A framework for transforming cultures and improving outcomes for people living with dementia

Introduction

This article sets out a work based action learning programme developed for managers across Health and Social care in Surrey managing services for people living with dementia. Participants included representatives from care homes, a Social Services manager and Community NHS Matron for Dementia, providing cross fertilisation of learning, ideas and practice over a two month period. Examples of learning actions three managers provide feedback about the changes they have implemented during and after the programme and the impact on their skills as facilitators of a person centred culture and learning organisation to deliver outcomes based on what older people want, staff need and relatives want for people living with dementia. At the same time implementing government policy, using a unique framework of behaviourally framed outcome standards fundamental to a healthy culture.

Policy context:

Relationship based person centred care has many interpretations. In health and social care it generally encompasses a person’s right to human dignity and respect, personal privacy and security, being treated with kindness and compassion, and proper involvement of the service user/patient and their close family in decisions about the person’s health, care and support.

There is wide acceptance among researchers, policy makers, managers, practitioners and other commentators that relationship based person-centred care is an essential feature of what constitutes good care in all health and social care settings. There is also general acceptance that health and social care organisations should be able to demonstrate their commitment to its achievement at all levels of operation as an inalienable cultural norm and goal. The 360 Standard Framework (360 SF) was created to enable health and social care organisations to achieve that norm and goal (Duff P 2014)

The 360 SF is a practice development and diagnostic quality improvement framework based on 4 sets of interdependent Standards. Helping homes and other care settings to measure quality from the perspective of the cared for person, their families and carers to achieve person centred outcomes. It provides guidance and a systematic improvement methodology with tools to ensure these outcomes become the cultural norm. It is also a diagnostic assessment framework that shows care organisations how to establish and maintain person centred cultures. Adopting the 360 SFprovides organisations with verifiable evidence to demonstrate their achievements in meeting the quality elements of their commissioning and regulatory obligations to CQC. Adoption of the guidancepromotes an enablingfacilitative management stylewith clear channels of communication, positive relationship building including collaboration and co-operation with multi disciplinary professionals and agencies.

About the course:

The aim of this course was to transform the culture of care through leadership and management training, using the 360 Standard Framework, a systematic framework to deliver a person centred approach to care for people with dementia which is collaborative.

- To demonstrate the person receiving care is at the heart of the service.

- Learn how to lead, manage and develop person-centred cultures involving staff and relatives in an integrated way

- Building collaborative relationships to achieve continuity and quality to people living with dementia across Surrey.

- Learn how to use a powerful quality improvement framework that helps organisations to learn how to achieve person-centred outcomes for excellence in quality and care.

The programme included:-

· 5 days of contact time over a period of 4 weeks with a follow up day.

· A pre-course self-assessment of management competencies for personal development

· An opportunity for reflective practice and to create a personal development plan

· Training and tutorials in the 360 SF methods using adult and skills based learning methods

· Group exercises and workshops

· Action planning for measurable change

Each Manager was guided through the management techniques and methods to develop an effective action plan based on the learning outcomes of the 360 SF linked to best practice in dementia care. Through telephone support, this action plan will be implemented and monitored by expert practitioners and educators. A follow-up day reviewed the outcomes of the course which was grounded in the 360 Standard Framework and outcome measures of success (interrelated Structure, Process and Outcome measures) in relationship activated person centred care and support.

Structure Criteria (the resources): e.g. competence, equipment, demonstrable skills, practice development, continuous education, testing new staff adequately, effective organisation

-Process Criteria (what people do): staff actionsand decision making, involvement of residents and others, most appropriate practice methods used

-Outcome Criteria: (what you expect): client perspective - measures of desired effects of care **

Achieving the outcomes of the 360 SF requires a pivotal leadership role in change management- operational, practice, quality and business planning. Good leadership, management and facilitation skills are needed at the stategic, operational and practice levels of organisation. Working with managers is a key part of the change and transformation process but it also requires the buy in and involvement of the senior management team of the organisation to lead and actively promote the philosophy, principles and values of the organisation and enable what is needed to achieve quality outcomes. Where this happens the value added business benefits quickly become evident.

The course was facilitated by educators with sector experience – two specialist OT’s in dementia care, an experienced educator and nurse manager and quality improvement specialist. The multi-disciplinary learning supported managers to further develop competencies needed to manage effective relationship based person-centred services and effect positive changes in the delivery of quality outcomes as defined by the service user.

This course included intensive work on nurturing the ‘relationship triangle’ (positive relationships between and among the service user, the staff and the relative) and of recognising the importance of long term reciprocal relationships and the development of an enabling culture through the implementation of the 360 Standard Framework with a focus upon meaningful activity and its application for residents living with dementia. One of the most important elements of the course was in gaining the understanding of how senior managers can often be a barrier to change through an autocratic hierarchical leadership style rather than one that facilitates involvement and bottom up engagement of staff, families and service users. Developing all staff and enabling residents and their families to have an equal role within the home is a successful model for change and requires a skilled multi-faceted approach by managers who can exhibit a light touch approach when possible which in turn promotes confidence and trust and breeds a culture and service that is constantly striving to improve through reflection.

Competencies:

· Facilitative management style

· Pivotal leadership role in managing change

· Operational management

· Quality improvement (QI) strategy

· Business planning

Benefits: managers will be able to:

· Create a personal development plan to support them in achieving the manager’s outcomes of the 360 SF.

Reflect on their practice in ways that help them to recognise their personal strengths and areas for development in the context of achieving the manager’s outcomes of the 360 SF
Develop the competencies managers and leaders need to manage person centred services based on positive relationships.
Deliver more effective care and support for the person, increased satisfaction with the service, fewer concerns and complaints, enhanced reputation of the provider organisation, better recruitment retention of quality leaders.

360 Cloud was provided as an on-line education platform

The quality improvement initiatives would consider improvements in :

· Knowledge in person-centred practice

· Management support and commitment

· Regarding interagency working and co-operation with other agencies

· Job Satisfaction

Findings after three months review:

• All participants have grown in skills

• Learnt how to action plan effectively using the 360 SF

• Actioned practice in the workplace and have acquired a new in depth awareness of leading a person centred culture and the nature of therapeutic relationships

• Applied skills in putting action plans into practice and in the process have grown as people, confidence building as they feel more equipped in their jobs

• Considerable group sharing for potential collaboration and developing ways of working together

• Able to delegate and work in more facilitative ways

• Better grasp of leading a culture with meaningful occupation at the heart of care as everybody’s business

• Already starting to implement and change culture

• Linking to reducing hospital admissions- better grasp of spotting UTI’s and infections

• More integration of meaningful activity into care plans – everybody’s business

Case Examples of learning put into practice through action planning and reflection

The participants were taught about Action planning to help them set out what the quality improvement priority objectives are and how they will be implemented and evaluated. This includes:

- Identify the key result to be achieved

- Identify the key tasks to be undertaken and by whom

- Identify who leads and co-ordinates the project

- Identify necessary training, for whom, how it will be carried out, by whom and when

- Identify how service users, relatives and staff will be involved.

- Identify how staff will be supported

- Agree the organisational structures and processes necessary for delivering the project, e.g. Information dissemination, information gathering, progress monitoring, recording evidence, evaluating results, giving feedback, deciding next steps.

Three examples are selected here to give a flavour of the practical ways each manager applied their learning, based on the organisational needs identified.

Key learning points from course re change and development

• One change related to dementia care:

• One development you have found in your self-management:

Manager 1

The change and development after the programme included being able to:

1. Educate staff to understand people’s behaviour,

2. Gain the confidence to delegate responsibility and say ‘no’.

Action plan Feedback

‘The 360SF is as a ray of sunshine that will grow and spread in the sector’

We are making steady progress. I have also started new action plans that will benefit the home now and for the future.

· Integrating the activity co-ordinator and carers, to promote activity for the residents at all times.

· Organising activities /events programme so that it is easy for the carers to ‘pick up’ throughout the day.

· Carer review/ strengthening keyworker role – observation of care provision is it task orientated or activity orientated?

Manager 2

This manager gained considerable confidence to take her skills into another setting where she would be able to implement learning through giving other managers support in the community, helping them move towards leading a more person centred culture.

The change and development after the programme included being able to:

1 Integrate activities into everything we do and staff have embraced this – the culture is changing.

The progress was as follows:

Staff team understood the concept of person centred and meaningful activity which was being integrated into everyday life for each individual
We had moved away from big group activities with the exception of the interactive music session which all residents enjoyed
We had moved into starting to engage with each individual resident and emphasising what was important to each of them ie having a daily walk and feeding the birds in the garden
We had collected 7 shoe boxes to make memory boxes
We were discussing with relatives and families what the contents of the boxes should be

Action plans

A follow up action plan was completed and involved the following:

Quality review of the existing care files to highlight specific weak areas to be addressed
Staff supervision over a two week period in conjunction with the home managers to create the right ethos and confidence within the staff team
Directly working with staff team in the residential home to bring the files up to date Creation of a sample care file including all available documents in the organisation to give examples of how the completed file should be.
Working with the admin team to scan the sample file onto the common computer system so a copy is available on all sites both as a hard copy and in the electronic form.
Evaluation of the support system by staff who had used or who were actively using it

This action plan has been completed and I have left the staff using it to ensure that the resident records are fit for purpose and ensuring safety and the resident’s well-being is being maintained.

Knowledge in person-centred practice

I have not significantly changed my approach in the clinical/social sense, but have become more confident to seek the right course of action or life style pathway for the individual whereas before I might not have been so keen to stand out of the crowd. I have always believed everyone to have equal rights regardless and people with dementia are no different.

Management support and commitment

My senior manager (company director) does not engage easily with change and specifically any change he has not instigated himself. This has made it difficult to implement changes and develop new ideas both during and after the course.

In leaving the company I have tried to leave a positive legacy for new care trends and meaningful activities with the staff group. there is a huge scope for up dating practice through embracing change, but unfortunately until the company ethos changes there will be many missed opportunities.

Interagency working and cooperation with other agencies

I have regained confidence to acknowledge that the quality of care being given to the residents who were under my care was on the right pathway and as a leaving legacy have tried to also instil this in staff. There were changes in the way staff were interacting with residents and the atmosphere became more relaxed and responsive to needs/wishes rather than focusing on specific tasks at set times.

Job Satisfaction

As a general note I would like to state that the course for me has enabled me to see that I was still on the right pathway and to regain the confidence that I had lost through a negative employment situation where there was not enough support for my role from the Senior Manager. It was a constant battle to make positive changes for the staff including promoting dignity in care and keeping the team motivated to do a good job. The factors that affected these positive behaviours were out of my control so often the best I could do was to lead by example and motivated the team to move with me. I believe that in a small way this contributed to a positive atmosphere at least in the home I was managing through the last few years.

Participating on this course was a fantastic way to network and share ideas with both other managers and also the training team, who would always facilitate useful discussions. As the course progressed my confidence began to re surface giving me back a 'voice' and enabling me to stand up for what I knew was the right thing.

Manager 3

Two key learning points that affected change and development after the programme included being able to:

1 Long term care is about long term relationships, i didn’t know what therapeutic relationships look like. Staff make it work but I never understood how to make it better or understand why they did good.

2 There were so many things on the management, liked the Change House exercise. I hope to validate people’s feelings more. Setting the time management and being firm with my time and the time I give to

Action plans are progressing very well. The (Hurtley, Waring 2010) What Do you See? 10 step in house dignity learning programme is now being held every Wednesday and is facilitated by senior nurse who has attended specialist communication training from 360 Forward. The feedback from staff is 100% positive with high levels of enthusiasm for all the outcomes. I am already seeing a positive influence on the floor and I expect this to continue. Each improvement is small but highly significant:

o A change in the layout of the dining room to better facilitate communication.

o Improved communication with relatives and residents leading to informal garden work parties.

o Greater understanding of carers and improved ability to ‘see’ the world from the clients perspective.

o Vastly improved personalisation demonstrated within care-plans with all parties having a greater input into the composing of such documents as well as the implementation of them.

Post course reflection:

Following this training, for the key managerial figures we implemented a personalisation and meaningful activities training program for all members of staff. Every staff member has now attended this training which stretched over a 6 month period and involved a number of classroom based study days, held in-house, followed by a period of implementing agreed action plans and reflection before returning to the classroom for consolidation and evaluation. We are still completing this phase which will then be followed by a repeat audit to measure the lasting effect that this work has had on the well-being of our service users and their families. However the benefits that we have witnessed first-hand cannot be overstated even before this process is concluded. This is a nursing home that meets the needs of clients who have the most complex of cognition and mental health concerns and who live with a wide range of co-morbidities. It is an environment that is joyous, full of laughter and music where even the most profoundly impaired client has the opportunity to express themselves through meaningful activity of their choosing and where staff are not afraid to ask “how would you like to spend your day”? This is what personalisation looks like and the benefits are equally powerful for families and friends as they are for service users and staff.

It is too early to measure KPI’s but I fully expect to see a reduction in falls, a reduced level of agitation, greater retention of staff and improved sickness rates over the coming months.

Other participants included improvements in resident and relative engagement and community building, implementation of protocols for improving use of mobility equipment, integration of activity into care plans, improvement of staff skills in communication techniques enabling more ‘therapeutic conversing’ and engagement.

Feedback

“The course shows the way that I can deliver the most outcomes with structure and process.”

“I thoroughly enjoyed the balance of practical and theoretical information.”

“The course raised a great deal of thought, areas for improvement and the methods I can use to improve dementia care.”

“I have learned so much, both directly and indirectly, that I went home exhausted, inspired and reflective.”

“The course was excellent for promoting reflective practice while adding in new ideas and culture.”

“My area is dementia care and this can only enhance the quality of delivery to individual care and how I put in structure to go forward.”

“I enjoyed the reflection on practice, sharing ideas.”

“I enjoyed the culture, skills for leading, managing and coaching. I feel I can promote the culture of involvement.”

“Very interactive and motivating. I feel I can now improve care and with support feel this is achievable.”

“I feel more confident to deliver.”

“Powerful and inspiring. I feel I can deliver performance management and improve methods of communication.”

“This was the best and most important training since I qualified in 1993.”

“I will use the action planning sections - on outcome-focused care.”

“This has improved my management style. I feel more confident to deliver feedback, ideas and plans to involved staff.”

“I feel I could deliver increased activities for residents, improved communication skills.”

“ “They kept us interested and motivated the whole time. I have learnt how to empower staff to adopt a new way of thinking and working. A truly memorable week.”

“After a time of reflection, I think I will be able to deliver a lot of the information.”

“Very informative and will add to my personal and professional development.”

“I have learnt the importance of focusing on the standards and on the resident as well as educating staff.”

“Loved the genuine commitment in the room to make a real difference to people with dementia. A subject close to my heart.”

“Thank you for such a positive experience.”

“Very enjoyable. Now need to reflect further before prioritising action plans.”

“I always felt comfortable to share experiences openly and contribute to group discussions.”

“Thank you for a thought-provoking training course which was delivered in a friendly, non-judgmental and supportive way.”

Conclusion

Implementation of learning for managers needs to have the full endorsement of the senior managers of an organisation to enable the manager to feel supported to implement change. The time out of work with other managers across the care pathway has enabled new insights, role understanding and mutual respect with collaborative relationship building potential. Evaluating effectiveness as outcomes are subsequently audited would provide evidence for commissioners and regulators alike for continuous improvement with outcome based action planning. The 360 Cloud could be used for learning and implementation of relationship activated care and support through changed behaviours and resources that ensure improvements are sustained.

Rosemary Hurtley 2014 November 11th

3,473 words