent development has been toequate RUG-III groups with the categoriescurrently in use when Primary Care Trusts arecalculating the Registered Nurse Care Contribution(RNCC) appropriate for individual residents inlong-term nursing care (see Part I of this report).

3 Issues considered by the group

Skill mix

JRF dual-registered homes’ staffing arrangementsare similar to those found in most establishments ofthis nature. The home manager (registered nurse)usually works ‘office hours’ Monday to Friday.During the daytime shifts there will be one seniorcare assistant and between two and five careassistants depending upon the needs at particulartimes of the day. One or two care assistants workwith a nurse to provide cover at night. Homemanagement staff are on call at home if there areany emergency situations. There is flexibility tovary shift lengths and request additional hours todeal with exceptional dependency but temporaryworkload pressures are normally managed withinthe existing budget.

The role of a nurse working in a care homesetting brings some tension. Some of these were

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identified by the Iain Carpenter research whereRGNs were interviewed by researchers. They havebeen confirmed in discussion with JRF homemanagers.

• It is universally agreed that proceduresrelating to complicated dressings, controlleddrugs and taking blood requires a trainednurse. In a dual home some care staff defer toa nurse on decisions which would be takenby staff in a residential home withoutrecourse to a nurse.

• The senior care role in a dual-registeredhome is often underdeveloped.

• Nurses in dual homes can often feel underpressure to ‘nurse’ residential clients.

• Nurses are trained to provide holistic care;whilst much of their time may be spentdoing ‘care’ rather than ‘nursing’ duties theysee this as part of the role – this has thepotential for conflict with care assistants.

• A corollary to the above should be moreopportunity for care assistants to offer socialor emotional care, but there is ofteninsufficient time for this.

• There has been a requirement that a nurseshould be the manager of such a home butthis may not always be the most appropriateuse of skills.

Stephen O’Kell has suggested that an enhancedrole for care assistants working in homes thatprovide nursing is wholly appropriate. It isrecognised, however, that the success of thisapproach will depend upon the acceptance of caresupport workers undertaking extended care rolesby registration units, the promotion of specific,extended care roles for support workers by homemanagers and the willingness of homes andmembers of the primary care team to provide the

necessary training and supervision to care supportworkers undertaking these roles (O’Kell, 2002).

What do staff actually do?

Alongside this project the Joseph RowntreeFoundation commissioned a study to look at thework actually carried out by nurses, senior carestaff and care assistants over a 24-hour period. Inaddition to the study carried out by Jan Gilbert(Appendix 2), staff working at Hartrigg Oaks kepta log of their work with individual residents. Stafftime was logged by grade (e.g. registered nurse)and analysed against the individual RUG group. Itwas clear that this study mirrored the original workdone for the RUG-III report (Carpenter and Perry,2001). The report notes that whilst nurses areoccupied positively throughout the day, their roleshave become task-orientated, working on expectedpatterns to fit the residents’ day. This appears to bearound medication and some work withcomplicated dressings so much of their time wastaken up by tasks which would ordinarily beperformed by senior care staff or care assistants.The report concludes that whilst clearly providingquality care and supporting members of the team,much of the work undertaken by nurses couldreasonably be undertaken by senior care staff. Thisis particularly evident between midnight and 6a.m. as there were no essential nursing tasksperformed for those residents designated ‘nursing’.

Taking these comments into account the matrixshown in Table 1 has been used as the basis for anallocation of staff responsibilities at Bedford Court.The matrix shows the key tasks involved indelivering care according to dependency levelsderived from the RUG analysis. The responsibilitiesindicated assume that the overall responsibilityrests with the general care manager; clinicalaccountability is to the clinical manager. (Theseroles are further described in the section ‘Towards astaffing model for Bedford Court’ below.)

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Dependency and staffing

As part of the development of national minimumstandards the DoH has commissioned theResidential Forum to conduct research and proposea formula which could be used by home ownersand the CSC to calculate the staffing requirementsfor a given home. Guidance was issued to CSCoffices in May 2002 (Department of Health andResidential Forum, 2001).

For existing homes, the staffing levels were tobe maintained at 31 March 2002 levels until March2003. It is accepted that the staffing levels requiredunder the previous regime ‘will normally havebeen appropriate’. Homes were asked to complete aquestionnaire for analysis to the Residential Forum.For all new applications, the CSC will use theResidential Forum guidance which is described bythe CSC as ‘a robust and flexible approach tostaffing numbers’ and is primarily based upon theestimated number of care hours required forresidents within three levels of dependency. TheCSC recognises that the approach will not besuitable for every new home; it will therefore beflexible and recognise that ‘some care homes willhave legitimate reasons for establishing alternativestaffing levels’(National Care StandardsCommission, 2002).

The present guidance does not cover nursingstaff and it is not yet clear how the formula willassist in calculating the mix of staff needed inhomes that offer both residential and nursing care.There are some concerns in the independent sectorthat the formula may create unrealistically highstaffing requirements and this indeed wasexperienced recently at one of the Joseph RowntreeFoundation’s care homes.

The Residential Forum formula takes intoaccount:

• dependency (high is 20 hours per resident/week, medium is 18, low is 16), althoughthere is no developed tool to assess andmeasure high, medium and low dependency

• ‘overheads’

• building layout if this is difficult

• staff training

• social, cultural and recreational needs of theresidents

• implications of moving and handling.

The flexible skills mix project envisioned asituation whereby information from MDS (RUG-IIIgroup) will help to determine the numbers of staff

Table 10 Allocation of staff resources at Bedford Court

Assessment/planning/RUG-III group/care category monitoring of care Delivery of care

Reduced physical function Senior care CareBehavioural problems and above Senior care Care – care tasksBehavioural problems and above Clinical manager Nursing/specialist nursing staff – nursing tasksEMI care Clinical manager/specialist nurse Specialist care/Specialist nursing

staffDomiciliary/bungalow – Senior care/domiciliary Domiciliary worker care tasks organisationDomiciliary/bungalow – Clinical manager/district nurse Specialist nurse or district nurse nursing tasks

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and the mix of staff types that will be appropriateto meet the needs of residents of Bedford Court at agiven point in time. This is rightly seen as the keyto the whole issue. In order to arrive at anappropriate formula considerable work has beendone by JRF colleagues and the project consultantin an attempt to link MDS data with information onstaffing levels in existing homes and the expertadvice of home managers.

Nursing/care balance

As indicated above there are some issues about therole of nurses in care homes and questions over thebest way of utilising experience and training. JRF isexploring the role of specialist nurses and alreadyemploys a registered mental nurse (RMN) whoworks across the organisation, supporting staff andresidents in the care of people with dementia. It issuggested that general nurses could work in asimilar fashion by providing specialist nursing care(e.g. dementia, pressure areas, continence, diabetes,nutrition). This would leave the trained care staff tohandle care tasks. The extent to which this rolewould be attractive to staff and residents is still tobe explored but it appears to make effective use ofa scarce resource.

There are questions about the inevitability ofhome manager positions being filled by aregistered nurse. Management and administrationmay not be the most appropriate task for those whohave comprehensive clinical training (and indeedthis may not always be the preferred career path ofthe individuals concerned). There is however, a rolefor a properly trained general care manager to haveoverall responsibility for a development such asBedford Court.

It follows that the need for a nurse to be inattendance on a 24-hour basis is not automaticwhere a home adopts a true resident-centred anddependency-led approach. It is considered that thefollowing elements should be present for such anapproach to be considered:

• the effective use of an agreed commonassessment instrument (e.g. MDS, EASY-Care)

• staffing arrangements linked to dependency(e.g. RUG-III)

• a tightly defined management structure

• a commitment to effective team working

• an enhanced role for care and senior carestaff

• the involvement of specialist nurses

• a robust approach to monitoring andevaluation.

Working together, these elements should createa responsive and flexible structure that is ofgreatest benefit to the residents.

4 Towards a staffing model for Bedford

Court

Taking the foregoing factors into account thefollowing principles have been established:

• Overall management of the project will bethe responsibility of a general care managerwho will have experience and qualificationsin both care and general management. He orshe will be required to hold the RegisteredManager’s Certificate as required by CSCand may be a nurse but this will not be aprimary requirement.

• A clinical manager will be responsible forassessment and monitoring in relation tonursing needs and will manage thedeployment of nursing staff according to thedependency of residents. He or she will be afirst-level registered nurse.

• The role of care staff will be enhanced inaccordance with the matrix above (Table 1). A

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senior care worker will act as team leader foreach shift and will be qualified to NVQ 3 or4. Care staff will have achieved or beworking towards NVQ 2 in accordance withthe Care Standards Act.

• Therapy staff (such as occupationaltherapists and physiotherapists as well asactivities specialists) will be engaged forsessional work, as identified in the residentassessment.

• Care and nursing staff complements will bebased on assessed resident need. A formulahas been developed that is based upon theResidential Forum guidance in respect ofcare hours. There will be an additionalallocation for nursing hours based on theappropriate RUG-III group. The hoursallocated to each group will be derived fromindependent research (see section 5 andAppendix 1).

• There will be a number of core nursing hoursemployed in order to carry out essentialnursing procedures. Other nurse hours willbe co-ordinated by the clinical manager andmay include input as appropriate fromgeneral and specialist nurses in continence,dementia, diabetes, pressure and nutrition.

• Domestic, kitchen and maintenance staff willbe expected to adopt a person-centredapproach to their work and be workingtowards appropriate qualifications.Flexibility and team working will be keyattributes.

• The model will be subject to detailedindependent evaluation and monitoring.

5 The model

Two examples for theoretical homes are given inAppendix 1 – Table 11 shows the staffingcalculations for a lower-dependency home andTable 12 shows the calculations for a higher-dependency home.

Part A uses information from the independentstudy to derive a formula for the number ofnursing hours needed in a week for residents in thethree most prevalent RUG-III groups (clinicallycomplex, behaviour problems and impairedcognition).

Part B is used to calculate the number of careand nursing staff needed for a given residentprofile. Residential hours are based on thedependency allocation in the Residential Forummodel. The basic hours are increased for social,recreational and cultural needs and staff training(based on Residential Forum formula); this gives arevised total of care and nursing hours required fora period of seven 24-hour days).

Part C indicates an approach to the distributionof these hours. The model assumes the following‘fixed’ staffing arrangements: one senior careworker on duty 24 hours a day (three shifts) andtwo care workers on duty at night. The figure for‘nurse days’ is brought forward from part B (totalnurse hours). This is a balancing figure to providestaffing to the revised total in part B. (In all casesfigures have been rounded to whole numbers.)

Finally, additional hours are added for thegeneral manager and clinical manager. It isassumed that the clinical manager will be able tooffer two shifts of ‘hands on nursing’ per week. Thetotal number of nursing hours available in theweek is expressed in terms of the total number ofnursing hours available over a 24-hour period. Itshould be noted that ‘nurse days’ are expressed interms of regular shift patterns but these hours willbe available for flexible use according to the needsof residents. The clinical manager will beresponsible for deploying these.

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References

Carpenter, I. and Perry, M. (2001) Identification of

Registered Nursing Care Time for Residents of UK

Nursing Homes using the Minimum Data Set Resident

Assessment Instrument (MDS/RAI) and the Resource

Utilisation Groups (RUG-III) Resource Use Casemix

System. Canterbury: University of Kent, Centre forHealth Service Studies

Department of Health (2000) Care Standards Act:

Care of Older People. London: The Stationery Office

Department of Health and Residential Forum(2001) Staffing the Standards: Minimum Staffing Levels

of Non-nursing Staff in Residential Care Homes for the

Elderly. London: Department of Health andResidential Forum

Johnson, M. and Hoyes, L. (1996) ‘Establishing aregulatory system for single registered care homes’,JRF Findings H200, November

National Care Standards Commission (2002)‘NCSC provides guidelines on staffing levels inCare Homes’, press release, 2 May

O’Kell, S. (2002) ‘The impact of legislative changeon the independent, residential care sector’, JRFFindings 142, January

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Appendix 1: Staffing calculations for Bedford Court

Example calculations derived from staffing formula using Minimum Data Set (MDS) Resource UtilisationGroups (RUG)

Table 11 Lower overall dependency

Part A Nursing time required

RGN mean mins observed in 24 hours Total mins Total hrsDirect care Indirect care Total mins per week per week

Clinically complex 34.3 12.6 46.9 328.3 6Behaviour problems 28.0 5.1 33.1 231.7 4Impaired cognition 23.1 4.4 27.5 192.5 3

Source: Carpenter and Perry, 2001.

Part B Calculation of staffing hours for Bedford Court

Dependency Nurse hrs Care hrs Total hrs Total hrs Total hrs(RUG-III group) Number (from above) (Res. Forum) nurse care per week

Clinically complex 4 6 20 24 80 104Behaviour problems 2 4 18 8 36 44Impaired cognition 2 3 16 6 32 38Residential 34 0 16 0 544 544Total 42 38 692 730

Add social, recreational, cultural at 1% total budget 7Plus fixed allowance of 15 hrs 15 22

Add staff training at 2.7% 20

Revised total 772

Part C Distribution of staffing hours

Staff Shifts per day Shift length Hours per week

Senior care days 2 7.5 105Care days 8 7.5 419Nurse days 1 7.5 38 for flexible useSenior care nights 1 10.0 70Care nights 2 10.0 140

772

Home manager 1 7.5 37.5Clinical manager 1 7.5 37.5Total hours required 847

Care manager 37.5Clinical manager Management 22.5

Nursing 15 37.5Nursing 38Senior Care 175Care 559

847

Nursing staff available in a 24-hour period: 8 hours

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Part A Nursing time required

RGN mean mins observed in 24 hours Total mins Total hrsDirect care Indirect care Total mins per week per week

Clinically complex 34.3 12.6 46.9 328.3 6Behaviour problems 28.0 5.1 33.1 231.7 4Impaired cognition 23.1 4.4 27.5 192.5 3

Source: Carpenter and Perry, 2001.

Part B Calculation of staffing hours for Bedford Court

Dependency Nurse hrs Care hrs Total hrs Total hrs Total hrs(RUG-III group) Number (from above) (Res. Forum) nurse care per week

Clinically complex 16 6 20 96 320 416Behaviour problems 8 4 18 32 144 176Impaired cognition 8 3 16 24 128 152Residential 10 0 16 0 160 160Total 42 152 752 904

Add social, recreational, cultural at 1% total budget 9Plus fixed allowance of 15 hrs 15 24

Add staff training at 2.7% 24

Revised total 952

Table 12 Higher overall dependency

Part C Distribution of staffing hours

Staff Shifts per day Shift length Hours per week

Senior care days 2 7.5 105Care days 9 7.5 485Nurse days 3 7.5 152 for flexible useSenior care nights 1 10.0 70Care nights 2 10.0 140

952

Home manager 1 7.5 37.5Clinical manager 1 7.5 37.5Total hours required 1027

Care manager 37.5Clinical manager Management 22.5

Nursing 15 37.5Nursing 152Senior care 175Care 625

1027

Nursing staff available in a 24-hour period: 24 hours

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Appendix 2: Nurse monitoring activity over a

24-hour period

Summary

In the light of the changes within the carestandards, the limited number of nurses availableand the developments in care staff education anddevelopment, a more flexible approach to staffingshould be considered.

Within The Oaks it was evident that over the 24hours observed, it was the team who, through theirknowledge and skills, ensured the quality of care.Whilst there can be no doubt that the knowledge,skills and ability of nurses are an essential element,this study cannot demonstrate that there is a needfor a 24-hour nursing presence in thisestablishment with the current skill mix and clientgroup.

Background

In line with the project purpose – to enable thedevelopment of a model for staffing the BedfordCourt establishment – it was agreed to monitornursing activity over a 24-hour period at The Oaksin York. In the light of the new care standards andthe registration of establishments as residentialhomes without the former labels of nursing/residential there is scope for more flexible andcreative staffing matrices that better meet the needsof the client and the organisation, as well as takinginto account the knowledge, skills and ability of thevarious team members.

In assessing the activities undertaken by thenurses whilst on duty it was felt appropriate not toidentify specific patients as the senior person onduty had a holistic role to ensure care wasdelivered appropriately to the whole of the clientgroup. The analysis therefore considers not onlythe actual ‘nursing’ activities undertaken but alsothe non-nursing functions inherent in the role.

This report is therefore to be considered as oneaspect of the overall project and should not betaken out of context.

In accordance with the new care standards(Department of Health, 2000), Standards of Care forOlder People and Clinical Governance, all decisionsshould be based on accurate and up-to-dateevidence. This study complies with thisrequirement in that the report relates to actual caredelivered in the period identified and has beenanalysed within a setting that holds currentaccurate data on client-assessed needs as based onthe RUG-III system (Carpenter and Perry, 2001).

Methodology

Monitoring of the nurse on duty

It was agreed that the activities undertaken by thenurse on duty would be monitored over a 24-hourperiod. Activities were monitored in one-hourchunks with the data being collapsed into moremeaningful periods as activities were determined.It was intended to use a pre-existing proforma(Appendix 1) as this had been used in thedevelopment of the MDS data sets. Additionalinformation was to be recorded separately on thesame record sheets. There was only one personmonitoring the activities over the period agreed toensure consistency of data collection.

Team information

All team members were advised of the purpose ofthe project, with special emphasis that:

• the resultant data was to be used for the newLeeds-based establishment

• the data were not to be linked to any onenurse’s activity and therefore were not to beviewed as an individual/personal review

• the staff were to be introduced to theresearcher by the project director and thehome manager.

Furthermore, the skill mix of the team on dutywas identified as a means of conceptualising thenurses’ workload and their actual activities.

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Gap analysis

In addition to the acknowledgement and analysisof the data in respect of what was observed activityof the nurses, analysis of what was not observedactivity and yet could be considered integral to theeffective management of the shift will be analysedto ensure that a comprehensive and explicit reviewis presented.

As noted by Carpenter and Perry (2001),decision making is a key part of the nurses’ role butis difficult to quantify and not always available forobservation.

Skill mix

The staffing levels for The Oaks is as detailedbelow. This complies with the current staffingnotice and does not include the senior nursemanager, other management, or administrative orcleaning/domestic staff who were on duty at thetime.

The complement of staff below was for 42clients with a mixed economy of care including 14nursing and 28 residential clients. All clients wereconsidered ‘long-standing’ clients with no newadmissions during the last week being reported.

Night staff – 9.30 p.m. to 7.30 a.m.

RGN × 1Care staff, NVQ 2 × 1Care staff × 1

Morning staff – 7.15 a.m. to 3 p.m. (Staff startingtimes were staggered over the first two hours of themorning with the full complement of staff being onduty by 8.30 a.m.)

RGN × 1Senior care, NVQ 3 × 2Care staff × 3Supernumerary × 1 student nurse

Afternoon staff – 3 p.m. to 9.15 p.m.

RGN × 1Senior care, NVQ 3 × 1Care, NVQ 2 × 1Care × 2

Data collection

Data collection limitations

Over the 24-hour period the researcher was presenton the unit for 21 of those hours. The time notpresent included a 2.5-hour rest period between thehours of 02.30 and 05.00 when the staff nurseagreed to self-monitor care activities, two mealbreaks taken in the canteen of 20 minutes and a ten-minute comfort break. During one of the mealbreaks the nurse in charge accompanied theresearcher; during the other break the nursereported that she would be taking a break and thenself-reported activities that had then beenundertaken during the researcher’s absence.

Although the researcher is a qualified nurse, shewas not present in the rooms when personal carewas being delivered. This was felt to be toointrusive and unnecessary.

Data analysis

Monitoring commenced at 22.00 on 26 September2002 and continued for the following 24 hours. Thefollowing figures show the activities undertaken bythe nurse during each of the periods shown.

The figures do not show the activitiesundertaken by other members of the team, howeveradditional notes are made where appropriate.

Period 1 – 22.00 to 23.00

During this period clients were settled for bed byall members of the team. The nurse on duty alsoescorted the doctor who was visiting a clientdeemed to be in need of medical review.

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Period 3 – midnight to 01.00 (27 September)

As one would expect, the majority of the clientshad settled by this time. The staff nurse spent 15minutes with the daughter of the client seen by thedoctor and continued to administer medication(analgesics) as requested by the clients.

Staff on duty communicated with the staff nursein a continuous informal manner but a more formalrésumé was given as staff congregated for a drinkat approximately 00.30.

Figure 3 Nursing activity, 22.00–23.00

As can be seen, for the first hour, the majority ofthe time involved direct client care. Fifteen per centof the first hour involved administration ofmedication – all of which were oral. The doctorgave the one injection required by the client hevisited.

Period 2 – 23.00 to midnight

Care continued during this time at the specificrequest of some clients (i.e. requesting sleepingtablets); the staff nurse also completed ‘domestic’checks, e.g. fire reports and security checks. Oneclient alone did take up a significant amount oftime (25 minutes) but this was for general ratherthan specific nursing care.

Staff supervision15%

Hygiene and care37%

Medical assistance21%

Escorting clients12%

Medication15%

Staff supervision8%

Hygiene and care67%

Administration17%

Medication8%

Figure 4 Nursing activity, 23.00–midnight

Staff supervision16%

Hygiene and care32%

Relative care23%

Medication6%

Admin. duties23%

Figure 5 Nursing activity, midnight–01.00

Period 4 – 01.00 to 05.30

As one would expect, this time period wasrelatively quiet. The daughter of one client was stillpresent and staff spent 28 minutes reassuring thelady that all care possible was being afforded herfather. Care of the remaining clients continued in aplanned manner in the form of ‘rounds’, withadditional care being provided as requested byclients. The staff worked as a team with care beingprovided by the team with no apparentdifferentiation as to the category of client (nursingor residential) and the two ‘rounds’ werecompleted in 35 minutes on each occasion.Medication was administered by the nurse, thisbeing analgesia predominantly in the form ofparacetamol tablets. During this time theadministration of medication accounted for tenminutes. There were no injections administeredduring this time.

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Household duties (setting tables and trays andmonitoring fridge temperatures) were carried outas a team effort and accounted for 40 minutes of thenurses’ time. In addition the staff nurse hadbrought materials to study that were for a care-related course she was on. The nurse took theopportunity to discuss her progress on the coursewith the researcher: this accounted forapproximately 40 minutes of our time. During thistime the care staff did answer client calls. Staffreported that she continued to study during theresearcher’s break.

Administrative duties were also carried out(record keeping), but staff reported that this wasnot particularly onerous on that shift as the careplans for her specific clients had only recently beenupdated and the client’s status had not changedsignificantly in the intervening period. This took 15minutes.

During this time one client was found on thefloor but was deemed not to have suffered anyinjury and was assisted back to bed after beingassessed by the nurse (seven minutes). Normalreporting of accidents was completed by the staffnurse.

Period 5 – 05.30 to 07.30

Again, as would be expected, this was a period ofincreased activity. Because they were an experiencedteam there was no significant time spent directingthe care staff as to their duties. The staff nurse madea personal ‘round’, checking on all clients, and

completed the care reports prior to handover. Nomorning medication was given by the night staffand the only significant event was that a client wasfound on the floor but this was dealt with by thecare staff initially with the staff nurse checking theclient following the delivery of care. Client careaccounted for 45 minutes; record keeping accountedfor a further 15 minutes with 18 minutes being takenup giving a report to the day staff.

Relative care14%

Hygiene and care36%

Personal study19%

Medication5%

Admin. duties19%

Record keeping7%


Handover23%

Hygiene and care58%

Record keeping19%


Period 6 – 07.30 to 11.00

This period begins at the beginning of the shift tothe official break time of 11.00. All of the day stafftook the report together from the night staff team.Team members’ workload was pre-prescribedaccording to experience and qualifications and thiswas apparently detailed within a workbook.Having taken the report the team dispersed andwent about their duties without the apparent needfor staff to direct them. Over the next three and ahalf hours the staff nurse went about her dutiesrelatively independently. The rest of the teamworked either independent of each other or inpairs. This related to the tasks they had to perform:for example, one senior carer allocated to the upperfloor was dispensing medication to those clientsidentified as ‘residential’ with the staff nursedispensing medication to all clients on the groundfloor and to those clients identified as ‘nursing’ onthe first floor. This did include the administrationof two insulin injections and one controlled drug(MST). Included on the team was a second-yearstudent nurse. She worked alongside different

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members of the team and her activities were clearlyco-ordinated by the staff nurse.

During the morning staff spent 17 minutesgiving family support, 75 minutes onadministrative/paper work/telephone calls, 90minutes on the administration of medication, 24minutes on direct client care and six minutesdiscussing with a client their medicationadministration and 12 minutes directing care staff.

At approximately 11.00 the team congregated inthe staff room for a break for 15 minutes.

by individual clients (21 minutes) andcommunicating with clients, relatives and visitinghealthcare professionals. The staff nurse spent 17minutes with the Macmillan nurse, 56 minutesundertaking administrative duties including reportwriting and 32 minutes in discussion with the SeniorNurse Manager on duty. A further 25 minutesinvolved talking with relatives. The care staff on dutyserved the meals and fed those clients needingassistance. Providing direct client care (hygiene etc.)took a total of 28 minutes with a further sevenminutes being spent directing staff. Whilst the staff onduty did take a meal break at ‘lunch’ time, the staffnurse continued to work over this period answeringcalls, administering medication with meals andwriting reports. Handover took place in the office andtook 22 minutes. Other members of the teamcontributed to the handover, especially the senior carestaff who reported on their clients specifically.

Directing staff 5%

Hygiene10%

Medication38%

Admin. duties31%

Family and client support10%

Break6%



Staff supervision 3%

Hygiene and care13%

Medication10%

Admin. duties28%

Escorting Macmillan nurse8%

Handover11%

Management meeting15%

Care of relatives12%Period 7 – 11.00 to 15.00

The morning staff continued to provide care upuntil shift changeover at 15.00. At shift changeoverthe qualified nurse coming on duty overlappedwith the morning staff and provided an escort toone client moving to another home within thelocality. It was reported that whilst it was normalfor a client to have an escort, it was not normal toprovide qualified nurse escort unless the client’scondition demands. On this occasion the conditiondid not warrant qualified nurse escort but staffinglevels permitted this. As this was not deemed to bethe norm this activity is not included in theanalysis, which only records the activities of thenurse remaining on site.

Between the hours of 11.00 and 15.00 the staffnurse continued to work as a member of the team,predominantly administering medication as required

Period 8 – 15.00 to 18.00

Following handover, the team once again dispersedand went about their work with little obviousdirection from the nurse in charge. Instructions werewritten in the workbook and the team clearly knewtheir roles and responsibilities. The staff nurse’s firstaction was to ‘tour’ the unit, obviously checking onthe status of every client (22 minutes). This time iscombined with the direct care delivered. Oncesatisfied the staff nurse then spent time with the

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student nurse. As this was the student nurse’s lastday on the unit the staff nurse spent 35 minutes withthe student completing her report. Administration ofmedication was undertaken by both the nurse andthe senior carer (who was responsible for the care ofthe ‘residential’ clients on the first floor as in themorning). Administration of medication took a totalof 37 minutes during this period.

Direct client care required 35 minutes of timewith a further 35 minutes being taken up withdomestic duties. As the senior member of staff onsite, the staff nurse also gave telephone advice tothe ‘bungalow’ staff (five minutes). Staff nurseassisted the care staff with the serving of the mealsand this is included in the overall care time.

Period 9 – 18.00 to 21.30

The staff nurse continued to work with care staffoverseeing the care delivered. During the eveningperiod staff spent 40 minutes providing physicalcare with a further 90 minutes being taken up withthe administration of medication. This includedinsulin injections (six minutes). Seven minutes weretaken up with telephone calls and a further 12minutes involved discussions with the seniormanager on duty. The staff nurse spentapproximately 18 minutes on report writing withthe handover taking 20 minutes at the end of theshift. A total of 30 minutes was taken as breaks –these were taken with all members of the team.

Review

Throughout the period of observation the teamconsisted of experienced team members –experienced in the provision of care andknowledgeable in the needs and wants of this clientgroup. There were a number of instances wherestaff were able to state what a client was calling forprior to answering the call bell.

The team were, relatively speaking, highlyqualified. Care staff were reported to hold either anNVQ level 2 or 3 with senior care staff on day dutyhaving completed the JRF Certificate in Care. Oneof the senior care staff is reportedly applying for amanager’s position within a residential home.Colleagues report that, in their opinion, he has theknowledge and the ability to meet the rolerequirements. It was noted that, in respect of the‘residential’ clients, their care needs were being metby the senior care and care staff allocated. Staffnurses all confirmed that care staff would referproblems to them should the need arise but, in themain, would ‘get on with the job’ without requiringdirection.

It is clearly shown that the nurses are occupiedpositively throughout the day. Their roles, however,do appear to have become task-orientated, workingto expected patterns to fit the client’s day. Thisappears to be predominantly around theadministration of medication, and yet othermembers of the team also perform this function. Itis also clearly demonstrated that, as a team, thisgroup of staff, either intuitively or through past

Hygiene and care33%

Medication22%

Admin./telephone3%

Teaching21%

Domestic21%

Hygiene and care20%

Management6%

Admin.13%

Breaks15%

Medication46%

Figure 10 Nursing activity, 15.00–18.00 Figure 11 Nursing activity, 18.00–21.30

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experiences, know their roles and responsibilities.The care provided by this group is clearly of a

high quality and the nurse call system in useenabled staff to be more efficient in their use oftime – by being able to talk to clients directly whenthey call for assistance, staff are able to respondappropriately without having to walk to the clientto ask what they want and as such the appropriatemember of the team is able to respond immediately.

The nurses had obviously spent time andenergy supporting and working with the studentnurse and she reported this on a number ofoccasions. She was also able to report that she hadbeen very well supported by the senior care staff,all of whom had gained her respect because of theirknowledge and care practices.

Summary

Whilst clearly providing quality care andsupporting members of the team, much of the workundertaken by the nurses could reasonably beundertaken by senior care staff. This is particularlyevident after midnight up until 6 a.m. During thistime in particular, for this client group, there wereno essential nursing duties that had to beperformed for those clients designated ‘nursing’,and the one client who required medical assistancewas seen by a doctor prior to midnight followingwhich his needs were met by all members of theteam equally.

The safe administration of medication in thisestablishment is undertaken predominantly by thenursing staff, but senior care staff trained in the safeadministration of medication do undertake thistask for ‘residential’ clients – and in many cases themedication is the same for both nursing andresidential clients. The administration of insulindoes remain a nursing task and was undertakenaccordingly.

There were no other significant nursingactivities observed during this 24-hour period, withno wound care or other specialist care beingrequired by clients at this time. Staff did report thatthey felt safer having a qualified nurse on duty anddid express concern as to their own knowledge andexperience should there be an ‘emergency’ orshould a client’s condition change.

In the light of the changes within the carestandards, the limited number of nurses availableand the developments in care staff education anddevelopment, a more flexible approach to staffingshould be considered.

Within The Oaks it was evident that it was theteam who, through their knowledge and skills,ensured the quality of care. Whilst there can be nodoubt that the knowledge, skills and ability ofnurses are an essential element, this study cannotdemonstrate that there is a need for a 24-hournursing presence in this establishment with thecurrent skill mix and client group.

PART IIIThe specialist nurse project

Enhancing the quality of residents’ care

Val Ellis, Chrysa Apps and Peter Cox

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1 Background

This project forms part of the ongoing commitmentto continuing evaluation and improvement in careto residents who live in homes run by the JosephRowntree Housing Trust (JRHT).

The Joseph Rowntree Foundation wished toexplore the manner in which nurses and other staffwith specialist qualifications and expertise can bedeployed in innovative ways across care homes toenhance the quality of residents’ care.

It was recognised that the needs of people livingin residential and nursing care homes are complexand multifaceted, with medical, nursing, social,psychological and practical care needs whichrequire a variety of input from professional staffincluding GPs, hospital consultants, nurses,community services, physiotherapists, occupationaltherapists, nutritionists, social workers and carerswho all have roles to play if these complex needsare to be met. However, most care homes employonly carers and nurses although most have accessto the other specialist services outlined above.

The Foundation has a small number ofresidential and nursing homes in and around Yorkmanaged by the Joseph Rowntree Housing Trust.These care homes include provision for people withspecial needs such as learning and physicaldisabilities as well as older people.

JRHT employs 12 registered nurses across twoof its care homes and many of the nurses alreadyhave expertise and specialist qualifications. Onehas experience of ENT (ear, nose and throat) and isinterested in hearing loss problems, and anothernurse has a diploma in diabetes care. It wasdecided to identify a specialist across as manyclient groups as possible for a pilot project wheredementia and mental health issues were recognisedas a major and growing problem for older peopleand those with learning disabilities. The problemsof mental health and mental infirmity were alreadybeing identified using the Minimum Data Set(MDS) assessment tool, evidence from home staffand the growing body of published research into

the increasing needs of older people.A registered mental nurse, Val Ellis, was

approached to see if she was interested in gainingextra skills and qualifications and applying theseskills not only to the home where she wasemployed but also across all of the homes.

2 Project aim

The project aim was to identify how a specialistnurse could work across a group of homes. The keyobjectives were:

• to develop services for the support ofindividuals who have mental healthproblems and/or dementia, and for thesupport of the staff and carers

• to develop services for the support of peoplewith learning disabilities who may havedementia and are not always in receipt ofspecialist nursing care

• to develop a model for specialist staff to offeradvice and guidance across a group of carehomes

• to set up training and developmentprogrammes across a group of homes tosupport people who have mental healthneeds and their carers

• to consider an assessment mechanism todetermine the level of need of people in aresidential, nursing and community setting.

Once the key objectives were agreed with seniorstaff of the Housing Trust a project advisory teamwas set up consisting of the following members:

Chrysa Apps Practice Development ManagerClive Bowman BUPAMaggie Coxan Care Standards CommissionPeter Cox Lecturer in Health Sciences,

University of YorkSue Davies Head of Home, Hartrigg OaksCedric Dennis Director of Care Services

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MDS – latest research: the specialist nurse project

Wendy Dixon Care Standards CommissionVal Ellis Specialist nurseJan Gilbert Independent consultantAmanda Kelsey University of YorkAlison Little The Retreat

The project partners who would steer the projectwere Chrysa Apps, Val Ellis from JRHT and PeterCox from the Department of Health Sciences at theUniversity of York. Peter would provide supportand mentoring to Val throughout the project.

The education and training needs of the projectnurse, Val Ellis, were identified:

• a University of York continuing professionaldevelopment module (‘Mental health in oldage’)

• attendance at conferences and seminarsincluding ‘Dementia care 2000’ and ‘Dementiacare 2001’ at the University of Leeds

• ‘Dementia care in the community’ inBirmingham in association with the Journal of

Dementia Care.

In 2002 she attended:

• ‘Dementia training skills’ with theAlzheimer’s Society

• ‘Dementia care 2002’ in Bradford

Training events included:

• ‘Moving from activities to person-centredoccupation’ with Dementia North

• carers’ workshops discussing mental healthservices for older people with theAlzheimer’s Society

• a dementia awareness training day

• ‘Non-abusive psychological and physicalintervention’ in association with NAPPI UK

• ‘Signs, symptoms and management ofmental health problems in care homes’ inassociation with Boots the Chemist

• ‘Dementia and residents with learningdifficulties’ with Graham Stokes (ClinicalPsychologist and Consultant Director ofMental Health to BUPA Care Services)

• ‘Anxiety and adjustment in old age’ withGraham Stokes.

The project nurse also visited The RetreatHospital’s Challenging Behaviour Unit to meet thestaff and discuss their philosophy of care.

3 Implementing the project

It was decided to concentrate the first part of thisproject in the home where the project worker wasinitially employed. This is at Hartrigg Oaks at NewEarswick near York. Work was also done at RedLodge, Lamel Beeches (both for older people),Alder House (for people with cerebral palsy),Dormary Court, Charles Court and FledglingsCourt (all for people with learning difficulties).

Hartrigg Oaks is the first continuing careretirement community in the United Kingdom. Itwas completed in 1998 and is situated in the villageof New Earswick on the north side of the city ofYork.

The development consists of 152 one- and two-bedroom bungalows with 41 rooms in the carecentre, called The Oaks. There are extensivecommunal facilities, including a restaurant, coffeeshop, arts/crafts room, library, music room, spapool/Jacuzzi, fitness centre and a small shop. Theaim is to provide high quality accommodation andcare services which meet the needs of older people(aged at least 60), ranging from independent livingin their bungalow to full care and nursing supportin The Oaks.

The Oaks offers both residential and nursingcare, and is registered with the City of York Counciland North Yorkshire Health Authority. It has 41 ensuite bedrooms. The residents who live in thebungalows can, if necessary, take up residence atThe Oaks if their health has declined to a point

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where it is not possible to maintain independentliving, even with the maximum care available inthe Hartrigg community.

The project worker was enthusiastic to improvethe assessment, care planning and education of staffwithin the organisation, trained and untrained, sothat those residents with mental illness wouldreceive the same level of skilled care as those withphysical illnesses. The training had to include allsections of staff from ancillary staff to office staff asall come into daily contact with the residents.

In principle, the aim was to bring together theexpertise available at Hartrigg Oaks and tocombine this with input and support from thecommunity psychiatric nurse (CPN), Linda Auer,who liaises with Hartrigg Oaks and University ofYork lecturers Peter Cox and Dr Amanda Kelsey.Latter stages of the project would include inputfrom other CPNs working in the other homes.

A particular focus for the specialist nurse is theincreasing need to respond to those residentspresenting with dementia.

It was important to establish the anecdotalevidence of dementia within the various unitsmanaged by the Foundation, so informal meetingswith the project worker and Peter Cox took placewith the home managers where it became apparentthat dementia was in evidence, with the followingfigures reported by nurses and other staff workingdirectly with residents.

Anecdotal figures

• Lamel Beeches (nursing and residential home):38 residents (19 identified with dementia)

• Red Lodge (residential home): 35 residents(12 identified with dementia)

• The Oaks (nursing and residential home): 41residents (23 identified with dementia).

Assessed figures

The assessment tool used within the JosephRowntree Foundation is the Minimum Data Set

(MDS). Using this tool, staff were able to produce astructured assessment of cognitive loss in residentsand produced the following prevalence figures inApril 2002. These figures show a close correlationwith the anecdotal figures from the care homes:

• Lamel Beeches: 19 residents identified withcognitive loss

• Red Lodge: 20 residents identified withcognitive loss

• The Oaks: 26 residents identified withcognitive loss.

However, the degree of cognitive loss variedfrom resident to resident. The cognitive loss scalewithin the MDS tool has a seven-point scaledescribing cognitive loss.

The cognitive performance scale was developedto describe the cognitive status of an individual andis based on:

• short-term memory

• cognitive decision making

• making self understood

• dependent eating.

The team considered using the MDS mentalhealth (MH) assessment tool which was beingdeveloped in the USA and Canada as a part of theoverall assessment process to try and determine thelevel of mental health needs. However, MDS (MH)was aimed at the acute hospital sector and notspecifically for those people with dementia andmental health needs of old age.

There is a need for a specialist dementiameasurement tool either as part of the MDS familyof assessment tools or as an independent measure.There was discussion within the team and theadvisory group about developing such a tool but itwas considered to be impracticable in the context ofthis project.

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Behavioural changes associated with dementia cancause carers to regard residents as ‘challenging’. Theconcept of challenging behaviour is directly related tocarer ability to respond appropriately: i.e. those whohave the necessary knowledge, skills and attitudes torespond positively may perceive less of a challenge.

The challenge is often one which affects both theclient and staff, impacting on the physical, emotionaland environmental well-being of all concerned. Thoseclients with mental health needs were identified inorder to establish met and unmet needs, and toprepare staff to respond therapeutically to both theirpsychological and physical care.(Peter Cox, unpublished)

Figure 12 Cognitive performance scales: Lamel Beeches,

April 2002

Score 049%

Score 116%

Score 216%

Score 45%Score 3

14%

Score 046%Score 2

17%

Score 317%

Score 43%

Score 117%

Score 033%

Score 218%

Score 326%

Score 45%

Score 513%

Score 65%

(Score 0 = no cognitive impairment, score 6 = severe

cognitive impairment)

Figure 14 Cognitive performance scales: The Oaks,

April 2002

Figure 13 Cognitive performance scales: Red Lodge,

April 2002

Case study 1

Brenda and her husband Jim retired to livenear York until they were not able to cope anymore due to failing ill health. They decided tomove to Hartrigg Oaks at New Earswick inYork where they took up residence in abungalow where they lived independentlywith only minimal intervention from the carestaff.

Over the months Brenda’s mental andphysical health began to deteriorate as shebegan to suffer more angina episodes whichled her to panic and repeatedly summon helpfrom the care centre during the day and nightwhen she needed much reassurance. Itbecame clear that she and Jim were notmanaging as well as they had been and theywere losing confidence. We began to givemore assistance to the couple in the bungalowin the form of cleaning etc. and assistancewith Jim’s care, i.e. getting up, bathing,dressing and putting to bed at night and for ashort time this helped and they continued tolive in their bungalow.

continued

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In 1999 Brenda had several admissions tohospital having suffered a CVA[cardiovascular accident] and various otherphysical health problems which led to asevere deterioration in her overall physicaland mental health including confusion,disorientation, paranoia and memorydifficulties. Whilst in hospital Brenda wasassessed and diagnosed as suffering fromdepression with a possible toxic confusionalstate.

After treatment it was decided by medicalstaff, the carers at Hartrigg Oaks and thecouple’s sons and husband that a return to thebungalow would be impossible. Brendareturned to Hartrigg Oaks and she and herhusband took up permanent residence in TheOaks.

On return to The Oaks full nursing care wasmaintained as Brenda was dependent on stafffor all ADLs [activities of daily living].Brenda’s condition was extremely poor, butafter a period of intensive nursing care withinput from the outreach physiotherapy andCPN service her condition improveddramatically. Despite this she remained toofrail to return to the bungalow. Theimprovement was maintained until October2000 and Brenda was able to enjoy her life atThe Oaks – she enjoyed the company of herhusband and the activities and the social lifethat were on offer.

In October she had another bout of physicalillness after which she became increasinglyrestless and agitated, obtaining very littlesleep, so various drug regimes werecommenced by the GP, all of which had to bediscontinued because they caused excessivedrowsiness or other side effects.

Brenda’s mental health appeared todeteriorate and she constantly shouted out forassistance. Despite much reassurance fromstaff, her husband and other residents, shewas unable to control this behaviour. Thebehaviour began to cause everyone involvedmuch distress, especially her husband. Shewas sleeping very little – in fact some nightsno sleep was obtained – and she continued toshout despite one-to-one nursing care beingmaintained.

Her gait started to become increasinglyunsteady and falls started to become aproblem. She sustained several minor injuriesand had a couple of trips to casualty.

I spent a lot of time talking to Brenda and shewas able to express that she felt low in spiritsand the reason for her shouting was becauseshe didn’t feel safe and she was frightenedthat she would be left alone and not get anyhelp when she needed it. Even when help wasactually present she would continue to callout. I challenged her about this and sheclaimed that she knew she shouldn’t shoutbut she couldn’t help it even though she knewhelp was present and then she apologised.

I found that she was disorientated in time andplace but with minimal prompting she couldagree where she was. She had no difficultyremembering individual staff and theirnames, but her short-term memory for otherthings was quite poor. There was some degreeof expressive dysphasia but no receptivedysphasia was apparent.

By early April Brenda’s condition was stilldeteriorating and despite all the efforts of theGP who had tried all the various medicationsa direct phone call was made to the psycho-

continued continued

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continued

It was recognised that education for all careworkers and eventually the residents’ peer groupwas vital to the success of the project. Thefollowing sessions were included:

1 ‘What is dementia?’ This session describesthe aetiology and different types andprogression of the illness. It gives the careassistant underpinning knowledge that willassist them in understanding the reasons forsome of the symptoms and behaviour thatthey may encounter.

2 ‘Approaches to care’. This session focused onthe concept of person-centred care and theimportance of obtaining a life history tomaintain individualised care.

(These two sessions were mainly aimed atcare assistants who had limited experience inthis field of work.)

3 ‘Dementia’. This session was aimed atregistered general nurses with little or noprevious experience of dealing with thisclient group. It gave an understanding of thecondition and the associated behaviour.

4 ‘An introduction to dementia’. This sessionwas aimed at ancillary staff/kitchen staff allof whom have direct contact with theresidents. Its aim was to raise the overallawareness of dementia within the Hartrigg

geriatrician to request an urgent visit and arecommended care plan/contract was drawnup with Brenda and Jim’s agreement. Fiveminutes of attention every hour would begiven but she would not get any attention as aresult of inappropriate behaviour. I discussedthis approach with the couple and theyagreed to try. I reassured them both the careplan would be reviewed daily to ensure that itwas still appropriate. I talked to the staff andexplained that although Brenda might bequiet at the time when a visit was due theymust still give Brenda attention as a way ofreinforcing appropriate behaviour. Brenda’sbehaviour remained almost unchanged withthe implementation of this care plan.

Brenda has remained resident in The Oaksuntil the current time (May 2003). Her mentalcondition is slowly deteriorating and theepisodes of loud behaviour are becomingeven more frequent and difficult to manage inthe Oaks environment. She is prone toepisodes of shouting continuously for up to48 hours.

She continues to display appropriatebehaviour when placed in situations that sheenjoys, i.e. shopping at the local mall, buteven this she now has difficulty controlling attimes. Although Brenda enjoys the companyof her husband in the home he has difficultycoping with her behaviour so is beginning towithdraw, spending more time with otherresidents with whom he has struck up afriendship.

Owing to the difficulties it has beenreluctantly decided that a period of respite inhospital will be sought to enable Brenda toexperience a change in environment, whichshe often responds well to, and enable other

residents including her husband to have aperiod of respite themselves.

By continuing to find appropriate solutionswe are enabling Brenda and her husband toremain together for as long as possible. At arecent case conference it was agreed thatwithout specialist input Brenda would havehad to move away from The Oaks up to threeyears ago. (Val Ellis, 2003)

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team. This session is also aimed at carers andolder people themselves in the community.

Graham Stokes visited Hartrigg Oaks on severaloccasions as an external speaker to provideupdated and current views on providing person-centred holistic care. These sessions included‘Dementia and residents with learning difficulties’and ‘Anxiety and adjustment in old age’.

Care staff, both trained and untrained, wereinvited to comment on the value of running amonthly staff support group. Staff felt that this wasa positive step, and would identify potential issuesregarding care. Val, Peter and Linda subsequentlyran these jointly, as this would facilitate networkingand better understanding of day-to-day staff/carerneeds and related stress.

Feedback from the support group training waspositive with recommendations that timing bevaried to ensure that a wide cross-section of staffwere able to attend. There was overwhelmingfeeling that the group should be confidential, with‘Chatham House Rules’ applying, to allow a freeand frank exchange of views, problems andanxieties.

Having run these sessions for a year, it is clearthat staff are enthusiastic about improving theirtherapeutic role when caring for those withdementia, especially in its early stages. In additionto providing a staff support facility the sessionshave proved to be an opportunity to increase theirknowledge and skills, using a problem-solvingformat, i.e. to resolve day-to-day concerns in orderto improve client care. Quite often staff are pleasedto discover that the care they have been providinghas been appropriate, and the feedback from Val,Peter and Linda to this effect has provedreassuring.

The original aim for the Specialist Nurse Projectwas becoming clearer and following a number ofdevelopment meetings of the project team thefollowing proposals were developed to ensure thework was ongoing:

1 Formulate an additional tool once cognitiveloss was triggered on the original MDS RAI(Resident Assessment Instrument) form.

2 Setting up of staff support groups.

3 Teaching and education of all staff.

4 Education and updating for project worker.

5 Implementation of group work andindividual support, i.e. reminiscence forclients.

6 Assistance to all grades of care staff withperson-centred care/planning.

7 Intervention with individual residents whenrequested by the care staff.

8 Education of all residents regarding mentalhealth issues for those interested orconcerned.

9 Respite day care for bungalow residents toallow the informal carers a break.

Case study 2

Jenny was a registered nurse who wasmarried to an army doctor who died beforeshe came to live at Hartrigg Oaks. She hastwo daughters and one son.

Jenny moved to Hartrigg Oaks and took upresidence alone in a bungalow.

She had some memory loss and had difficultycoping alone so the bungalow care teamarranged in conjunction with her family apackage of care that enabled her to live withsome independence. This included care staffvisiting the bungalow each morning to assistwith dressing, preparing breakfast andmaking sure Jenny had taken her medication.They would escort Jenny to and from the

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restaurant for lunch where the carer wouldstay with Jenny providing company anddirection if this was needed. A mid-afternoondrop-in visit was made to the bungalow toprepare an afternoon drink and the eveningmeal and finally each day a carer visited andwould assist Jenny to prepare for bed andagain ensure that all medication was taken.This package of care worked well forapproximately two years.

I visited Jenny at her bungalow with a seniorhome care assistant and found that latterly thesituation she was experiencing had becomevery isolated and disabling. Her only socialinteraction was with her carers and infrequentvisits from her family – this was possiblyaffecting her withdrawn state and inability toconverse and she also complained of a verydry mouth.

I suggested that Jenny could begin to interactwith the Oaks residents to improve herquality of life, perhaps by attending activitiesin The Oaks like the games afternoon, orsimply inviting her to the care centre tointeract with the other residents, therebyreducing her loneliness and providing herwith a role that could be partially fulfilled byoffering simple help and company to some ofthe more dependent residents, showing hercaring nature. Care staff would also be able tomonitor Jenny’s overall condition and provideadequate fluids etc.

Before this package of care was in place Jennyrequired hospital admission for physicalhealth problems, therefore after consultationwith the family and Jenny it was decided thatshe would become a permanent resident inThe Oaks care centre.

Initially after taking up residence Jennyseemed unsettled owing to her memory lossand her difficulty expressing herself verbally.She compensated for this by taking on herprevious role as a nurse and tried to occupyherself by assisting the staff etc. but as she hasbecome more familiar with the environmentshe has settled in and takes an active yet quietpart in the activities available such as thereminiscence group, physical activity andindividual outings to local attractions. She hasalso been able to interact with acquaintancesthat she had previously acquired in the widerHartrigg community. (Val Ellis, 2003)

continued

What became clear was that specialist supportwas just that – support. Staff did not necessarilyneed to have a full-time RMN/specialist workingin their unit all of the time. What they did need wasready access to specialist help as and whenrequired.

Interviews with staff at Hartrigg Oaks revealedthat they valued having someone to call on whenrequired.

One group of staff, those working in ancillaryroles, i.e. cooks, cleaners etc., particularly valuedtraining. These staff members are often left out oftraining sessions related to care and yet arefrequently faced with situations they feel unable tocope with. For instance, simple understanding ofmental health conditions and good communicationskills has enabled this group of staff to supportclients more fully and sympathetically.

At the start of the project staff felt unable tomanage people who displayed behaviourperceived to be out of the ordinary. Many staffmembers had little experience of close contact withpeople with dementia and had preconceptions thatwere based on media and other stereotypicalnegative portrayals. One very positive changefollowing on from training and support groups is

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that the staff almost completely turned aroundtheir attitude. Understanding about dementia andthe reasons for behaviour made many staffincreasingly tolerant, sympathetic and supportiveof residents with dementia, and indeed upheldtheir right to live within the community like others.

One group of residents posed specificchallenges. These were the peers of the people withdementia themselves. We were finding a limitedtolerance of people with dementia from fellowresidents. It was hard to determine whether thispeer group were against the individual, theirbehaviour or their condition.

Informal focus groups were formed to ascertainwhy some residents were concerned. Viewsexpressed included:

these people [those with dementia] should not behere.

Other people, however, expressed the view thatwhilst they valued a service that allowed people tobe cared for regardless of their condition, they didnot wish to be in close proximity to people whoexhibited different behaviour to theirs, i.e.integration versus segregation concerns.

Several issues emerged from these groups:

• Real lack of understanding about dementia –its cause, symptoms and prognosis.

• ‘Not in my backyard’ syndrome. Manypeople wanted a specialist service forthemselves if they needed it in future but didnot want to see a service for others in theirhome.

• Fear about dementia: some people stillthought it was a contagious disease.

• Embarrassment (and a degree of revulsion)about some behaviour, especially thosepeople who showed lack of inhibition.

• Fear of challenging and violent behaviourand a degree of helplessness in coping

themselves when confronted by suchbehaviour.

These issues fell into two categories:

• lack of basic understanding

• fear that they may be affected by thecondition themselves in the future.

It was decided to address these issues in twoways:

• by setting up a resident/carer group toconsider all the issues

• by trying to reach a consensus on the bestway of handling dementia in the home andby an education programme.

A different group of people posed verychallenging problems. Whilst we had concentratedon the needs of people living in our homes forother people, we also had the need of adults withlearning disabilities to consider. Many of theseadults had been cared for by the Trust for up to 20years and were beginning to age and consider theirretirement options. We found that medicaladvances meant that many people were now livinginto late middle age and beyond and were in manycases also experiencing many of the symptoms ofdementia and other mental health issues. Thechallenge for the Specialist Nurse Project will be toprovide a service to these residents and their carers,to enable them to lead fulfilled lives and to remainin their homes wherever possible.

4 Dementia awareness group

A working group consisting of Hartrigg Oaksresidents, care staff, management, JRHT specialistnurse and external advisers including a consultantpsychiatrist has been formed at Hartrigg Oaks.

The purpose of the group is to study the issuessurrounding the care of people with dementiawithin a continuing care retirement community

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with particular focus on how the care can bedelivered in the context of a general nursing home.

Particular areas of discussion are centredaround the assessment and definitions surroundingdementia and challenging behaviour.Consideration is also being given to ways in whichthe well-being of residents can be increasedthrough appropriate activities, diversional therapyetc. The use of technology is also being considered.

A broader concern is how to increase awarenessof issues surrounding the care of people withdementia and the condition in general with regardto residents in the wider community at HartriggOaks.

5 Education

Since undertaking the ‘Mental health in old age’module at the Department of Health Sciences at theUniversity of York Val has endeavoured todisseminate her learning about the topic and skillsrequired associated with mental health care to hercolleagues across a variety of disciplines.

She has achieved this by facilitating trainingsessions and support groups with a variety of careworkers who come into contact with clients, e.g.trained staff who are not RMN, care assistants andgeneral assistants including kitchen and ancillarystaff. By increasing the overall level of awarenessand understanding for all staff who come intocontact with clients, they now have a greaterunderstanding/knowledge base to respondpositively and sympathetically to client need. Inaddition, this has improved staff morale and jobsatisfaction.

6 Conclusion/points arising

Even before the project was completed it was veryclear that the benefits of specialist staff wereapparent. Lessons that were learnt were:

• The need for thorough, holistic assessment ofpeople and the use of an assessment tool thatcan highlight the multifaceted needs of eachindividual. MDS was able to indicate via thecognitive loss scale that people had varyingcognitive impairment and that earlyintervention was beneficial to their quality oflife for residents and those around them.

• Interventions had to be negotiated with allconcerned and the role of the specialist nursein helping to determine care plans was vital.Whilst specialist assistance from psycho-geriatricians and community psychiatricnurses was available through the healthservices, an on-the-spot specialist meant thatassistance could come quickly, could beregularly monitored and was flexible to meetrapidly changing needs.

• A whole-systems approach needed to betaken with mental health issues. The studyshows that everyone concerned with theindividual resident should be included.

• The specialist staff also need a supportmechanism and throughout this study Valreceived clinical supervision from Peter Coxfrom the University of York. This supportwas multifaceted and included mentoring,professional advice, guidance withcontinuing professional development etc.

• The specialist staff need to be part of themainstream funding/staff complement.

• Support to residents with special healthneeds cannot be considered in the short term.

• People, especially those with dementia, needlong-term support which can be bestachieved by long-term specialist input.

It is envisaged that the work and researchalready undertaken for this project will continue tobe investigated and developed further.

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Acknowledgements

I would like to thank Linda Auer for her help andsupport over the course of the project. Thanks arealso due to the Alzheimer’s Society, DementiaNorth and Dr Graham Stokes for their informationand resource facilities.

Documents

MDS – latest research · (RNCC) tool was introduced in 2001 to determine the amount of NHS-funded registered nursing care that residents in care homes need. • This study evaluated