Overnight Care at Home Service: Highland
In 2014, NHS Highland was providing older people with a traditional in-house care at home service and a small amount of independent sector contracting. We embarked on a transformational change programme within the care at home service. Our new model seeks to deliver increased care at home hours through a transfer of budget from the NHS service to the independent sector, that will improve outcomes for service users and increase the volume of delivered hours within the existing budget. The NHS care at home service focuses on the provision of short-term reablement only.
Work with the independent sector, facilitated through the Partners for Integration Team identified that the creation of discrete small geographical zones best supported providers to effectively and efficiently deliver the service requirements.
Prior to the introduction of the Overnight Service, there was no care at home provision of either scheduled or unscheduled care for older people between the hours of 10pm -7am. In general, older people requiring overnight care at home would have been admitted to hospital as an emergency, remained in hospital awaiting a care home placement, admitted directly to a care home or remained at home at significant risk. The Operational Unit clearly identified that this was a gap in service.
Development of the Service
In order to pilot this approach to overnight care at home all support and care at home providers who met the NHS Highland commissioning criteria were invited to participate in a consultation event to discuss the commissioning of an overnight service. Following this initial consultation this was narrowed down to care at home providers as other support providers do not provide personal care. This created the opportunity to use existing care at home providers with the caveat that any provider subject to placement restrictions or support with service delivery was unable to participate.
Building on the firm foundations the care at home transformational change programme presented, the opportunity to work further in a collaborative manner to design and develop an overnight service was embraced by three independent sector providers, namely Gateway, Eildon and Castle Care.
They elected to work as a co-operative, which, supported by Scottish Care, offered a creative response to the challenges of both capacity and sustainability in delivering such a service. Central to the service model is a reablement approach.
Advice was sought from the Care Inspectorate regarding the proposed operational model for the three providers working in partnership. Each partner operates under their individual care at home registration and is inspected under its own auspices. Each partner also employs a proportion of the workforce. However, to more closely align working practices, policies and procedures specific to the Specialised Overnight Service were produced. All workers, regardless of their employer, were recruited, trained and work together as a single team. There is a Heads of Agreement in place, which includes a dispute resolution process. A part time Co-ordinator is employed by one of the partners, with financial contributions made towards the post from the other two partners.
Recruitment, Training and Workforce Support
Experienced and qualified care at home staff at SVQ level 3, (or working towards), were recruited utilising a Values Based Approach underpinned by the SSSC’s programme, “A question of care, a career for you?”
There was service user participation in the selection process from the Highland Senior Citizens Network (HSCN). HSCN consists of a Highland-wide network of local voices to represent the interests of the 77,000 people of the Highlands who are over 55 years.
Training was structured to ensure an authentic learning experience. It was both competence and confidence building. It offered a range of skills delivered by a spectrum of professionals. Within this range of proffered skills, was the inclusion of decision making and was delivered by a host of local independent sector and NHS professionals from a range of disciplines including OT, Physiotherapy, District Nursing, Care at Home, Psychology and Pharmacy. This was further enhanced by a session from a Service User on personalisation and individual outcomes.
This total partnership approach to staff development and training between the NHS, the 3rd Sector and the three providers is a good example of the close working and the ready access to skilled support this change has brought about.
A thorough evaluation of training showed the usefulness of each session and staff identified there were no gaps in their training.
Part of the training examined decision making and managing risk. This has empowered the workers to work more flexibly within a broad structure to ensure individual need is met.
Staff satisfaction is high. This is reflected in individual support and supervisions, practice audits, team meetings as well as in the sickness record for the service. In the 7 months of operation of the service, the total staff sickness within the service has been only one shift.
A team of two workers provide a service from 10pm to 7am each night with an optimum of 17 interventions per night. This has gone as high as 22 per night where there was difficulty in discharging some people from the service due to individual or family member’s expressed lack of confidence which has now been addressed.
The number of interventions varies depending on:
- The amount of referrals
- Complexity of calls
- Throughput in the service
The service delivers both scheduled and unscheduled care, with the bulk of the visits being scheduled. Common interventions of the service include:
- Helping people to return to bed
- Help with continence
- Repositioning to prevent pressure sores
- Uninjured falls response
- Telecare response to 3 sheltered housing complexes
We are seeing patterns emerge with some service users who need an unscheduled response overnight. An example of this is around acute periods of discomfort during the night for people that have palliative conditions. As a result of this type of request the inhours integrated health and social care neighbourhood teams are alerted to ensure appropriate follow up including review and support.
Service users and family carers who received scheduled interventions rated the service highly. This was confirmed by practice audits. Whilst an initial questionnaire was issued with good response, it was recognized that a continuous measure of satisfaction using postcards would help towards more effectively measuring satisfaction with unscheduled interventions.
The care outcomes for the service gives us some baseline data to standardise the length of time the service is provided to an individual for before other alternatives are considered.
There are multiple sources of referral which include:
- Integrated health and social care teams
- OOH Social Work
- NHS 24
- Discharge Support Team
- Care at Home
The service has demonstrated an ability to provide a more flexible and responsive approach to meeting the needs of individual service users and has been able, because of this, to fit unscheduled visits around a scheduled programme of support at night.
Former Regional Lead, Scottish Care