How can local authority commissioners work with the care home sector to ensure older people consistently receive high-quality, relationship-centred care?
This report reviews the improvements Essex County Council made to the commissioning of its care home services for older people. It evaluates the implementation and outcomes of the My Home Life Essex programme, introduced to improve the relationship between commissioners and care home providers, and to enable care home managers to focus on providing relationship-centred care.
The study found that:
- support networks established through My Home Life Essex resulted in better quality commissioning and an increase in managers’ ability to motivate staff to provide relationship-centred care to residents;
- Essex County Council’s corporate ownership of the new approach led to positive changes in the relationship between the council and the county’s care home sector, investment in the care sector, a focus on quality improvement rather than monitoring compliance, effective leadership and a support network for managers.
Care homes are facing intense scrutiny, local authorities are under financial pressure and national policy is emphasising the importance of personalised care, choice and control. There is a growing consensus that care services for older people have to change.
Essex County Council has shifted its commissioning approach from top-down monitoring, inspection and regulation to one that builds relationships, invests in the development of care home staff, and instils a shared vision for care and support for older people.
- The ‘Essex approach’ is based on the social movement My Home Life, which aims to improve quality of life in care homes. A relationship-centred approach focuses on building positive relationships and connections between and among older residents, care home staff and managers, and with commissioners.
- This approach has been embedded in commissioning and procurement of care through a self-assessment process using indicators based on the relational aspects of living in a care home.
- Care home managers are in a pivotal place to model relationship-centred care; where this occurs there are signs of staff empowerment and a change in emphasis from task-orientated care to relationship-focused care and support.
- A Leadership Development Programme and facilitated network for care home managers was introduced in Essex, reducing the isolation of care home managers, enabling problem solving with peers and improving the recruitment of care staff.
- Adopting an appreciative enquiry approach that relies on a ‘no-blame’ culture has enabled staff to build on successes rather than dwell on negatives, and to see everything as a learning opportunity.
- In some homes, adopting a relationship-centred approach and shared decision making with residents has led to care home staff describing a more balanced, creative approach to risk.
Care homes are under scrutiny as never before and a series of shocking failures have tarnished the reputation of the sector as a whole. Financial pressures affecting local authorities are influencing commissioning decisions, as well as relationships between commissioners and providers. In spite of these difficulties, there are some positive signs of change.
Essex County Council (referred to here as ‘Essex’) has developed its own distinctive quality improvement programme based on the social movement My Home Life (MHL), which aims to improve quality of life in care homes. NDTi evaluated the approach and early signs of progress in Essex.
The Essex approach
Like most other councils, Essex faces considerable pressure on its services. Over time, the intention is to shift towards more older people living independently in their own homes with a wider range of options for care and support. Essex also recognises the need to provide good-quality residential care for the large numbers of people who already live in residential care. In seeking to support a sustainable, competitive social care market that encourages new and innovative ways of developing support, Essex built its approach on:
- a unifying principle of relationship-based care – MHL evidence suggests that positive relationships between older people, relatives and staff are interdependent and create a culture in which staff are able to connect with older people as individuals, to understand and respond to their interests, opinions, aspirations and needs;
- an underlying philosophy of appreciative enquiry – focusing on what older people, their relatives and staff in care homes want, what works and how to make it happen;
- a vision for care based on the eight central MHL themes:
- managing transitions;
- maintaining identity;
- creating community;
- sharing decision making;
- improving health and healthcare;
- supporting a good end of life;
- keeping a workforce fit for purpose:
- promoting a positive culture.
A core feature of the Essex approach was the simultaneous focus on commissioning and provision; the council did not expect just care homes to change and improve, but required sustainable, systemic improvements across the health and social care community. Putting this approach into practice, Essex replaced the previous Quality Monitoring team in the council with a small Quality Improvement (QI) team, changing its relationship from a ‘hands-off’, punitive approach to monitoring, to working alongside care homes to achieve better outcomes for older residents.
The MHL themes have become part of the council’s contracting and procurement processes, meaning that funding and contractual decisions are based on quality outcomes, rather than traditional measures such as numbers of people or beds. A self-evaluation process has been introduced in Essex care homes, measuring progress against indicators that focus on relationship-based aspects of care. If no progress is made or sustained by the home, there are processes in place to bring in a breach of contract.
Essex has invested in a leadership development programme for care home managers, and established a facilitated network (community of practice) to support care home managers in their role.
What has changed?
As a result of the changed relationship between the council and care home sector, many care home managers in Essex feel better supported to promote a positive culture in the home, improving quality, managing risk and ensuring safety. One hundred and sixty-eight care home managers participated in the leadership development programme, resulting in increased personal self-esteem, confidence and relationship skills among managers.
There are signs that through modelling relationship-centred care, managers have begun to shift the power dynamics between staff and older residents. In some homes, there is a concerted effort to move away from too much focus on physical tasks towards more positive relationships and individual outcomes for older residents.
A culture of positive and informed risk-taking is developing between the council and care home managers as a result of shared decision-making arrangements and network meetings where managers air problems and find solutions in a safe and mutually supportive way.
The confidence gained through the leadership programme and the support of the Quality Improvement team has led to care home staff and council managers developing stronger links with health and social care partners, including Clinical Commissioning Groups. Trust between organisations is growing and, where concerns arise, joint solutions are sought.
Discussion is underway between commissioners and providers about a broader range of models of care and support, with older people’s voices and preferences central to these developments.
Learning from Essex
The evaluation identified key factors driving changes in Essex:
- Corporate ownership by the council: Staff described the MHL themes as embedded in the council’s culture and values. Senior colleagues were committed to achieving better outcomes using these themes: for example by building them into contractual arrangements with care homes, with additional resources available for demonstrable improvements.
- Investment in the care sector: Essex has invested in both sides of the relationship (commissioning and provision) to create change. It has invested in staff development in the Quality Improvement team and provided resources to support the care sector to change (e.g. the Leadership Development programme and a 12-month action-learning programme). Eight million pounds has been made available to incentivise care homes to adopt the relationship-centred approach.
- Effective leadership: Systemic change of this nature requires strong leadership. Essex invested in a member of the Quality Improvement team to take up a Quality Innovations Lead role. Senior staff in Adult Social Care encouraged and supported the lead to work corporately, recognising that MHL was relevant to the council as a whole, rather than limiting information to Adult Social Care.
- A community of practice: An organised, facilitated community of practice provides a crucial mechanism for driving change on the ground. Care home managers involved in the leadership programme valued the opportunity to meet with their peers, establish shared values and explore practical solutions to problems. It provided a reflective space to appreciate individuals’ roles in creating change and build a confident workforce committed to raising quality and eradicating poor practice.
Conclusion and recommendations
This evaluation has demonstrated the benefits and potential impacts of a shared, local vision for current and future delivery of care and support for older people. Council leaders (e.g. via the Local Government Association), the Care Quality Commission and JRF are in strong positions to work collaboratively with each other and with care providers to develop common principles, practices and features in care provision, in line with the requirements and potential statutes set out in the Care Bill and based on learning from MHL and the Essex approach.
The following recommendations are designed to inform ongoing work in Essex, but also have relevance for other areas, commissioners and providers of care and support:
About the project
This evaluation forms part of a wider JRF programme of work on risk and relationships in the care sector. A theory of change framework was used to deliver this work and the main data collection was through nine case studies in a sample of Essex care homes.
- Other care homes and staff that are not yet part of MHL Essex should be encouraged to get involved. A peer challenge approach, undertaken by the managers from the MHL Leadership course, has been suggested, to help ‘capture hearts and minds’ and drive forward improvement.
- There is tension between the business model of care homes and improving quality through investing in relationships. Not all proprietors and large corporate organisations are fully committed to the Essex approach; further strategic engagement, as well as incentives and regulation, may be required to involve them.
- The voice of older people in the improvement programme has not been strong to date; the next phase of MHL Essex should focus on engaging with older people living in care homes and the wider older population. A greater emphasis on coproduction with older people and other stakeholders to ensure that issues concerning them are addressed would help ensure the underlying ethos of MHL is fully embraced.
- Essex and partners have recognised the need to create a sense of community between family, friends and the wider local community and to develop stronger community connections. The Community Visitors programme, offering a structured approach to volunteering in care homes, is being piloted in three homes.
- The QI team should continue the dialogue with the care home sector about new, alternative models of care including integration with the health sector. This links to findings from other JRF work as part of the Better Life Programme, around widening options for older people – for example through models such as Shared Lives, Cohousing and Homeshare.