Pressure ulcer compliance in care homes within Newark and Sherwood CCG

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1 Introduction Pressure ulcer compliance in care homes within Newark and Sherwood CCG This paper briefly outlines the current evidence and practice in relation to pressure ulcers in care homes in the geographical area covered by Newark and Sherwood Clinical Commissioning Group. Harm free care sets out to eliminate harm in patients from four common conditions, pressure ulcers, falls, urinary tract infections and venous thromboembolism. These conditions affect over 200,000 people in England, leading to avoidable suffering and additional treatment costs. Newark and Sherwood CCG has a zero tolerance towards pressure ulcers graded 3 & 4. This vision is also adopted by NHS England. Background Pressure ulcer management in care homes that provide nursing care is the responsibility of registered nurses (RN) employed by the home. Pressure ulcers in care homes that provide only residential care are managed by the community district nursing team (DN). In care homes registered for both nursing and residential care the practice varies and depends on how the unit is managed. In some the pressure ulcers for residential people is managed by the RN, in others are managed by the DN. All care homes are provided with access to awareness, information and training on pressure ulcer care periodically. They also have the option to directly refer any resident with a pressure ulcer to a Tissue Viability Nurse (TVN) for assessment, advice and support. There are 48 care homes within NHS Newark and Sherwood CCG of which 24 (50%) are part of NHS Continuing Healthcare s (CHC) Any Qualified Provider (AQP) contract. An AQP care home is an approved care home which meets NHS standards. Of these 24 homes, eight are for people with learning disabilities, nine are for older people with nursing care needs and the remaining seven are for older people with residential care needs. Information is received monthly from CHC and this indicates the majority of CHC funded residents are placed in those homes providing nursing care. These homes are monitored through an annual audit programme; the current audit schedule examines pressure prevention care practices. Homes that do not meet current quality standards in this area are required to produce action plans and progress is followed up. Care homes are not currently required to report pressure ulcers to the CCG. They are required to notify the Care Quality Commission (CQC) of pressure ulcers that are graded 3 and 4. CQC do not currently share this information. Consequently the full Agenda Reference GB/14/020 1

2 picture on the prevalence of pressure ulcers across Newark and Sherwood care homes is unknown. The Quality and Safety Team currently receives some data on grade 3 and 4 pressure ulcers in care homes; this is sourced from information shared by the tissue viability nurse service, incident reports from Community Health Partnerships and Sherwood Forest Hospitals NHS Foundation Trusts. Information is also gained through involvement in safeguarding investigations. This information is inconsistent and does not reflect the whole picture of pressure ulcers in care homes therefore can not provide reliable quantitative data on pressure ulcer numbers however this information and the audit process provides qualitative data. Actions to address this The quality schedule of the AQP contract is currently being reviewed by a regional working group. The CCG is represented at this group by the Chief Nurse. From April 2014 care homes on the AQP contract will be required to report the numbers of new pressure ulcers to the CCG each month. This will, in the medium to longer term provide quantitative data in relation to care homes which are providing CHC funded care. A Pressure Ulcer CQUIN (Appendix A) has been agreed for Care Homes; this was established at a regional level to enable data collection and facilitate improved care at a local level. The Quality and Safety Team Work will continue to collect qualitative data and work is currently underway to improve the collection and collation of this data i.e. information to be reported to a single point within the team and recorded on a single data base. This will support improved data cleansing and analysis. It is anticipated that these combined actions will assist in understanding the prevalence of pressure ulcers and what commissioning responses may be required to support zero tolerance towards pressure ulcers graded 3 & 4. Themes emerging from qualitative data It appears the standard of pressure ulcer care across the area is variable. Audit has found that some care homes have been successful in managing and healing pressure ulcers that have been acquired prior to admission to the care home. Areas of inadequate practice include: Staff not recognising when to refer to the TVN or DN service Inadequate care planning to evidence care arrangements A lack of knowledge on pressure ulcer incidence within the care home, although this is an area were improvement has been noted. CCG audit has promoted the introduction of pressure ulcer registers in care homes and the majority of care homes with nursing do now collect and hold pressure ulcer information as part of their own internal quality monitoring measures 2

3 Inadequate monitoring of pressure prevention equipment Ineffective communication between care home and DN staff Limited knowledge of how to undertake a root cause analysis when a pressure ulcer develops; this can impact on opportunities to learn. Currently the Quality and Safety Team support improvements through quality audit processes and one off support to care homes when a safeguarding or quality concern visit finds areas for improvement. While process improvements have been noted, the lack of quantitative data means we can not determine whether this has impacted on the overall numbers of pressure ulcers. Conclusion The Quality and Safety Team will continue to work with individuals homes to improve practice through quality monitoring and responsive safeguarding and quality concerns visits. The prevalence of pressure ulcers within Newark and Sherwood care homes is not currently known; this will begin to be addressed in 2014 through the implementation of a CQUIN. Knowledge of prevalence of pressure ulcers can then better support commissioning decisions. Recommendations The Governing Body is recommended to REVIEW the findings within the report; IDENTIFY any additional information to be included in subsequent reports; AGREE the frequency of subsequent reports. 3

4 Appendix A Local contract ref. Goal number Goal name Indicator number Indicator name Indicator weighting (% of CQUIN scheme available) Description of indicator Numerator Denominator Rationale for inclusion Data source Frequency of data collection Organisation responsible for data collection Frequency of reporting to commissioner Baseline period/date Baseline value Final indicator period/date (on which payment is based) Final indicator value (payment threshold) Rules for calculation of payment due at final indicator period/date (including evidence to be supplied to commissioner) Code Unknown Nursing Home Pressure Ulcer Prevention Pressure Ulcer prevention - implementation of preventative mechanisms Reduction in the incidence of pressure ulcersin NHS funded patients. Implementation of the SSKIN: five steps to prevent and treat pressure ulcers. Monthly audit against SSKIN. Report Grade 2, 3 & 4 pressure ulcers to CCG as part of the Serious Incident policy. Root cause analysis into Grade 3 & 4 pressure ulcers. Number of patients (fully funded NHS) with newly identified pressure ulcers acquired in the care home Total number of NHS fully funded patients in Care Home To reduce the incidence of pressure ulcers acquired in care homes. Avoidable pressure ulcers are a key indicator of the quality of nursing care. Preventing them happening will improve all care for vulnerable patients Provider audit of NHS fully funded resident care record Quarterly Provider Quarterly n/a n/a End of Q4 77% Audit to provide evidence of 1. Implementaiton of SSKIN; 5 steps to prevent and treat pressure ulcers. 2. Reporting of pressure ulcers to CCG 3. Reduction in acquried pressure ulcers Final indicator reporting date End of Q4 Are there rules for any Yes if yes complete below agreed in-year milestones that result in payment? Are there any rules for No partial achievement of the indicator at the final indicator period/date? 4

5 Milestones (only complete if the indicator has in-year milestones) Date/period milestone relates to Q1 Rules for achievement of milestones (including evidence to be supplied to commissioner) Project Plan submitted to commissioner and progress report Q1 baseline for acquired pressure ulcers Milestone weighting (% of CQUIN Date milestone scheme to be reported available) end of Q1 2.00% Q2 Quarterly audit & progress report end of Q2 2.00% Q3 Quarterly audit & progress report end of Q3 4.00% Q4 Quarterly audit & progress report demonstrating reduction in pressure ulcers end of Q % Total 35.00% If milestones are specified, this total should equal the overall indicator weighting (from cell B6). Rules for partial achievement at final indicator period/date (only complete if the indicator has rules for partial achievement at final indicator period/date) Final indicator value (payment threshold) % of CQUIN scheme available Additional milestones and/or rules for partial achievement at final indicator period/date may be added to the CQUIN template. 5