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Upskilling residential and nursing care home staff to provide better care for service users with complex condition reduces A&E attendances and increases staff satisfaction


    • Growing complexities and population in care homes; social care sector unskilled in clinical care and prevention
    • High staff turnover
    • High rate of admissions and attendances to hospital from care homes
    • Improve day-to-day care for residents
    • Empower staff, making them more knowledgeable and better able to care for their residents


    • Upskilled residential and nursing care home staff to prevent clinical complexities
    • Provided social care practitioners with clinical upskilling and investment
    • Created a training package to cascade knowledge within the home
    • Trained champions and encouraged them to develop a complex care team to review complex residents


    • Empowered staff and reduced use of clinical services
    • Decreased agency use by care homes
    • Reduced attendances and admissions to hospital from care homes
    • Improved relationship between care homes and health professionals
    • Increased staff satisfaction; improved patient experience

We upskilled residential and nursing care home staff in prevention of clinical complexities to better care for service users, who are presenting with more complex conditions. This has empowered staff and reduced use of clinical services


Growing complexities and population in care homes

Social care sector unskilled in clinical care and prevention

High staff turnover due to lack of appreciation by medical community

High use of clinical services, including GP’s

High rate of admissions and attendances to hospital from care homes


Set up an integrated partnership between local authority, CCG and Hertfordshire Care Providers Association Assessed most common reasons for admissions and use of clinical services

Recognised the gap between regular local authority funding and Continuing Healthcare Funding, agreed new funding structure for residents with higher complexities but not meeting CHC conditions.

Created a training package whereby knowledge could continually be cascaded within the home

Focused all training on prevention rather than just urgent care


Increased Staff Satisfaction

Reduced A&E attendances

Decrease in agency use by care homes

Improved relationship between care homes and health professionals


•We are currently evaluating the financial impact on the project:

•Overall satisfaction of staff increased on average by 4.5%

•Some care homes have seen a decrease in agency use, as homes were able to develop a bigger bank staff out of existing staff members to cover shifts.

In detail


For more than 3,000 people in east and north Hertfordshire, ‘home’ is one of 92 care homes in and around the county. Most of Hertfordshire’s care home residents are elderly, and many have complex health conditions. In the last 10 years residents who used to be in acute hospitals are being moved into nursing homes and those who would formally have been nursing are signposted into residential homes. Residents in these homes are increasingly living in homes with more complex conditions and have a corresponding higher level of need. Care homes are increasingly concerned that they are unable to meet these higher expectation. In Hertfordshire, we have over 20,000 employees working in the social care sector. Staff working in the care homes often feel unacknowledged and worry that they are not properly trained for the role, this leads to a higher turnover in the sector.

Social care has traditionally been a difficult sector to recruit to; this issue is escalated with a high employment rate in Hertfordshire. A joint project, Complex Care Premium (CCP), was set up between Hertfordshire Care Providers Association (HCPA), Hertfordshire County Council (HCC), East and North Herts CCG and Herts Valley CCG to understand whether training could tackle some of these issues. CCP homes were given the opportunity to receive an uplift in their local authority payments for residents with certain complexities.- this would be gained from training for a more highly skilled workforce.

Care homes were asked to identify passionate people for each pathway to become the homes ‘advanced champion’. CCP aimed to improve day-to-day care of residents, making staff feel more empowered, more knowledgeable and better able to care for their residents, therefore reducing reliance on other clinical services, such as hospital admissions and GP calls out. Their increased knowledge allowed them to have more informed conversations with GPs and district nurses and prevent some issues like pressure ulcers, weight loss and falls. CCP also aimed to reduce spend in clinical services, by recognising social care practitioners have the ability to better care for residents by providing them with clinical upskilling and investment.

By creating champions the home is able to have a multi-disciplinary team where staff feel recognised and appreciated, at the same time developing cascade training within the home. An added value from the project has been that even if champions move on, they are likely to move to another home in the county and therefore the knowledge continues to be utilised. The project started in April 2015, with 20 homes across Hertfordshire and a further 10 in East and North Hertfordshire came on track in January 2016. Currently 166 champions had been trained.


In order to understand which training would have the biggest impact, research was undertaken looking at usage of acute services by care homes. This included analysing the residents and their clinical reasons for attendance and admissions to acute hospitals in Hertfordshire; reasons for the GP call out; urgent care use and other clinical services. From this, it was agreed the complexities to focus on were:




•Tissue viability

•Respiratory conditions

•Neurological conditions

•Continence care

•End of life care

•Engagement and wellbeing

HCPA was already running a training programme called ‘Advanced Champion Pathway’ where a care practitioner, focused on a particular subject area, gained a qualification in the subject and learnt how to mentor, coach and train staff. Evidence showed that this model was successful. Therefore, it was decided to use the same model for CCP but on a larger scale, with six pathways. The key being that once the champions were trained they would form an internal multi-disciplinary team. The pathways are:




•Wound management

•Health (incorporated Respiratory conditions, Neurological conditions, Continence care, End of life care)

•Engagement (in home training)

Training varied from 10 – 18 days depending on the subject. Champions needed to be care practitioners, working at a supervisory level and have the personality profile able to confidently pass on knowledge.

Alongside the champion, the manager of the home completed pathway ‘strategy sessions’ where they focussed on strategy and best use of the champion. This management level support was vital to the success of the champions because it allowed them to implement changes, have support from the home and feel recognised. Champions were encouraged to develop a ‘complex care team’ within the homes. Where they could meet to review complex residents and agree what actions they are going to put into place to either improve current conditions or prevent deterioration.

These meetings have proved important to promote team working across champions. Quarterly engagement events were held with care home managers, proprietors and champions to understand how the project was progressing; scope any areas of development or improvement - and discuss how homes could be supported further. These events provided the opportunity to make small tweaks to the programme.


As part of the evaluation, a survey was sent out prior to the training to staff, residents, families and professionals in each home, to discover their views based on questions linked to the CQC lines of enquiry. A second survey was sent out after the training had been completed.

This found:

•Overall satisfaction of staff increased on average by 4.5%

•Attendances and admissions to hospital from care homes have reduced since training has been completed. By virtue this improved patient experience, as fewer people are admitted to hospital, better care and prevention occurs in the care homes, enabling residents to stay in their preferred place to live.

•Some care homes have seen a decrease in agency use, as homes were able to develop a bigger bank staff out of existing staff members to cover shifts.

The relationship with champions and health professionals had dramatically improved. Champions reported feeling more comfortable discussing resident’s health issues and ways to improve their health and wellbeing with the clinical professionals and are able to decide on the best course of action without always needing clinical intervention. It was important to break down the barriers between health professionals and the social care sector and this project engaged the clinical professionals in delivery of the training giving both sets of staff the time to understand each other roles and understand how they can work better together.

As part of the Care Homes Vanguard, the team have now delivered many presentations to other organisations across the country, showing how they can adopt our model in their area. The project is also due to roll this out with more of our care providers in East and North Hertfordshire.