My Health, My Care, My Home - healthcare framework for adults living in care homes: summary

Framework providing a series of recommendations that aims to transform the healthcare for people living in care homes.

Table of Recommendations

Framework Chapter: Nurturing Environment


1.1 We must recognise and value the important role of all staff working in the care home in improving health and wellbeing of people living in care homes.

1.2 The care home team should continue to play a leading role in the healthcare of people living in care homes, alongside a keyworker who co-ordinates the day-to-day care of the individual.

1.3 Health and social care professionals must work together to address any healthcare needs within the nurturing environment of the care home and ensure that people living in care homes are not over-medicalised.

1.4 Everyone living in a care home should have access to nursing care. These nurses may either be employed by the care home, or, if employed externally, should have expertise in care homes.

Framework Chapter: The Multi-Disciplinary Team


2.1 Regular MDT meetings (face to face, virtual or hybrid) should take place involving the care home team, the GP practice and relevant other professionals to co-ordinate and plan healthcare.

2.2 The administration and support of MDT meetings should be co-ordinated between the HSCP and the care home.

2.3 People living in care homes should have the opportunity to involve a family member or any legally appointed welfare guardian or attorney during consultations with members of the MDT.

2.4 As MDTs form and develop, opportunities for shared learning should be explored, to develop the knowledge, skills and experience required to provide the best possible care.

2.5 Wherever possible, each care home should be linked with a named GP practice that will play a lead role with that home. Where this is not possible, HSCPs should work with the local care homes and GP practices to establish safe and reliable alternative arrangements that enable effective MDT working

2.6 People living in care homes should be made aware of the benefits of being registered with the GP practice that is linked to the care home that they live in, however they should not be forced to change GP practice.

2.7 Health Boards should review Local Enhanced Services (LES) that relate to care homes and revise them in line with the aspirations of the 2018 GP contract and the ambitions of this framework.

2.8 HSCPs must ensure that there is access to appropriate specialist provision when commissioning with the care home sector to provide specific services for people with highly complex care needs.

2.9 Care home teams must be provided with contact details and referral routes for all members of the MDT. Where these are not clear, the HSCP should work with the care home to obtain these.

Framework Chapter: Prevention


3.1 People living in care homes must be supported to access any relevant age-specific public health programmes with appropriate information to allow an informed decision.

3.2 Application of IPC standards in care homes should be supported by access to relevant IPC advice, education and guidance.

3.3 Everyone living in a care home will have a regularly reviewed personal plan.

3.4 Ensure there are effective systems in place to deliver a consistent approach to the development and implementation of proactive, personal plans.

3.5 A person centred medication review, using the 7-step approach should be initiated by a pharmacist when someone first moves into a care home, and then at least annually thereafter. Certain high risk drugs, such as antipsychotics, will require more frequent monitoring and review

3.6 Routine dental, sight, and hearing reviews should continue to be part of an individual's personal care plan when they move to live in a care home.

3.7 There should be a named dentist / dental practitioner for each care home and contracts with local optometry and hearing services.

3.8 There should be a proactive approach to hydration, nutrition, continence promotion, meaningful activity and mobility using appropriate resources and should be considered with the same degree of importance as reactive healthcare.

3.9 Religious and philosophical beliefs in relation to food and diet should be enquired about and catered for.

3.10 Psychological and spiritual aspects of healthcare should be assessed and regularly reviewed within care plans.

3.11 Individuals should be supported to maintain links in their local community which enables cognitive stimulation, mobility, independence and communication.

Framework Chapter: Anticipatory care, self-management and early intervention


4.1 'What Matters to Me' and 'Thinking Ahead' ACP conversations should take place at the earliest opportunity, ideally prior to entering the care home, and at regular intervals throughout the individual's stay.

4.2 Where someone has a complex health condition, or there are a variety of different treatment options, a senior clinician, such as GP should be involved in discussions.

4.3 All health and social care staff must be provided with support and training in communication to improve confidence and skills in conducting these meaningful conversations.

4.4 Everyone living in a care home should have the opportunity to develop an Anticipatory Care Plan.

4.5 All health boards should seek to agree and adopt a robust approach (such as the HIS ACP Toolkit, Lothian 7 Steps, ReSPECT) to conducting ACP discussions.

4.6 Anticipatory Care Plans should be shared with everyone involved in providing the individual's care, and a summary should be included in the Key Information Summary (KIS).

4.7 Establish community-based supporting self-management programmes to consider how best to support care home teams to adopt self-management approaches.

4.8 People living in a care home should continue to have regular assessments of their long term conditions, as appropriate, from their Primary Healthcare Teams.

4.9 Realistic Medicine principles should be adopted to reduce unnecessary or inappropriate investigations and treatment.

4.10 Where possible, people with complex medical conditions should be supported to attend hospital-based clinics. Where this is not possible, specialist input into the care of the person living in a care home should be adapted to the situation. This may be by telephone, video consultation or by visiting the care home.

Framework Chapter: Urgent / Emergency Care


5.1 Support and empower care home staff by providing and encouraging participation in training opportunities and enabling all staff to have the tools to assess and communicate in acute and emergency situations using the SBAR format.

5.2 People living in care homes should have timely access to members of their MDT, 24/7 when urgent or unscheduled care is required.

5.3 HSCPs should develop dedicated community healthcare teams comprising advanced practitioners who can respond quickly and visit people in care homes requiring urgent unscheduled assessments, with support and advice being easily available from the GP by phone. These services should cover both weekdays and weekends.

5.4 Both care home staff and healthcare staff should be familiar with the SBAR format when discussing urgent or emergency care, and consider using a structured proforma for these conversations.

5.5 Care home staff should be able to contact healthcare professionals during an urgent or emergency situation in a consistent and timely manner - this includes exploring possibilities for dedicated professional to professional communication channels.

5.6 Scoping work should take place to explore the use of near patient and point of care testing within care homes, taking into account Realistic Medicine principles.

5.7 Health boards should develop Hospital@Home services that support people living in care homes to receive hospital-level care within the care home.

5.8 Further work is required across Scotland to improve the accessibility and provision of medicines during an urgent situation. This includes exploring mechanisms to enable care homes to hold a stock of certain drugs within the home.

5.9 People living in care homes should never be denied admission to hospital solely on the basis of living in a care home, and at point of admission older people should be assessed by a senior clinical decision maker with experience in caring for frail older adults.

5.10 Timely and safe transfers to and from hospital for older people in care homes should be optimised.

5.11 Digital access to an individual's health records, and clinical outcomes should be timely and accessible to all parts of the system.

Framework Chapter: Palliative and End of Life Care


6.1 Care homes should consider how they can incorporate identification tools and assessments within normal practice to help identify people who may require a palliative approach to their care, and support the individual as their health needs change.

6.2 Provide training in the use of appropriate symptom assessment tools, and enable early involvement of dementia link workers to ensure that those living with dementia receive the care and treatment they require.

6.3 Anticipatory Care Plans should be reviewed as people are nearing the end of life to ensure they are firmly rooted in a clear understanding of the values, beliefs and preferences of the individual.

6.4 Care home providers should use the 'enriching and improving experience' framework to identify need and plan the learning and development of their employed staff in relation to palliative and end of life care.

6.5 HSCPs and NHS boards should ensure that there is a specialist palliative care service available and easily accessible to the MDT, and these services should foster close "co-working" and "shared learning" relationships.

6.6 Care home providers and specialist palliative care teams should work together to explore shared learning and peer support opportunities, through initiatives such as Project Echo.

6.7 GPs and other members of the MDT should be available to support the care home staff with end of life care, and speak with relatives when required.

6.8 Dedicated out of hours palliative care lines, allowing direct and fast access to community nursing and medical staff for people who are nearing the end of life, should be available in all HSCPs.

6.9 There should be prompt access to appropriate medication (including anticipatory 'just in case medication' and oxygen) and equipment, such as syringe pumps and pressure relieving mattresses.

6.10 Scotland's bereavement charter should be adopted by all those working in and with care homes and used to guide the support that is offered to those who are bereaved.

Framework Chapter: A sustainable and skilled workforce


7.1 Seek to improve the timeous availability of workforce data to support robust workforce planning, recruitment and retention in line with requirements of The Health and Care (Staffing) (Scotland) Act 2019

7.2 Invest in the development of care home managers and consider access to enhanced leadership training, mentoring and leadership networks.

7.3 Plan and ensure clinical and professional leadership through the provision of registered nurses as key members of the care home team.

7.4 Explore opportunities for recruitment within the community, by placing a greater emphasis on values rather than experience.

7.5 Organisations should take steps to ensure the emotional wellbeing of their staff, and provide access to support and signposting to the range of resources currently available to them.

7.6 Ensure workforce plans include dedicated time for staff to undertake recommended and required education and training.

7.7 Explore opportunities for career and development pathways for support workers, ensuring consistency and transferability of skills and knowledge across the sector.

7.8 When complete, implement the Induction Framework, developed by NES, SSSC & Scottish Government, across the sector in a 'Once for Scotland' approach.

7.9 Identify the mandatory and core elements of training for care staff to ensure the essential knowledge and practical skills are readily available for use in the care home.

7.10 Have meaningful and consistent education and training that is fit for purpose, includes more practical support tools, and is supplemented by online training.

7.11 'Care Home Liaison Service' models should be explored, whereby multidisciplinary teams work alongside the care home team to build competence and confidence in meeting the needs of the people living in the home.

7.12 Explore opportunities to develop and introduce a one-stop repository for tools and resources, that everyone can access and that will highlight and share good practice already happening for others to draw from.

7.13 Encourage interdisciplinary multi-sector learning and development to develop the skills required to support people living in care homes

Framework Chapter: Data, Digital & Technology


8.1 Undertake a review of the existing care home data landscape to ensure it is used to benefit those living in care homes.

8.2 Data standards should be introduced, so that data entries from different organisations are understood to mean the same thing.

8.3 The Sharing Toolkit should be used to help organisations sharing or handling NHS Scotland's data to take the necessary steps to confidently share and use health data

8.4 People living in care homes should have opportunities and support to use technology to connect with the world outside the care home, including access to good Wi-Fi and broadband connections.

8.5 There should be access and support for people living in care homes to use NHS Near Me for video-consultations with healthcare professionals.

8.6 There must be appropriate technology within every care home to support virtual MDT meetings.

8.7 The actions listed within Connecting People Connecting Services should be implemented.

8.8 All care home staff should have access to resources that build and strengthen their digital skills, such as those developed by Technology Enabled Care.

8.9 Digital initiatives that support learning, such as Project Echo should be explored.



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