Introduction

The Enhanced health in care homes (EHCH) framework is for primary care networks (PCNs) and providers and commissioners of community health and social care services. It guides the commissioning of and delivery arrangements for health and social care services in collaboration with care homes, so that the entire system works together to provide personalised care, improve outcomes and promote independence for people living in care. It recognises the life course of people who live in a care home and promotes the ethos of living, ageing and dying well.

The implementation of EHCH was a key Ageing Well programme set out in the NHS Long Term Plan (2019). This signalled a new direction for care delivery, towards proactive care (formerly known as anticipatory care) centred on the needs of a person, their loved ones and care home staff.

This framework also highlights the effective changes to working practice driven by the pandemic, including collaboration between professionals and innovation, such as that using digital advances to improve integration and information sharing.

This framework should be considered alongside other policies relating to wrap-around care for people in the community (see section 14: Resources).

2. Principles of the EHCH model

A. Personalised care

• Centring the needs of the person through ‘what matters to you’ conversations, ensuring the person has choice and is actively involved in shared decision-making, including about end of life care.
• Supporting people to talk about what matters most to them; and encouraging and enabling them to take as much responsibility as they want for managing their own care, health and wellbeing.
• Supporting carers and a person’s loved ones, recognising their needs as well as those of the person receiving care, and acknowledging them all as experts in their own care and lives.

B. Co-production and collaboration

• Acknowledging the value and expertise of the care home sector for all they do, including the significant level of healthcare delivered by social care staff, who work alongside the NHS as equal partners.
• Equal partnership between health and social care: the NHS working with local government, the community, acute trusts, voluntary, community and social enterprise (VCSE) and independent care homes sectors to co-design and co-deliver the model of care.
• Adopting a whole-system approach, breaking down the organisational barriers between health, social care and the VCSE sectors.
• The workforce committing to collaboration, mutual respect and improving the experience and outcomes of care home residents, and investing time for this.

C. Quality

• Using research, innovation and evidence-based practices to drive and sustain improvements.
• Ensuring that the views of people living in care homes and those close to them inform service development and quality improvement.
• Quality improvement is driven by truly collaborative teams responding to local need and intelligence as well as national priorities.

D. Leadership

• Strong, collaborative leadership at local, regional and national levels between health and care, and a shared vision for better care across the multidisciplinary team (MDT), led by the care home clinical lead.
• Recognising cultural differences between organisations and sectors, and the different types of commissioner and provider, but having a shared vision and aims despite differences in ways of working.

E. Digital

• Digital technology is a key enabler for all the conditions critical for the success of the EHCH model, underpinning improved information sharing between health and care teams and the enhanced quality, safety and personalisation in the care people receive.

3. Impact of implementing the EHCH framework

Implementing the EHCH framework should have impact at the individual, neighbourhood, place and system level.

At the individual level this enables:

• improved quality of life for people living in care homes, and support to die well
• recording of personal preferences for current and future care needs, even those that may have an urgent or acute presentation, as part of a personalised care and support plan
• involvement of a person’s carers and loved ones in the planning and delivery (where relevant) of their care
• all relevant and appropriate health and care professionals able to access the person’s records in a timely way to facilitate the delivery of their preferred choice of care/intervention at the point it is needed
• improved experience of receiving co-ordinated care from a dedicated MDT
• receipt of appropriate care in the person’s place of choosing, including palliative and end of life care.

At the neighbourhood level, care homes implementing the EHCH framework enables:

• inclusion as part of the MDT, with those who know the person receiving care best able to input key information to augment decision-making
• better co-ordination of care, with care home staff supported to care for the person in their preferred place
• care home staff to work with wider system partners in integrated neighbourhood teams, and not feel siloed.

MDTs delivering the EHCH model enables:

• reduced ad-hoc demands on services through advance planning and co-ordination of care across integrated neighbourhood teams
• greater capacity influenced by collaborative working and less need to repeat conversations
• opportunities for professional development as staff learn and grow together.

The intended impact at the place and system level is:

• fewer unplanned conveyances and admissions to hospital for people who live in a care home due to proactive care planning by the MDT with the person
• co-ordinated and efficient use of resources designed to support people who live in a care home (eg urgent community response and virtual wards)
• greater use of and contribution to research and innovation to improve care.

4. Contractual elements of the EHCH model

The key contractual requirements for PCNs are detailed in the Network Contract Directed Enhanced Service (DES), and for community healthcare service providers in the NHS Standard Contract.

5. The home round and supporting multidisciplinary team working

Under the requirements in the Network Contract DES, each CQC-registered adult-age care home must have a weekly home round that is maintained and co-designed with care home staff and supported by the MDT in its aligned PCN. The way that the MDT functions is bespoke to each care home, to support the needs of the people who live there, whether temporarily or permanently. The MDT must provide oversight and a broad range of interventions; therefore, it is essential that commissioned proactive and responsive therapy services (eg speech and language, dietetics and specialist falls interventions) are part of the MDT and readily available.

There is an important distinction between the MDT meeting and the home round, as they are unique but interdependent processes, and both critical to the success of the EHCH model.

The MDT meeting is a dynamic group of health and care professionals who meet (usually virtually) to share their expertise through discussion on how the needs of identified individuals in care homes can most appropriately be met. The weekly home round is usually carried out (in person) by the clinical lead, supported by the care co-ordinator and a member of the care home’s staff, and is the opportunity to clinically assess individuals, form and review their personalised care and support plan, and deal with any acute illness.

A. The MDT meeting

The MDT meeting involves collaboration between primary care, community healthcare and social care services and where appropriate, VCSE and secondary care-based specialist clinicians, and its membership will likely depend on the needs of the individual being discussed, particularly where these require specialist secondary care input. Key personnel tend to be the GP or clinical lead, care home manager or nominated deputy, clinicians from the community service provider and staff employed through the primary care Additional Roles Reimbursement Scheme (ARRS), such as care co-ordinators, clinical pharmacists and advanced clinical practitioners.

The MDT should include specialists who can meet the individual’s needs, such as speech and language therapists, dietitians, specialist falls therapists and other colleagues in heath, social care and VCSE. The MDT will likely differ based on the size and type of care home. Fundamentally, the MDT will:

• Use a partnership approach to clinical governance, shared risk management and decision-making, with social care staff being core team members.
• Help determine which people need to be seen during the weekly ‘home round’ (noting that this is not the only route for prioritising an individual to be seen during the weekly home round).
• Co-develop and maintain PCSPs for each person.
• Support delivery of these plans to meet the individual needs of the person receiving care.

MDT discussions are supported by PCSPs and access to information from health and care records.

Digital tools, virtual platforms and apps are increasingly available to enhance MDT working across systems. Commonplace software like Microsoft Teams can enable clear and responsive communication across health and social care teams. As more adult social care providers adopt digital social care records and make use of virtual or remote monitoring tools, teams will be able to view appropriate information from the primary care and social care record, meaning staff in the MDT will be working from the most up-to-date and relevant information.

Best practice in establishing and managing the MDT includes:

• Investing time in developing strong and trusted working relationships within the MDT and between professionals across organisational boundaries, with community provider and PCN leads discussing and agreeing with care homes what is important to care home staff and residents.
• Determining in advance how team members prefer to communicate with each other, as well as what the person’s and their carers’ preference is, ensuring all MDT members are aware of the format and have access to the technology and systems that will facilitate this.
• Locally determining the format for the weekly MDT meeting; this will depend on the needs of the people identified as requiring MDT input.
• Including a care co-ordinator in the MDT, who will collate information pertaining to the challenges or ongoing issues that people are facing, from various sources/records of care (eg GP, community services, care homes, the person receiving care and their loved ones) and used alongside the PCSP to influence the best delivery of care.
• All members of the MDT have access to shared care planning and shared care records through information sharing protocols established across all system partners. Personalised care and support planning best practice is that the person and their carers are actively involved in developing the plan, and subsequently have sight of it in digital or hard copy format.

B. The home round

The home round is a weekly event led by the GP/clinical lead or another clinician with advanced assessment and clinical decision-making skills, and is supported by the care co-ordinator and members of the care home staff. The minimum attendance should be the clinical lead and manager for the care home or deputy and suitable clinicians from within the care home. Other appropriate members of community services may also be invited to attend.

In the weekly home round those receiving care are reviewed, although this will not be every person in the care home every week. It is carried out by the clinical lead (usually a GP or a clinician with advanced clinical assessment and decision-making skills). Not every person seen or discussed during the home round will need to be discussed in the wider MDT meeting. Any health or care professional, including care home staff (with the knowledge of the resident and their families), can recommend that a person’s case is reviewed in the care home round or the wider MDT. The decision to bring forward the case review would normally be discussed in the care home round and enacted by the clinical lead.

Generally, far fewer personnel attend the home round than the MDT meeting. Individuals to be seen in the home round are identified in advance, through discussion with care home staff and through the MDT meeting. Some form of clinical review will be undertaken for each person seen, the format and function of this being determined by factors including, but not limited to: the person’s presentation on the day; any recent changes in their condition/presentation; their underlying long-term conditions; and their personalised care choices. A review date will be set for follow-up of each person seen, either during a subsequent home round and/or by the MDT, and their PCSP(s) will be co-written or updated with them.

Best practice for the weekly home round includes:

• Involving key care home staff who know the person’s history, usual presentation(s) and any deviations from this (as well as support networks and the person themselves), to support the clinician during the home round.
• The clinician leading the home round knowing in advance the people they will be reviewing, reflecting the proactive and planned nature of EHCH.
• Using the collated relevant information pertaining to the person receiving care, including from discussions that may have taken place with the MDT (collated by a care co-ordinated).
• Using technology to improve the flow and availability of information.
• Setting review dates for follow-up for each person reviewed.
• Reviewing and updating PCSPs as appropriate, paying particular attention to those for individuals who have recently had urgent needs met or have had a fall and require further/new MDT input.
• Identifying people whose care needs warrant future MDT discussion and input.
• Clinicians able to record their findings in digital records and to share that digital record with other health and care providers where required.
• Using templates to ensure information is collected in a standardised way and collated for national datasets to support more proactive and preventative care.

6. Living and ageing well

The priority should be that people living in care homes can live well. This means supporting the health of residents, whether physical or mental. All health needs of individuals should be addressed sensitively, especially their sexual health and emotional, spiritual, cultural or social needs. They should expect to live fulfilling lives, connected to their loved ones and their local community, with support that promotes their wellbeing and independence through to the end of their lives. This is a system responsibility.

The support and care needs of people who live in a care home are multifaceted and have increased in complexity over the last two decades (Barker et al, 2021). Health and care professionals must work collaboratively to proactively manage the person’s long-term conditions, while recognising that, particularly with older people, this will be influenced by the person’s frailty and their proximity to the end of their life. There is potential for shared learning and development of roles in care homes, including through participation in research and use of innovative technologies, which together can enhance the lives and wellbeing of the people who live there and drive improved outcomes.

The connectedness a person feels toward and their contribution to their local community and network supports a sense of belonging and can improve their long-term physical and mental health. Social prescribing is designed to support people with a wide range of social, emotional or practical needs, by focusing on ‘what matters to me’ and taking a holistic approach to people’s health and wellbeing. These schemes can benefit people living in a care home by facilitating their access to appropriate community groups and statutory services.

Best practice to promote quality of life and wellbeing in care homes includes:

• Ensure appropriate access to healthcare services and promote health for people living in care homes, their loved ones and staff, to optimise their quality of life.
• Enable loved ones to continue to care for people living in care homes if they so wish, making them equal members of the MDT and part of planning.
• Work creatively with people, their loved ones and staff to maintain the person’s sense of identity as an integral part of the care provision; by engaging them in meaningful and purposeful everyday activities (eg making a drink for a visitor, slicing bread at the table and making their bed).
• Create champion roles in the care home that focus on the health and wellbeing of all people living in care homes, including those with complex health needs.
• Provide diverse, meaningful activities (eg music, arts, gardening, animal-assisted therapy and physical activity) that create a welcoming social environment for all individuals and visitors and access to outdoors space, drawing on community assets and the VCSE sector as appropriate.
• Consider use of digital technologies and innovations in the care home to support a person’s needs, interests or management of a condition in a personalised way (eg medication reminder technologies).
• Promote relationship-centred care, encouraging positive relationships between people living in care homes, their loved ones and staff, supported where appropriate with digital technologies (eg video calls and social media, reading stories to family, connecting to the wider community).
• Ensure staff have access to professional development opportunities that enhance knowledge, skills and confidence in promoting wellbeing, person-centred activities and community engagement.

7. Working with care providers and local authorities

The EHCH framework is for PCNs and providers and commissioners of community health and social care services. It guides the commissioning of and delivery arrangements for health and social care services in collaboration with care homes, so that the entire system works together to provide personalised care, improve outcomes and promote independence for people living in a care home. It recognises the life course of people who live in a care home and promotes the ethos of living, ageing and dying well.

8. Digital fundamentals to enable the EHCH model

Digital technology can support people’s health and wellbeing by giving them greater choice, control and independence wherever they draw on care. There are opportunities to implement evidence-based digital solutions, such as smart devices, personal alarm systems, remote monitoring solutions and other sensor technologies, to enable the provision of personalised care for people. Adopting and delivering high-quality care through digital innovation releases staff time for more hands-on care.

A. Implementing digital social care records

A digital social care record (DSCR) can be used to capture the critical information for a PCSP and in this way free up care worker time. The CQC recognises the benefits of implementing DSCRs and the Department of Health and Social Care continues to work with integrated care systems (ICSs) to ensure as many people as possible benefit. 

Financial and implementation support to purchase and adopt DSCRs is available to providers through ICSs and care providers are advised to use the assured supplier list to purchase DSCR products that meet key functional, technical and commercial standards, ensuring information can be shared more easily, and securely, between health and care settings. For example, appropriate members of staff working in care settings can access primary care information via DSCRs, eg, medications and allergies.

B. Digital readiness

Care providers need to improve their readiness for digital working so that care can be delivered more effectively, safely and where the person requires it, and widen access to the tools and information needed to support the person receiving care. Care providers are encouraged to access the Digital Social Care website, the single point of information for the foundations of digital working, including good broadband connectivity, digital skills and cyber security. This website is one part of a comprehensive digital learning offer that also includes accessible training and online resources to build transferrable digital skills in the adult social care workforce.

C. Data sharing

Data sharing agreements can enhance MDT delivery by allowing appropriate access to rich information from both the social care and health records. All organisations that have access to NHS patient data and systems must use the Data Security and Protection Toolkit (DSPT) to provide assurance that they are adhering to data security good practice  and that personal information is handled correctly. CQC-registered adult social care providers should be supported to complete the DSPT ‘standards met’ level of compliance, which also enables providers to register for NHSmail, or opt to use an equivalent accredited secure email service to ensure their data is protected.

D. NHSmail

NHSmail is a secure email system available to all social care providers that have achieved the DSPT ‘standards met’. By choosing NHSmail providers will have access to a free Microsoft Office 365 licence and with this, full functionality of Microsoft apps, including Outlook for email management and Microsoft Teams, which can support virtual MDT meetings.

E. Digital switchover

The public telephone service currently runs on a copper-wired analogue system. The telecommunications sector is working to upgrade this system to full digital capability. If a care service includes provision for people to access telecare alarm devices and these are analogue based, the care home will need to discuss the switchover with their service provider or equipment supplier, checking whether current equipment will work reliably on a digital line until it is upgraded.

9. Comprehensive personalised assessment of need

A clinician with advanced assessment and clinical decision-making skills should carry out a proactive and comprehensive personalised assessment of need within 7 working days of admission or re-admission to the care home. This will involve interdisciplinary and interagency working, which places the person and their loved ones at the heart of care and has due regard for their intersectionality (Holman et al, 2021). This is part of the contractual agreements set out in the Network Contract DES, and the assessment will inform the development of the PCSP.

The principal aim is to support the proactive and ongoing management of a person’s complex and/or long-term conditions, which are influenced by their level of frailty, mental health needs and proximity to end of life.

The format of the assessment can be locally determined but should always be based on the principles and domains of the Comprehensive Geriatric Assessment, which includes all elements of an effective assessment regardless of age. The assessment will be tailored to fit the needs of the person, who may require additional reasonable adjustments depending on their preferences.

10. Personalised care and support planning

As set out in the NHS Standard Contract, the PCN works to establish arrangements for the MDT to develop and refresh a PCSP with people living in care homes. PCSPs cover the whole person – their life, health, care, wellbeing and death. It facilitates integrated, co-ordinated care by providing a single plan that enables people, their loved ones and the staff supporting them to work together to agree goals, identify support needs, implement personal plans and monitor progress that supports holistic care. More information about the criteria for PCSPs can be found on the NHS England webpage for personalised care.

Where possible, the PCSP should be digital, aligned to the information standard for personalised care and support plans, and part of the digital social care record so that people receiving care, their MDT and, where appropriate, those involved in the care of the person (their loved ones/carer/advocate) have easier access to information about what matters to them and their agreed goals and actions.

Digital care records are a vital enabler and key infrastructure for integrated working between health and social care staff, by enabling information exchange between the MDT and other health and social care professionals and services involved in the person’s care. A digital care record helps ensure continuity of care as well as best outcomes for the person. Digital records should be used wherever possible to facilitate sharing of a person’s PCSP and with this the co-ordination of care, as well as to avoid the need for a person and/or those important to them to repeat themselves unnecessarily.

A. Joining up care planning records

PCSPs should be viewed as the single overarching plan, describing not only clinical and medical health and care needs, but also what matters to the person, so holistic and personalised care can be delivered in a streamlined and effective way, and the management of their health and wellbeing is co-ordinated. It should be the place where all regular conversations pertaining to the care of the person are recorded.

PCSPs should encompasses all condition- and provider-specific plans (eg care plans, holistic assessments, proactive care planning, advance care planning, urgent and emergency personalised care plan, and other condition-related plans), as well as the person’s normal observations so that changes and ‘soft signs’ of deterioration are identified more quickly. (‘Soft signs’ are a set of observed physical changes that may indicate a decline in a person’s health; these signs may be present before physiological changes are observed.) The plan should also include information about any escalation of care, such as that after discharge from hospital (eg medications and discharge documentation).

Individual plans may be created for particular care needs, but it is fundamental to PCSPs that all information is systematically and coherently held in one place that is accessible to all who need it.

B. Ownership of the PCSP

The plan is owned by the person receiving care. This supports their decision-making and they can use the plan to establish goals and then work to achieve these, with the support of the care home and MDT.

Care home staff are best placed to gather the information for the PCSP, as they will know the person well and can connect with them, which is essential in ensuring that the plan is truly personalised.

While the plan is owned by the person receiving care, the care records remain the property of the care home, in line with other records, and the care home will have a role in safeguarding the data as the data controller.

11. Management of health and wellbeing

People who live in a care home will have a broad and complex range of conditions and health needs, and the care delivered will differ for each person. Delivering holistic care that meets the unique needs of the person and wider care home population requires strong clinical leadership and an appropriate MDT skill mix. It is expected that alongside the MDT, the wider primary, community and secondary care services adopt best practice in addressing the specific needs for the person receiving care, which could vary from continence promotion, wound care and positioning, oral care, rehabilitation, community engagement and more.

Comprehensive personalised assessments of need should capture all health needs, but prominent conditions engender specific vulnerabilities, and these are likely relevant to most, if not all, people receiving care in care homes. So, although the needs of each person are unique, specific attention to the health elements below (not an exhaustive list) should be given for all residents and should be part of the comprehensive assessment of need.

A. Structured medication review

Structured medication reviews (SMRs) are an evidence-based (NICE, 2015) and comprehensive review of a person’s medication, their views, concerns and safety – taking into consideration all aspects of their health. The National overprescribing review recognises the importance of regular SMRs.

In an SMR, clinicians and the person receiving care work as equal partners to understand the balance between the benefits and risks of, and alternatives to, taking medicines. A shared decision-making conversation is led by the person’s individual needs, preferences and circumstances, and it is best practice to have clinical pharmacists as part of the home round and MDT.

People who live in a care home are likely to be taking multiple medicines (polypharmacy). They may not fully understand the implications of the medication regimen they are taking, such as when:

• the medicines are no longer clinically indicated, appropriate or optimised for that person
• the combination of multiple medicines has the potential to, or is, causing harm to the person, and this outweighs the benefits
• the practicalities of taking the medicines become unmanageable or is causing harm or distress.

SMRs benefit people taking multiple medicines by:

• improving experience and quality of care through being involved in the decision-making process and having a better understanding of the medicines they take
• reducing the risk of harm from medicines (eg adverse drug events, side effects, hospitalisation or addiction).

They can also provide better value for local health systems, eg by reducing medicine waste.

B. Learning disability and autism 

People with a learning disability or who are autistic and who live in a care home are often young, working age adults, and their additional support or health needs will differ from those of older adults. They are also more likely to spend a greater proportion of their lives in a care home than the general population, but as some do move to independent or supported living, promoting learning and retention of independent skills is crucial.

People with a learning disability are more than twice as likely to die from ‘avoidable’ causes, with the leading causes of death being circulatory system diseases, respiratory diseases and cancers. Health conditions can be missed due to ‘diagnostic overshadowing’, where health problems are incorrectly attributed to a different cause, such as autism or a learning disability. All partners need to collaborate to identify the underlying health problems in people with a learning disability and/or who are autistic, as well as promote their physical activity, both to improve quality of life and life expectancy (King’s College London, 2021; Norfolk Safeguarding Adults Board, 2021).

Best practice to support people living in care home who have a learning disability and/or who are autistic includes:

• The MDT works with the GP to ensure that residents with a learning disability who are recorded on their GP’s register obtain their free annual health check, which can improve their health by identifying health problems earlier and managing existing conditions, and support reduction in health inequalities where the person may need support with self-checks (eg breast exams or testicular checks).
• Consider use of relevant resources (eg reasonable adjustments) to support assessments for those with a learning disability.
• The MDT supports the physical and mental wellness of people living in care homes by encouraging physical activity in a form suited to a person’s interests or sensory needs, referring to the recommended levels and duration of activity for people of different ages (eg physical activity guidelines).
• Care home staff and the MDT consider the unique physical fitness and nutrition needs of people with a learning disability and/or who are autistic, recognising that medications and lower activity levels may result in weight gain.
• Staff and the MDT are encouraged to access training and follow national advice on prescribing of psychotropic medication following the principles of the national Stopping over medication of people with a learning disability, autism or both (STOMP) campaign.

C. Nutrition and hydration

Good nutrition and hydration are fundamental to the health and wellbeing of people living in care homes, as it has a positive impact on their mental and physical health and contributes to reduced confusion and prevention of falls. Care home providers should be supported to consider the population of people living in their care homes and individual requirements to improve nutrition and hydration patterns and overall health. Particular attention needs to be given to people who require psychotropic medication as it may reduce or remove their desire to eat and drink, as well as those who may comfort eat. NICE clinical guidance sets out how oral, enteral tube feeding and parenteral nutrition support should be administered.

To improve care and independence, MDTs are encouraged to provide people and carers with information on managing adult malnutrition.

Best practice to support healthy nutrition and hydration includes:

• Adhere to CQC Regulation 14: Meeting nutritional and hydration needs.
• A validated and evidence-based nutritional screening tool, such as the Malnutrition Universal Screening Tool (MUST), should be used where clinically appropriate to identify people who are at risk of malnutrition or who are malnourished. The use of nutritional screening tools should be audited.
• Every person’s hydration and nutrition are monitored and reviewed regularly, in association with nutritional screening. Their PCSP should describe the nutritional aims of care; dietary requirements and/or allergies, food and fluid preferences; and where appropriate, recommended fluid consistencies together with information on their swallow function, and whether they require specialist equipment or assistance with eating/drinking or repositioning for meals and drinks.
• Each person’s PCSP includes any specialist recommendations, or pending specialist input, and is updated if nutritional care changes, such as when nearing end of life.
• Concerns around hydration and nutrition are escalated to the most appropriate member(s) of the MDT (eg dietitians, GPs, speech and language therapists, pharmacists and community nursing).
• A Food First approach is taken, and oral nutritional supplements are used when clinically appropriate.
• Care home staff receive regular clinical training and professional development in nutrition and hydration.
• Care staff feel confident in identifying the seven diet and fluid consistencies as part of the International Dysphagia Diet Standardisation Initiative (IDDSI), and can monitor for signs of dysphagia and refer to experts according to local policy.
• Technology enabled care is used to support eating and drinking prompts and monitoring of fluid intake.

Refer to best practice for hydration (eg I-Hydrate Resource Pack) and nutrition (eg Quick guide for AHPs EHCH).

D. Falls and falls prevention  

Each year around one third of people aged over 65 experience one or more falls, rising to 50% in those over 80. People living in care homes are three times more likely to experience a fall than people living in the community (British Geriatrics Society, 2020). A fall can result in suffering, disability, loss of independence and decline in quality of life, even when there is no injury. However, over 40% of hospital admissions from care homes are falls related (Anaba-Wright and Kefas, 2020), 10% of residents who fall sustain a fracture, and 40% of all injury deaths in care homes are the result of a fall (Rubenstein, 2006). The Falls in Care Homes study (FinCH) found the Action Falls programme reduced the rate of falls by over 43% compared with residents who did not receive this intervention, without restricting a resident’s activity levels or increasing their dependency (Logan et al, 2021).  

People with a learning disability are at risk of falls throughout their lives and, while the NICE guidance on preventing falls focuses on older people, the growing body of evidence relating to people with learning disabilities suggests that much of it may be equally applicable to people with a learning disability, while taking account of some specific considerations (Public Health England, 2019).

Through the use of falls prevention technologies and with the support of the national grants (DHSC, 2023), the ambition to support people identified as at high risk of falls in care homes can be realised.

Best practice in promoting physical activity, strength and balance, and preventing falls includes:

• Implement Action Falls (Logan et al, 2021). Falls risk assessments are part of the comprehensive assessment in the nationally commissioned EHCH model. The World Falls Guidelines 2022 recommend that all people living in care homes should have a multi-factorial falls risk assessment, and this and the NICE CG161 make recommendations for what this should include. Action Falls is a comprehensive multifactorial falls risk assessment and action planning tool, designed with and researched in care homes in England.
• People living in care homes are encouraged to remain physically active to maintain and/or improve their physical conditioning, and have access to local falls specialist services.
• Care home staff are trained in frailty, falls prevention and management, and personalised physical activities (including advice on muscle strengthening and balance activities), and work with the MDT, VCSE or other partners to support personalised exercises. Some of this training can be accessed online (eg React To Falls: Training resources for care home staff; All Our Health: Falls and fractures).
• The MDT is proactively engaged in supporting the care home staff to manage all identified falls risks in collaboration with the people living in care homes and their loved ones.
• Every care home has policies and procedures in place to determine how falls will be assessed and managed, aligned with NICE guidelines: how to get a person who has fallen up from the floor, how to use mechanical lifting aids, and when to call for additional support/advice from community falls team/urgent community response before 111/999 (unless calling 999 is the most appropriate action).
• Care homes have access to post falls assessment tools (eg iSTUMBLE and HelpFall) and mechanical lifting aids (eg lifting cushions/chairs and hoists).
• An individualised falls prevention plan supports care home staff to ensure the safety of the person; this is linked to the person’s PCSP.

E. Skin and wound care

Pressure ulcers (sometimes called pressure sores or bedsores) are injuries to the skin due to prolonged pressure on the skin. They can happen in anyone, but usually affect people confined to bed or who sit in a chair or wheelchair for long periods of time. They often develop gradually but can sometimes form in a few hours.

Pressure ulcers can be prevented by regular changes in position, checking skin at least daily for early signs or symptoms of pressure damage, and ensuring a healthy, balanced diet that contains enough protein and a good variety of vitamins. Those caring for anyone at risk of developing a pressure ulcer should carry out a risk assessment, monitor skin on a regular basis and use preventative measures, such as regular repositioning.

Best practice in skin and wound care includes:

• The care home has an up-to-date pressure ulcer policy, either as a standalone document or as part of another policy such as wound care. Such policies should reflect national guidance where it exists (NICE, 2014).
  • Care home staff are offered training and support to enable them to provide care that minimises the risk of residents developing pressure ulcers.  
  • Care home staff ensure that residents who develop pressure ulcers receive appropriate, individualised wound care with appropriate referral to the local service that undertakes wound care.
  • Care home staff are supported to implement the care plan recommended by the local service that undertakes wound care.  
  • The care plan focuses on enabling and empowering the resident to keep active and undertake activities and interventions that promote wound healing.

F. Leg and foot ulcers

These are wounds below the knee that fail to heal within a few weeks. They are common in older, less mobile people and can have a profound negative impact on quality of life in terms of pain, malodour and leakage, impaired mobility, anxiety, sleep disturbance and social isolation. Therefore, it is important that anyone who has a wound on their leg or foot that is not healing or unlikely to heal should receive an assessment from a clinician with expertise in leg and/or foot ulcer management as soon as possible.

Care for leg and foot ulcers varies according to the underlying cause, as outlined in the National Wound Care Strategy Programme leg ulcer recommendations (NWCSP, 2023a) and foot ulcer recommendations (NWCSP, 2023b).

Best practice in leg and foot ulcer management includes:

• The care home has an up-to-date leg and foot ulcer policy, either as a standalone document or as part of another policy such as wound care. Such policies should reflect national guidance where it exists.
  • Care home staff are offered training and support to ensure the appropriate care of a resident with a leg or foot ulcer by undertaking initial wound care and referring to the local service that undertakes leg and/or foot ulcer assessment and care planning.
  • Care home staff are supported to ensure that the resident receives appropriate individualised care while awaiting the outcome of the leg and/or foot ulcer service recommendations.
  • Care home staff are supported to implement the care plan recommended by the leg and/or foot ulcer service in partnership with local NHS services.
  • The care plan focuses on enabling and empowering the resident to keep active and undertake activities and interventions that promote wound healing.

G. Mental health

People with mental health illness benefit from high quality settings with staff who understand mental health conditions, and from specialist clinical input that delivers expert interventions in supportive environments.

The mental health of all people living in care homes needs to be maintained or improved, and specific needs met for people with enduring mental health conditions. The best practice guidance below does not cover the more specialist mental health interventions provided in specialist mental health, learning disability or dementia homes.

Best practice in promoting good mental health includes:

• The initial comprehensive personalised assessment on admission to the care home includes a systematic, proactive approach to identifying and recording mental health and wellbeing needs. Diagnosed mental health ‘conditions’, as well as experiences of grief, loss, anxiety and behaviours which challenge, should all be considered.
• The person’s biological, psychological and social needs are recorded in their PCSP along with signs of relapse, so staff will know how to recognise these changes and escalate accordingly.
• People with mental health illness, such as anxiety and depression, have access to a wide range of therapies and specialist support services, such as NHS Talking Therapies. 
• Individual PCSPs include access to wide-ranging activities that support mental health, such as social activity and community engagement.
• People have easy and timely access to specialist mental health services for assessment and management of complex mental health needs, including advice on the management of mental health medications and response to complex mental health crisis needs. This can be achieved through the MDT, which may include mental health specialists.
• Education, training and professional development are available to ensure that carers, the person’s loved ones and care home staff feel supported and confident in identifying mental illness, and in maintaining good mental health and wellbeing.

H. Dementia

An estimated 80% of people living in care homes have dementia or severe memory problems (Matthews et al, 2013; Alzheimer’s Society UK, 2014). While these will predominantly be those living in care homes for older people, some people with a learning disability and/or mental health conditions also have dementia. However, despite a growing prevalence, dementia and cognitive impairment remain under-diagnosed in care homes (Lang et al, 2017), and too many people living with the condition are admitted to hospital due to a lack of appropriate support. A quarter of acute beds are occupied by people with dementia (Healthcare Quality Improvement Partnership, 2019), and they often stay in hospital twice as long as other people over 65 (Alzheimer’s Society, 2016).

It is important that people have the opportunity and are supported to engage in assessments for dementia. Having a diagnosis helps ensure a person’s needs are better understood by their loved ones, carers and professionals, and that they receive appropriate post-diagnostic support.

Many people living in care homes are at the later stages of the condition and may require alternative methods and support to communicate their needs and preferences. They may also experience a range of other physical and mental health conditions and co-morbidities.

Best practice in supporting people with dementia includes:

• The MDT agrees an approach to the identification of dementia, delirium, anxiety and distress behaviours in care homes, aligned to the Dementia and OPMH: Guidance for primary care networks and care homes, and recognising signs and symptoms for those who do not have a formal diagnosis. The MDT should provide information on how people with dementia and living in care homes can be supported (eg Enhancing the healing environment: Developing supportive design for people with dementia).
• The MDT, including care homes, understand the local dementia diagnostic and post-diagnostic pathways, including how to access additional support from the VCSE (eg Dementia UK) and use social prescribing.
• As soon as a diagnosis is confirmed, access to post-diagnostic support is facilitated.
• The dementia diagnosis and holistic needs are recorded in a single PCSP as part of an integrated care record, accessible to all involved in the person’s care; this should align with the principles outlined in the Dementia good care planning guide.
• People living in care homes have access to specialist dementia/mental health services for assessment and management of complex dementia needs, including management of mental health medications (see section 11A: SMR) and behavioural and psychological symptoms of dementia, such as depression, agitation, aggression, distress and psychosis. One way this can be achieved is through a weekly review by the integrated MDT.
• Care home staff and primary care consider the guidance in Appropriate prescribing of antipsychotic medication in dementia and non-pharmacological approaches, focusing on what can be done if someone appears distressed or exhibits behaviours that challenge those caring for them.
• People living with dementia and cognitive impairment have access to a wide range of NICE recommended therapies and post-diagnostic services, including cognitive stimulation therapy, cognitive rehabilitation therapy, reminiscence therapy and music therapy. Consideration is given to therapies such as those provided through Talking Therapies, which can support their functional mental health needs, including depression and anxiety (see section 11G: Mental health).
• Connection with loved ones and friends is encouraged, and access to meaningful and purposeful community activities (see section 6: Living and ageing well) is facilitated and promoted. Some people living with dementia may benefit from access to technology that provides them with enrichment activities, games and other support around their instrumental activities of daily living.
• Evidence-based and validated education, training and professional development are available to ensure that care home staff feel supported and confident in identifying, assessing and managing dementia and cognitive needs.
• All MDT members are encouraged to use the freely available training resources, such as Dementia Care: eLearning for health, React to Dementia, Dementia Awareness, Dementia Training Standards Framework and become a Dementia Friend, to support provision of care for people living with dementia.

I. Recognising early signs of deterioration

Care home staff and the loved ones of those receiving care are skilled at recognising and noticing when a person may be becoming unwell, before the person exhibits obvious clinical signs of deterioration. As such, they can quickly identify deterioration in the person receiving care, which is especially crucial for people who do not have the capacity to fully engage in their care process.

All care homes should be supported and encouraged to have clear processes to follow once a change in someone is identified, to prevent any further deterioration and avoid escalation of care where possible. Many care homes have implemented tools such as RESTORE2, RESTORE2mini, NEWS2 and others, which prompt staff to take a set of clinical observations that they can share with the clinician when not present in the home, to support their decision-making.

With quicker identification of worsening acute illness and clear escalation routes, care home staff can support the person to stay in the home and have their needs met by wider services, such as virtual wards or urgent community response services, avoiding hospital admissions.

Digital tools can remotely monitor a person’s condition, while still promoting their safety, helping with early detection of changes in their condition, and supporting management of deterioration or long-term conditions. Assistive technology is also increasingly used for immediate intervention, recovery and reablement.

Best practice in recognising early signs of deterioration includes:

• Providing training to care home staff to help with the implementation of tools to support the identification of deterioration including escalations plans (eg RESTORE2, RESTORE2mini, soft signs, NEWS2).
• Implementation of a clear escalation route in-hours and out-of-hours for clinical advice and decision-making, supported by an appropriate treatment escalation plan or through the ReSPECT process, which creates personalised recommendations for care and treatment in a future emergency.
• Recording a person’s normal physiological observations, ‘soft signs’ or signs of mental health relapse to enable staff to identify deterioration more quickly.

12. Palliative and end of life care

Palliative and end of life care (PEoLC) supports a person with a life-threatening or life-limiting illness to live well and comfortably up until their death. It prevents and relieves suffering by means of early identification and comprehensive holistic assessment and treatment to meet their physical, psychosocial, spiritual and cultural needs. Care homes are an important provider of PEoLC for their residents and those important to them.

People should have access to generalist and specialist palliative care services and there is statutory guidance on PEoLC to support integrated care boards (ICBs) with their duty to commission these as per the Health and Care Act 2022.

PEoLC may be provided by the person’s usual care providers across primary care, secondary care, social care (including care homes) and the VCSE sector, or specialist services (such as hospices), all working together to provide integrated care and support for the individual.

A. Advance care planning

Advance care planning (ACP) is a key part of a PCSP and when done well gives people the opportunity to plan their future care. It supports a personalised holistic approach through understanding a person’s preferences and gives them confidence that their care and treatment will focus on what matters most to them if, at a future point, they cannot fully participate in decision-making.

Every person living in a care home should have the opportunity to express their wishes, feelings and values, which may include their wishes and decisions should they be unable to make decisions for themselves. ACP covers emergency care and treatment plans (eg the ReSPECT process), and future care preferences at end of life.

ACP must always be a voluntary process; people must not feel forced or rushed into these conversations, or denied the opportunity to discuss ACP in the future. The six universal principles for ACP in England aim to support the person, those important to them, and practitioners and organisations involved in delivering ACP conversations and honouring their outcomes.

Best practice in supporting people receiving PEoLC includes:

• The MDT uses a systematic, proactive approach to identify people who could benefit from a palliative care approach.
• People identified as benefiting from a palliative care approach are included on the GP palliative care register.
• Every person living in a care home (unless they indicate otherwise) has the opportunity to express their care preferences and to develop and document a PCSP, including an ACP (in accordance with the universal principles for ACP), treatment escalation plans, ReSPECT or equivalent emergency care and treatment plans. They must also have regular opportunities to review and revise these plans.
• The person and those important to them are involved in ACP decisions to the extent that the person wishes.
• Timely access to equipment and medication for symptom control.
• Advice or input is sought from specialist palliative care services as required.
• Care home staff are supported in delivering PEoLC by the MDT and partner organisations, including secondary care, hospice and specialist palliative care services, as needed.
• Care home staff have access to education and training on PEoLC knowledge and skills, delivered in partnership and collaboration with health and care providers and the VCSE sector. This should include recognition and assessment of symptoms, communication skills, ACP, supporting a person and those important to them, and recognising the procedure and support required after death.
• Staff are supported to reflect on the end of life care experience of those in their care using an after-death analysis tool, and have the opportunity to debrief and receive clinical supervision and support.
• Care home staff understand what support is available and how to access it whenever necessary.
• Staff are supported to use the Mental Capacity Act Code of Practice where required.

13. Workforce and support

The EHCH model is underpinned by a skilled and confident workforce that is committed to partnership working across health and social care. This is supported by the workforce planning conducted by ICBs and the ARRS, which enables PCNs to employ clinical pharmacists, care prescribers, social prescribing link workers, care co-ordinators and other roles to support and complement the delivery of the EHCH framework.

Integrated care partnerships should work with providers to plan, recruit and develop ‘one workforce’ that delivers system-wide co-ordinated health and care. ICBs are responsible for delivering the people functions including, but not limited to: supporting staff health and wellbeing; developing system plans to grow workforce supply; creating a culture of inclusion, belonging and learning; establishing a collaborative approach to lead transformation; developing a system approach to train and develop people; collaborating to support broader social and economic development. More information on the ICB responsibilities is set out in the guidance on the ICS people function.

Workforce development within the care home builds on the existing learning and training opportunities, which could also be supported by PCNs as they identify and/or engage in locally organised shared learning opportunities as appropriate and as capacity allows. It is recognised that carers and a person’s loved are often an invaluable source of support for people living in care homes.

14. Resources

Collaboration across health and social care is fundamental to effective implementation of the framework and must be the central premise of delivery. NHS England alongside other partner organisations will continue to update available resources as new data, best practice and guidance emerges.

For resources, please visit the our Enhanced Health in Care Homes webpage or the Care Provider Alliance website. To join the EHCH community, sign up to the FutureNHS workspace: Enhanced Health in Care Homes (log-in required).

The policies relating to wrap-around care for people in the community which relate to EHCH include:

• virtual wards
• urgent community response
• intermediate care
• research and innovation
• population health management
• infection prevention and control
• community-based falls services
• care home ambulance conveyance reduction.
• proactive care (publication pending).

15. References

• Anaba-Wright U, Kefas J (2020). Reducing pressure ulcers in care homes in Barnet: A quality improvement project. Br J Community Nurs 25: S33–7.
• Alzheimer’s Society (2014). Demetia UK Update.
• Alzheimer’s Society (2016). Fix Dementia Care: Hospitals.
• Barker RO, Hanratty B, Kinston A, Ramsay S, Matthews FE (2021). Changes in health and functioning of care home residents over two decades: what can we learn from population-based studies? Age Ageing 50(3): 921–927.
• British Geriatrics Society (2020). Falls in care homes: “Let’s go and invent tomorrow, instead of worrying about what happened yesterday….”.
• DHSC (2023). Next steps to put people at the heart of care.
• Healthcare Quality Improvement Partnership (2019). National audit of dementia – Round 4 Audit Report.
• Holman D, Salway S, Bell A, et al (2021). Can intersectionality help with understanding and tackling health inequalities? Perspectives of professional stakeholders. Health Res Policy Sys 19: 97.
• King’s College London (2021). Learning from lives and deaths – people with a learning disability and autistic people (LeDeR).
• Lang L, Clifford A, Wei L, et al (2017). Prevalence and determinants of undetected dementia in the community: a systematic literature review and a meta-analysis. BMJ Open 7(2): e011146.
• Logan PA, Horne JC, Gladman JRF, et al (2021). Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation. BMJ 375: e066991.
• Matthews FE, Arthur A, Barnes LE, et al (2013). A two-decade comparison of prevalence of dementia in individuals aged 65 years and older from three geographical areas of England: results of the Cognitive Function and Ageing Study I and II. Lancet 382(9902): 1405–1412.
• NICE (2014). Pressure ulcers: prevention and management Clinical guideline [CG179].
• NICE (2015). Medicines optimisation: the safe and effective use of medicines to enable the best possible outcomes [NG5].
• Norfolk Safeguarding Adults Board (2021). Adult safeguarding review: Joanne, Jon and Ben.
• NWCSP (2023a). Leg ulcer recommendations.
• NWCSP (2023b) Foot ulcer recommendations.
• ONS (2022). Care homes and estimating the self-funding population.
• Public Health England (2019). Preventing falls in people with learning disabilities: making reasonable adjustments.
• Rubenstein LZ (2006). Falls in older people: Epidemiology, risk factors and strategies for prevention. Age Ageing35(ii): 37–41.

Annex: Legal elements that apply to all residents

Systems, providers and care home staff will work within the legal requirements for people receiving care in care homes to ensure that their individual needs and preferences are identified and met where possible. These include but are not limited to:

• Making reasonable adjustments for people receiving comprehensive assessment of need (Equality Act 2010).
• Ensuring that a person’s capacity is appropriately determined, and they are supported as necessary to make decisions about their healthcare and treatment (Mental Capacity Act 2005).
• Upholding a consistent approach to identifying, recording, flagging, sharing and meeting the information and communication support needs of people receiving care, carers and the loved ones of people with a disability, impairment or sensory loss (NHS Accessible Information Standard, 2016).
• Adhere to the nomination of a Lasting Power of Attorney (LPA) for health and welfare of the person receiving care, including the LPA’s decisions around life-sustaining treatment on behalf of the person if they do not have mental capacity at the time, depending on the level of authority granted.

Publications reference: PRN2153