New clinical roles for care home staff are being touted so the future needs of frail older people can be met. Jill Manthorpe reviews the findings of a three-year study
KEY WORDS: Care homes; Older people; Skills; Workforce
AUTHORS: Deidre Wild, Ali Szczepura and Sarah Nelson
Aim: This is a report of a three-year study examining the best way of meeting the future needs of older care home residents.
Methodology: This study was an evaluation of different approaches adopted in three care homes in England that aimed at improving residents’ care. Research methods included surveys, interviews, focus groups, documentary analysis and audit.
Conclusion: Care homes need to be better equipped in terms of the workforce skills to meet the needs of people with high levels of frailty and at end of life. The authors recommend the development of new roles for care home staff, involving clinical tasks usually carried out by nurses, as a way of improving integration between health and social care.
A new role worker would have greater skills in areas of nursing care and would be better able to support residents in poor health or approaching end of life. This would be an extension of the role of a care home worker who is not usually qualified or supported to undertake work associated with nurses.
The distinction between care home workers and people working in nursing homes might decrease. While some of this work might be around people with declining health, it might also equip care home staff to work in reablement more consistently and effectively.
This study examines ways of meeting the future needs of older care home residents. Exploring evidence from an in-depth study of three care homes where changes were implemented and practice considered, it explored whether training care home workers in basic clinical skills could enhance residents’ health and social care.
The authors wanted to investigate practice and policy levers for change, and to consider if financial support for “new role” care home workers was likely to improve outcomes or to have wider support.
This evaluation examined the strengths and weaknesses of different approaches to developing new care roles. It looked at the implications of these roles for people working and living in care homes.
The research team argues that if staff are trained in new roles, particularly clinical skills, continuity of care improves, there is better quality of life and security for residents, and care workers derive greater job satisfaction, with lighter workloads for community health staff, such as district nurses, and potential cost savings for the NHS.
However, new approaches need to be long-term. Local care home managers play a central role. They are keen to see change but need help in its management from local stakeholders, such as those working in primary care. Higher level skills, in clinical areas such as nursing care and treatment, cannot be safe if staffing levels are too low.
The research team argues for better understanding between hospital, community and care home staff about each others’ roles and responsibilities. It is currently difficult for these groups to work alongside one another because of the different charging, workforce and funding streams of the NHS and social care services. These affect individual payments and funding; but they also reflect differences in status, training, rewards and resources.
The researchers recommend more clinical input in National Vocational Qualifications (NVQ) level 3 courses (shortly to be supplanted by the Qualifications and Credit Framework), and pay incentives for staff to undertake these courses. Yet, as a recent Social Care Institute for Excellence review (Moriarty et al 2010) points out, we know little about what training is most effective and durable for frontline care workers.
The researchers also recommend a registration system for care home workers. In noting that social care employers have not uniformly provided additional money to foster new learning and responsibilities, the resources gap remains significant. It will be interesting to see whether NHS commissioners prompt change by contrasting the cost and outcomes of inpatient care with care home packages.
Many older people and family members seem to want care homes to be a “home for life” but are disappointed when nursing care seems to be difficult to access. This raises the question of whether we need any longer to have both care homes and care homes with nursing, if they are all to be able to offer nursing or access it.
However, the devil may be in the detail. The researchers note that agreements about what is basic nursing work that is suitable for care staff in any new roles remain unresolved. Nurses, in particular, are concerned about accountability, liability and competency. This may not be professional defensiveness because nurses may argue that these systems that have been built up to protect both care workers and frail older people.
The authors envisage that care homes whose staff are developing new roles should offer learning opportunities for students of many disciplines. They suggest that this would help integrate health and social care, as well as highlighting the good service provided by “new role” care workers.
At the level of the workforce these include the pay and status of care home workers, funding and registration systems, differences in health and social care practice and cultures, staff/resident ratios and workloads. They predict that the leaders of care homes will need to be more familiar with change management and that national leaders must change policy.
Above all, they maintain that this cannot be done without investment in the care home sector, some of which might come from savings in productivity but much of which will require new funding sources.
For care home commissioners:
* Commissioners should concentrate on outcomes and not the service specification of a home.
For care home providers:
* People working in care homes are often highly motivated and interested in developing their skills. This is a tremendous resource and providers may wish to develop their roles further.
* Care homes may wish to engage with educational providers to offer placements to a very full range of students, undertaking clinical courses in particular.
* Employers need to address how to achieve high quality integrated health and social care without staff’s workload becoming overburdened.
For care workers
* Acquiring new skills in clinical areas could provide opportunities for personal growth and delivering a better service to residents.
* Moriarty, Kam, Coomber, Rutter and Turner (2010), Communication training for care home workers: outcomes for older people, staff, families and friends, Social Care Institute for Excellence.
Jill Manthorpe is director of the Social Care Workforce Research Unit and professor of social work at King’s College London. She is associate director of the NIHR School for Social Care Research
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