Beyond inspection: how a lay visiting service can help improve care home quality

By Pam Robinson and Sharon Wilson

It was really depressing. The Care Quality Commission’s reports on the home were really good, but my Dad was so unhappy there and I was certain that it could and should be so much better.”

This was a fairly typical comment shared by a group of former health or social care professionals who were meeting together to discuss their concerns for their older relatives living in care homes or nursing homes.

The group decided to establish a framework to capture what they would want for their relatives; which would be for them to be:

1. happy and content;
2. comfortable and healthy;
3. feeling individually valued and respected;
4. not lonely;
5. influencing our own day (choice);
6. appropriately stimulated, and
7. safe.

CQC inspection not enough

The group’s view was very clear that something was needed to complement the Care Quality Commission inspection framework. Though the CQC’s current framework places a greater emphasis on outcomes than the previous one, the relatives’ group felt that the evidence sought by inspectors supporting these outcomes was more based on processes than on how residents felt. The group strongly felt that there was a need for an approach that focused instead on how residents were feeling. The group’s concerns included the potential vulnerability, between CQC inspections, of those residents who did not receive regular visits from relatives or friends to check on their welfare.

Lay visitors

The group approached Hampshire County Council (HCC) and received support to develop and test a scheme to recruit and train lay visitors to assess quality in homes based on the seven themes outlined above. They hoped that lay visitors, visiting two or three times per year and reporting back to the local authority, might enable them to improve services for residents. During an early pilot scheme with HCC, members of the group and lay volunteers were able to talk with residents and their relatives, which facilitated the development of hints and prompts under each theme. These were not intended to be a checklist but to give ideas to the lay visitors on how they might know if a resident was happy, comfortable, safe, feeling valued, able to influence their own day, appropriately stimulated and not lonely.

Piloting the scheme

Once the framework was finalised by the relatives’ group, Hampshire’s adults’ services department agreed to a one-year pilot in six of its residential and nursing homes – including three residential homes, one nursing home and two homes with both nursing and residential units.

The local authority recruited the lay visitors using local publications and websites and set up a contract with one member of the relatives’ group to deliver the training they had designed and to offer support and quality assurance on the reports written by the lay visitors. Lay visitors went out in pairs, and on their induction visit were accompanied by the trainer who offered support on site. A project group was set up to oversee the evaluation of the scheme and a decision was made that the management of the pilot would sit with the quality and governance team in the council’s adults’ services, providing independent scrutiny.

Evaluation

Evaluation was carried out by:

• unit managers completing questionnaires after receiving a report, saying what they had changed as a result of the visit;
• service managers completing a similar questionnaire;
• all lay visitors completing evaluations of the training and support received;
• the trainer/ supporter providing the local authority with a summary of the themes and issues emerging through the visit reports.

Findings

The lay visitors found the framework and its seven themes helpful. It is important to emphasise that in every home there were some wonderful, understanding and patient relationships between staff and residents. What became very clear, however, is that some issues impacted on every one of the seven themes:

• the quality of the environment;
• the morale of the staff group;
• difficulties with any disruptive residents.

If these issues were good and well managed, then residents were more likely to be happy and content, comfortable and healthy, and feeling individually valued. As a result, the framework for the reports was amended to include these observations under the opening section of the report on general impressions.

Helpful observations

By far the majority of the reports were complimentary and positive about the quality of care provided within the homes in the pilot. Even within this positive context, however, the lay visitors were able to come up with helpful observations and suggestions for change. They were very clear when certain aspects of the environment worked well and that more could be done to spread this good practice elsewhere. Even in the most positive reports, they observed that staff appeared rushed and they felt that the happiness of the residents could be improved if staff were less rushed; this did not detract, however, from their praise for the quality of the relationships between staff and residents.

Key themes

The following themes emerged from the visits:

• The layout of most homes is confusing to visitors and this must be the same for residents.
• Environments that worked the best for residents had a good variety of themed areas, such as cafes, pubs, gardening areas, music areas, cinemas.
• If staff morale was poor, this had an impact on that of the residents.
• Disruptive or distressed residents had a huge impact on others.
• A high value was placed on activities coordinators, and hair dressers.
• There was a wish for more outings.
• Access to physiotherapy and occupational therapy was sometimes problematic.
• There were very varied opinions on the quality of the food
• There was some evidence of residents feeling rushed in some homes, whereas in other places they were given plenty of time
• There was some evidence of residents not expressing their preferences, for example in choice of music.
• Residents feel embarrassed that they cannot remember staff names and they would like them to wear easy to see name badges.
• There was some confusion over the frequency of checks on those residents who are unable to get up from their beds in some areas.

Time and attention

A frequent positive comment from lay visitors concerned the amount of time and attention given by staff to ensure that residents do not feel lonely or excluded. Lay visitors had been trained to ask to speak with residents who do not have regular visitors; none of them expressed concerns about this more vulnerable group.

The pilot has now ended and HCC has agreed that a lay visitor scheme is valuable and provides an alternative view and additional feedback to enable services to be developed further and improve the quality of life for residents that live in their homes. The council is keen to continue with a lay vistor scheme and is currently identifying how best to do this.

Training, common sense and a keen eye

Both the relatives’ group and the local authority believe that the pilot has shown how much residents in residential and nursing homes can benefit from lay visitors who, with a little training, some common sense and a keen eye, can add to the quality of residents’ lives. Furthermore, it has shown how the local authority can improve its care in being open to a range of suggestions from a resident’s perspective .

Hampshire council is responding to the generalised themes of the lay visitor reports and sharing these across all its homes. In doing this a clearer picture of the changes that could be made to improve life for residents can be established and best practice can be disseminated. Some of the recommendations made by the lay visitors were innovative and reflected the real benefit of new visitors to the homes. Other issues highlighted were those that the council is already aware of and addressing.

Actions taken

Following the lay visitor scheme Hampshire council has already taken the following actions:-

• Staff name badges are being used so that residents can identify staff.
• The dining experience is being reviewed as well as improvements in the quality of food being served. Improvements are being made to the quality of the puree meals providing for appetising choices for the residents.

Other actions may take longer to put in place, but the council is considering all the feedback and how it can address any areas that are not already being tackled.

Extending lay visiting

This approach has both safeguarding and general wellbeing implications and the relatives’ group recommends that adult safeguarding boards consider whether, if they have concerns about the quality of care being provided in residential establishments, this kind of project might help.

The relatives’ group recognises that the private sector provides by far the most homes for older people, and, as this project is obviously based on cooperation and goodwill from providers, they are intending to discuss with private providers whether they too would like to run a similar project. Hampshire council is supporting the group to promote the lay visitor scheme to other providers and would encourage providers to consider a new approach of review.

The seven themes are just as relevant to choosing a home for a relative as checking on its quality during an inspection. The relatives’ group has designed a leaflet, which they are currently testing through a health centre to see how useful people find it . They also hope to secure the interest of a national organisation to extend the testing.

Positive verdict

The experience of the lay visitors was positive. They enjoyed their role, whilst occasionally finding it emotionally challenging.  Perhaps it can best be summed up by the following comment:

We saw some wonderful care, and we sometimes we were upset by things we saw. But overall, it was worthwhile as we really felt we could make a difference.”

Pam Robinson is a member of the Hampshire Relatives’ Group and Sharon Wilson is director of operations, residential and nursing care, at Hampshire County Council.