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Best practice in end of life care
Developments with Gold Standards Framework

Professor Keri Thomas OBE updates on best practice in end of life care, developments with the Gold Standards Framework for Social Care and the impact it can have on social care and health.

Since the start of the millennium, there has been a radical transformation in the way nursing and residential homes care for their residents as they approach the last stage of their life. While pockets of good practice undoubtedly existed then, the standards of care in some homes and investment in staff training and support left much to be desired. I’ll never forget a conversation with one manager of a residential home in London who said they have no deaths in their home – they just sent them all to hospital to die.

There is increasing recognition of the vital importance of this sector within the integrated care context, and the impact that low investment in social care has on the rest of the system, particularly affecting hospital admissions, deaths of residents in hospitals and delayed transfer of care.

In 2018, the profile of a typical care home resident has changed significantly, with an estimated eight out of ten likely to die within a year (this figure is higher in nursing homes) and one in five deaths in the UK now occurring in a care home. But still too many residents are admitted to hospitals in crisis, especially in their last weeks or days of life. This is despite the fact that, through planning and better staff training, many such admissions could be avoided, up to half in fact, according to a National Audit Office report in 2009.

Improvements in end of life care

Meanwhile, many improvements in care homes have been made over this time. This period of progress in delivering improved care for people in the later stages of their life coincides with 3,000 homes having completed the Gold Standards Framework (GSF) Care Homes Training Programme since its launch in 2004. Hundreds of those homes have also progressed a stage further to complete accreditation and many of these have gone on to be reaccredited multiple times.

For a considerable number of those homes, the training and accreditation was the launchpad for a new way of thinking about the way they cared for their residents, not just in the final weeks and days, but for their entire stay – from the day they moved in. Many homes used GSF as a way of standardising and systemising the already good quality care they provided and as a catalyst for further improvement. They’ve embedded that good practice and continued to adapt and grow even stronger. At September’s National GSF Awards in London, several homes will be receiving their award for the fourth time, 12 years since starting GSF – this is a truly significant milestone and a demonstration of its long-term sustainability and their enduring commitment to do more and go further to provide the best possible care for their residents right up until the end of their lives.

There are countless stories of extraordinary transformation and wholesale culture change amongst these 3,000 homes, catalysed by the use of GSF. Many say that GSF continues to be the bedrock of the ongoing positive change they’re achieving as well as a key factor in their attainment of Outstanding Care Quality Commission (CQC) reports.

GSF in practice

At Kineton Manor Nursing Home in Worcestershire, for example, Dr Paul du Rand said, ‘I really think it was GSF that helped us get the Outstanding rating. All the principles you implement when doing GSF are principles that help you to get an Outstanding inspection from CQC. Inspectors mentioned that our care for people who are dying is like a hospice.’

The 2017 winner of the GSF Care Home of the Year award, Cholwell House, in Somerset, is an excellent example of a home that has transformed the way it cares for residents, particularly as they approach the end of life. Fiona Trezise, Manager of the 46-bed home which specialises in care for people with dementia, said, ‘When I started at Cholwell House in 2008, we had no clear way of looking after people at the end of life. They were really dark days. The staff here truly do give themselves and are so motivated and passionate about providing the best care they can.’

Fiona invites every resident and their family to a meeting, soon after admission, to discuss how and where they would like to be cared for in the form of an Advance Care Plan. In line with their wishes, all residents at Cholwell House who died in the last year, did so at the home. There have also been no crisis admissions to hospital from the home since 2010 – an outstanding achievement in the context of the daily traumas for patients and staff in A&Es all over the country.

While Cholwell House is an exemplar, its approach is now far from unique. Advance care planning has become a routine function in many homes, laying the foundations for compassionate, personalised care, dramatically reduced admissions and a major increase in residents fulfilling their wish to die at home.

Making excellent approaches the norm

How then can these excellent exemplars of care become the norm rather than the exception? GSF has spent the last year taking soundings from the industry. This has culminated in the launch of a revised care homes training programme which is updated to include all the latest developments, shorter and more affordable – designed to be accessible for all homes, delivering on the mission to mainstream gold standard care across the whole sector.

The new programme draws on the learning from the Vanguards, the experience of our multi-accredited homes and includes lessons from the shorter Six-Steps programme that developed from GSF some years ago.

The training has been streamlined to focus on seven key tasks and is delivered across just three and half days over six months, with homework and a starter-kit portfolio preparing homes for accreditation, which is now achievable within a year. The shorter nature of the new programme is reflected in the lower cost, helping more homes, smaller ones in particular, become a part of this national momentum of best practice, for the price of one resident’s bed for a week.

The ever-expanding network of GSF regional training centres around the UK ensures homes can access the programme easily too.

Benefits of GSF for health and social care

Aligning with the seven key principles announced by Jeremy Hunt, Secretary of State for Health and Social Care, in March this year, the revised GSF Care Homes Programme retains its focus on quality.

Mr Hunt highlighted the postcode lottery endured by many residents, with a 90-fold difference in hospital admission rates for over-75s between the highest and lowest performing areas. On average, nationally, GSF-accredited homes halve the number of residents’ admissions and improve delayed transfers of care.

GSF Homes experience closer working relationships with GPs, specialists and hospitals through better integrated care in line with Mr Hunt’s second key principle of whole-person, integrated care. The new GSF programme helps homes implement another of the Health and Social Care Secretary’s principles – to respect and nurture the social care workforce – the ‘modern-day heroes’ as he rightly calls them. Staff in GSF homes report increased job satisfaction, with many describing being reminded of the reasons why they entered the profession in the first place.

As Fiona Trezise of Cholwell House said, ‘Caring for someone at the end of their life is a privilege and doing it well provides those that excel at it with a huge sense of satisfaction. That in turn, improves morale and decreases staff turnover. By embedding co-ordinated, compassionate and personalised end of life care, homes will experience better outcomes for them and their residents, helping them to stand out in this vital area of care, preparing them for the next decade, at the end of which it’s predicted considerably more than the current 20% of deaths will occur in care homes.’

Professor Keri Thomas OBE is Clinical Director at GSF Centre. Email: Twitter: @GSFCentre

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