“BAILANDO AFIANZO MI LATERALIDAD” PROBLEM A PRIO RIZADO

To gain a better understanding of the nature and type of unplanned hospital admissions, we conducted a descriptive analysis of the data, summarised inTable 23(see alsoAppendices 11and12). In total, 39 residents were hospitalised at some point during the 12-month data collection period, just 16% of the total number of residents recruited to the study. The length of stay ranged between one night (n=17) and 47 nights for one case involving a dementia-related mental health assessment, with 22 residents being hospitalised for more than five nights in one episode. These support the findings from the quantitative analysis above of a greater reliance upon secondary care in site 3, but also highlight the tendency for patients to stay much longer in hospital in this site.

The reasons for residents being hospitalised did not differ much across the three sites (Table 24). The most common reason was falls (n=13), eight of which resulted in a fracture, followed by respiratory-related conditions (n=6), including pneumonia, chest infection and breathing difficulties. No information was available in the care home record about the reason for admission or discharge diagnosis for six admissions. Substudy of medication data

Medication data were available from 214 out of 239 residents. All residents from site 1 had full medication data. Twenty-four residents from site 2 had missing data, related to difficulties in obtaining baseline

TABLE 23 Unplanned hospitalisations by site

Site

Number of residents hospitalised

Hospitalisations as a percentage of the total number of residents recruited

Number of residents hospitalised for . . .

1 occasion >1 occasion 1 night ≥5 nights

1 14 15% (n₌93) 9 5 9 6

2 11 12% (n=92) 9 2 7 5

3 14 25% (n₌57) 9 5 1 11

medication data from one care home. One resident from site 3 was not taking any medication. Where baseline data were successfully retrieved, our mechanism for collecting follow-up data from the care home yielded a full follow-up data set. Thus, there were 90, 68 and 56 residents from each of sites 1, 2 and 3, respectively, with fully analysable medication data.

The mean number of medications at baseline for all sites was 8.28 (SD 3.4), and–8.00 (SD 3.5), 8.24

(SD 3.6), 8.77 (SD 3.1) for sites 1, 2 and 3, respectively, with no statistically significant difference between sites. The range of medications was 1–21. Forty-nine residents were taking opioids at baseline, with 47 of those taking a single opioid medication. Two were taking two opioid medications. Participants were significantly less likely to be taking opioids at site 1 (p<0.01). Thirty-four residents were taking antibiotics at baseline. Participants were significantly less likely to be taking antibiotics at site 3 (p<0.01). The median (range) ACB score was 1 (0–14), with no statistically significant difference in distribution of ACB scores between sites. Over the study period, there were 366 medication changes (starting, stopping or substituting a medicine) in site 1, 261 changes in site 2 and 266 in site 3. This represents 0.40 (SD 0.66), 0.44 (SD 0.84) and 0.49 (SD 0.79) changes per resident per month in sites 1, 2 and 3, respectively.

Follow-up data did not demonstrate consistent trends in antibiotic or opioid prescribing. Site 3 reported the lowest ACB score throughout the study, with evidence of a rising ACB score in sites 1 and 2 (Figure 8). In summary, the cohort was representative of UK care homes generally in terms of the prescribing rates seen. For most variables measured, the sites were not substantively different at baseline and differences seen at baseline in antibiotic and opioid prescribing disappeared with follow-up. The implications of the tendency towards lower ACB scores in site 3 are unclear; it could either be attributable to the dementia specialist nurse’s involvement in the reduction of antipsychotic prescribing in the study care homes or be indicative of a different culture of care within the care homes in site 3, consistent with their participation in the My Home Life leadership training programme. There is, however, no evidence to suggest that increased GP contact in site 2, or case management as part of‘wrap-around’care, worked to optimise prescribing in any way over the more traditional models of working seen at site 3.

TABLE 24 Reasons for hospitalisations recorded from residents’care home notes

Site 1 2 3 Reason for admission Number of admissions Reason for admission Number of admissions Reason for admission Number of admissions

Fall 1 Fall 2 Fall 2

Fall and fracture 3 Fall and fracture 3 Fall and fracture 2

Respiratory conditions 2 Respiratory conditions 2 Respiratory conditions 2

UTI 3 Urinary retention 2 Urinary retention 1

Syncope 1 Osteomyelitis 1 Hypotension 2

Pyrexia 2 Pyrexia 1 Abdominal pain 1

Transient ischaemic attack

1 Chest pain 1 Clostridium difficile

infection

2

Chest pain 1 No information 1 Rectal bleed 1

Vomiting 1 Mental health assessment 1

No information 3 Not eating or drinking 1

No information 2

UTI, urinary tract infection.

DOI: 10.3310/hsdr05290 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 29

© Queen’s Printer and Controller of HMSO 2017. This work was produced by Goodmanet al.under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.

Staff satisfaction substudy

Data collection for this substudy took place towards the end of the case studies, by which time the research team were aware that the care homes were suffering from‘research fatigue’following the case study process, and it was anticipated that engagement might be suboptimal. A total of 562 questionnaires were sent out by post, with two rounds of follow-up telephone reminders on a weekly basis to maximise response rates. The forms were mislaid at two sites and further copies were sent. One care home subsequently refused to return their staff questionnaires because of a change in management and a decision that supporting this final stage of the study was no longer a priority.

Consequently, out of a potential total of 562 questionnaires, only 94 were returned, a response rate of 16.7%. Sites 1, 2 and 3 returned 55, 14 and 25 questionnaires, respectively. The bulk of responses from sites 1 and 3 came from care assistants, while in site 2, the number of responses was low overall (Table 25).

There were no differences between the sites in respondents’age, duration in current profession or current post. Patterns of working differed, with participants significantly more likely to undertake split shift working on site 1 (Table 26).

4

3

2

Mean ACB score

1

0

0 1 2 3 4 5 6

Time point (months)

7 8 9 10 11 12

Site 1 Site 2 Site 3 Care home site

FIGURE 8 Mean ACB score across the three study sites over 12 months. Error bars: 95% CI.

TABLE 25 Overview of responses by site

Profession

Site, number of responses

Total

1 2 3

Care assistant 32 5 17 54

Registered nurse 0 5 1 6

Care home manager 2 2 2 6

Activity co-ordinator 0 1 1 2

Other 21 1 4 26

A total of 83 out of 94 (88%) respondents thought that their workplace was staffed sufficiently, either sometimes or usually, with only 10 out of 94 (11%) respondents raising concern about staffing levels; 91 out of 94 (97%) respondents were somewhat or absolutely satisfied with their current working hours; and 79 out of 94 (84%) respondents felt able to influence their current patterns of working. There were no significant differences between sites for any of these variables. In all sites, the bulk of the working week was spent caring directly for residents (Table 27).

Satisfaction with the care provided within the care homes was high across all sites (Table 28), but was significantly higher for‘information provided to residents about work routines and nurse in charge’and

‘activities provided to residents’in site 1 (p<0.05).

Almost all (96%) of the sample responded to the question about quality of care provided to residents by the NHS on an analogue scale from 0 to 10, whereby 10 represented extremely satisfied and 0 represented not at all satisfied. The mean score was 7.5 (range 3–10), with no significant difference between sites.

The low response rate means that the data may well be biased in favour of positive responses from those staff members who had remained enthusiastic about the project throughout. Despite this, the staff responses suggest a staff group that, on the whole, reported high levels of job control, job satisfaction and satisfaction with the services provided by their employing care homes and the NHS services with which they interfaced. This is somewhat contrary to the narrative of a sector commonly portrayed as beleaguered and on the edge of collapse. Few significant differences were observed between sites, but where they did occur they tended to favour site 1.

TABLE 26 How working hours were organised

How are working hours organised?

Site, number of participants

Total

1 2 3

Scheduled working hours with split shifts 21 2 13 36

Scheduled working hours without split shifts 33 10 10 53

Part-time sick leave 0 0 0 0

Full-time sick leave 0 0 0 0

Leave of absence 0 0 0 0

Other 0 2 2 4

No reply 1 0 0 1

TABLE 27 Breakdown of the average working week

Activity

How working hours are distributed on an average week: all sites

No reply

0% <25% 25–50% 51–75% >75%

Working directly with residents 7 11 16 10 40 10

Administration 25 19 8 6 9 27

Cleaning/service 31 15 4 1 3 40

Travel 29 19 5 1 3 37

Other 24 6 4 0 3 57

DOI: 10.3310/hsdr05290 HEALTH SERVICES AND DELIVERY RESEARCH 2017 VOL. 5 NO. 29

© Queen’s Printer and Controller of HMSO 2017. This work was produced by Goodmanet al.under the terms of a commissioning contract issued by the Secretary of State for Health. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.