My Health, My Care, My Home - healthcare framework for adults living in care homes

7. A Sustainable and Skilled Workforce

The vision of this framework – that the health and wellbeing needs of people living in care homes are met so that they can live their best life – will only be fully achieved by a sustainable and skilled workforce.

The care home workforce demonstrate care, compassion, professionalism, and a broad range of skills in working with people living in care homes, their families, and the multi-disciplinary team to deliver personalised, relationship-based services which not only keep people safe, but also preserve their identity and promote their independence.

During the COVID-19 pandemic care home staff have had to take on additional responsibilities in relation to testing and adherence to IPC guidance. They have supported individuals, families, and colleagues through the very particular and emotional challenges of the pandemic. They have had to work through their own experiences of grief and bereavement. This has all been within the context of long-standing pressures within care homes with regards to attracting, recruiting, and retaining staff, exacerbated by the combined impacts of the withdrawal from the EU and the pandemic itself.

In December 2021, the Care Inspectorate and the Scottish Social Services Council (SSSC) published their vacancies report which confirmed that care homes for older people in Scotland had 55% of services reporting staff vacancies and 38% of services reporting nursing vacancies.

There is also the need to strengthen the healthcare workforce. GPs, Community Nurses, and Primary Care teams are under considerable pressure to meet the increasing demand that is associated with the ageing Scottish population.

The Health and Social Care: National Workforce Strategy makes clear the need to grow the workforce. The Five Pillars of Workforce: Plan, Attract, Train, Employ and Nurture, are key to the strategy and to how the vision of a 'sustainable, skilled workforce with attractive career choices where all are respected and valued for the work they do' can be achieved. This section of the framework focuses on this vision and identifies the necessary conditions to sustain and further develop the care home workforce.

The care home workforce

The Multi-Disciplinary Team section uses concentric wheels to describe how the MDT is made up of individuals and professionals and how they work together in the direct provision of care. The effectiveness and impact of the MDT will be influenced by the availability of a skilled and sustainable workforce.

The Adults' services workforce table published by the SSSC informs that as of 2020, 46,340 staff were employed in care homes for older people in Scotland. Additionally SSSC's 2020 report on workforce data (August 2021) informs of 52,920 (41,390 WTE) people working in all adult care homes in Scotland.

Analysis of the latter indicates that 75% of all staff are reported as care staff providing direct care, support or clinical assessment. Data relating to the nursing workforce is limited as they are categorised along with others who are responsible for assessment of care needs, for example Social Workers and Occupational Therapists. However, this group account for only 11% of this direct care and support function in care homes, with care home managers accounting for 2% of the total workforce. The data available, along with the time lag in it becoming available, not only makes robust workforce planning challenging, but adds concern regarding the provision of clinical and professional leadership to support the increasing levels of dependency and complexity that now exist.

Care home workforce skills

As described in the introduction to the framework, Scotland's population is ageing and as people are living longer, some are living with increasingly complex health and care needs. This demographic change is also reflected across the care home population impacting on the current and future skills needs of the care home workforce. The SSSC's Workforce Skills report (2021) highlights that over 90% of care home managers felt existing qualifications are fit for purpose. However, 72% believed new skills needs will develop over the next five years that existing qualifications won't address. Particular areas of skills needs that were highlighted were Infection, Prevention and Control, and Digital skills. Survey respondents to the consultation on this framework also identified the value in developing care home workforce skills in preventative asset based approaches and some basic clinical procedures for example, wound dressing.

Care home managers

The responsibilities of the care home manager are all encompassing. In short, they are responsible for the overall management, development and quality assurance of care and support provided in a care home service, including the supervision of staff and the management of resources.

Care home managers are dedicated and caring, they are motivated to meeting the needs of people. Studies on job satisfaction inform that care home managers cite the provision of good quality care, their use and development of skills in their work, working with capable staff, having a good reputation in the care home sector and opportunity for career development as essential. Investment in the development of care home managers, which should include leadership training is required to enable this.

Challenges to be overcome in dispensing these responsibilities are described throughout this framework. Changes to regulation, legislation, policy, challenging recruitment and retention of workforce, fragmented care and communication systems and not least the impact of the financial climate.

Registered Nurses

The NHS Education for Scotland Post-registration Career Development Framework for Nurses, Midwives and AHPs defines four pillars of practice (clinical practice, facilitation of learning, leadership, evidence, research and development). These are core components of education and development which support the development of Registered Nurses to increase their knowledge and skills to work across levels of practice from Newly Qualified Practitioner, Senior/Specialist to Advanced Nurse Practitioner and Consultant Nurse. These are demonstrated in page 5 of the Chief Nursing Officer Directorate, Transforming Roles, Paper 5: Transforming education and career development in nursing.

Whilst Registered Nurses work across these levels of practice, fundamentally they have the skills, knowledge and experience required to undertake assessment of an individual's needs, ensuring that appropriate response to their findings is taken leading to the best outcomes for the individual. At Level 5 of practice (newly qualified practitioner), some examples of responsibilities and roles defined within the four pillars of practice are provided on page 8 of the CNOD: Transforming Nursing, Midwifery and health Professions (NMaHP) Roles; pushing the boundaries to meet health and social care needs in Scotland.

The CNOD Transforming Roles paper: Advanced Nursing Practice set out the core competencies, education priorities and supervision requirements for ANP roles in Scotland. The paper defines Advanced Nurse Practitioners (ANPs) as 'experienced and highly educated registered nurses who manage the complete clinical care of their patients, not focusing on any sole condition.'

In working with, and as part of, the care home team, all four pillars of practice will be utilised in meeting the needs of the person. However, the attributes, skills and knowledge as leaders that the Registered Nurse brings to the team is key. They bring leadership and co-ordination to the team – they are critical to managing and overseeing infection, prevention and control practices, food, fluid and nutritional care and safe medicines management. Using mentorship and a coaching ethos they oversee and support the wider care and support team. Provision of registered nurses is required, as there is a well reported correlation between provision of Registered Nurses and high-quality, safe and effective care.

Regulation and registration

The Health and Care (Staffing) (Scotland) Act explicitly states that staffing is to provide safe and high-quality services and to ensure the best health care or care outcomes for people experiencing care. Once enacted, it places a statutory duty on care home providers to ensure that, at all times, suitably qualified and competent individuals are working in such numbers as are appropriate for the health, wellbeing and safety of people using the service, and the provision of high-quality care. Providers are also required to ensure staff are appropriately trained for the work they perform. The Care Inspectorate's Guidance for providers on the assessment of staffing levels has been designed to support care home and other care service providers in assessing and providing staffing levels to best meet the needs of people in their care.

Statutory regulation of the health and social care professions serves to protect the public from the risk of harm associated with the provision of health and social care services. There are 9 regulators of healthcare professionals in the UK, overseen by the Professional Standards Authority (PSA), regulating 34 professions, which all must be registered with their professional regulatory body by law. The regulators maintain and hold the register of those qualified to practise in each regulated profession they oversee; they set the education and training requirements for entering a profession; set the standards of conduct and competence needed to continue to practise and take action where concerns are raised about a registered professional.

There is some variation in the mechanisms for maintenance of registration across the professions. However, it is the individual responsibility of the registrant to maintain registration, providing and demonstrating evidence of practice, maintenance of skills and knowledge together with evidence of ongoing learning and development. Employers have a duty to regularly check the registration status of their healthcare professional staff, however, it is the individual responsibility of the registrant to maintain registration.

Care home workforce registration

All care staff and managers within care homes for adults require to be registered with the SSSC, if not already registered with another regulatory body. There are four register parts related to working within care homes for adults. To register individuals must satisfy the criteria for registration, this includes gaining employment in a relevant role and holding or agreeing to work towards the appropriate qualifications for their role, usually within a 5-year period. Individuals working in Social Care, who are registered with one of the 9 Healthcare Professional Regulators, are not required to register with the SSSC; for example, Nurses. Social care employers have a legal responsibility to make sure all their staff are correctly registered within six months of their start date.

The SSSC Code of Practice for Social Service Employers sets out the responsibilities of employers in the regulation of social service workers, which states "As a social service employer, you must provide learning and development opportunities to enable social service workers to strengthen and develop their skills and knowledge". The Care Inspectorate take the Codes of Practice into account during inspection of services and may take action to support improvement or require change if providers don't meet the required standards.

Recruitment, retention and wellbeing

There are difficulties with staff recruitment and retention throughout the health and social care workforce which have been present for a number of years, with many care homes experiencing high turnover of staff. The workforce data reported by SSSC informs of a decrease in workforce in care homes between 2011 and 2020 (-2.3%). In addition, many staff move between care homes so they take their skills, knowledge and experience attained through training and education with them. This puts additional pressure on the current workforce and impacts their own personal wellbeing. Recruitment and retention are key to providing adequate care, along with sustaining and improving resilience of the care home team.

The National Workforce Strategy for Health and Social Care in Scotland acknowledges these significant pressures that care home staff, and the wider workforce are facing and emphasises that sustained actions are required from planning for and attracting into the workforce through to support and development of our workforce, and supporting and delivering Recovery, Growth and Transformation of our workforce. Care home staff and wider workforce should experience wellbeing support, meaningful work and attractive terms and conditions, which reflect modern society; all helping to deliver the high-quality care that citizens expect.

There is a need to look at recruitment of workforce and career opportunities around it, including the implementation of training. Placing a focus more on values than experience when recruiting may assist to grow, nurture and sustain the workforce. Exploring opportunities for people leaving school and ways we can link in with schools and the school curriculum, as well as advertising such opportunities also need to be considered.

The health and wellbeing of those working in care homes is of equal importance to that of those living in care homes. The needs of staff should be addressed and they should feel supported as they deal with difficult and traumatic experiences. The range of supports put in place in Lanarkshire are captured in this recent video by the CH Wellbeing Group. NHS Greater Glasgow and Clyde have introduced short care space sessions.

NHS Greater Glasgow and Clyde 20 minute care space sessions

With the increasing pressure on care home staff during the pandemic NHS Greater Glasgow and Clyde developed weekly 20 minute care space sessions to provide a space for self-care through facilitated connection and support. It is an experiential, reflective learning based exercise aimed at providing support to busy healthcare staff. Sessions are hosted by the Senior Principal Clinical Psychologist and have been co-facilitated by previous Trainee Clinical Psychologists and currently, by an Assistant Psychologist.

A number of sessions have been delivered since the programme's inception and staff feedback has been wholly positive in increasing their awareness of self-care and building connections with their colleagues. The programme also has the support from the Care Inspectorate.

Leadership

Effective leadership at all levels is in integral to ensuring that the health and wellbeing outcomes of people living in care are met. As part of our online survey just under half (48%) of respondents highlighted the value in having good leadership but this was counteracted by 41% suggesting that leadership in care homes could be better.

The Scottish Government recognises that having a strong leadership in place within the Health, Social Work and Social Care workforce can improve the culture and the wellbeing of staff and also lead to better care and outcomes for the people who use services. That is why in August 2022, we are launching a National Leadership Development Programme (NLDP), which will build on the work of Project Lift, and complement existing leadership development and support on offer within health, social work and social care workplaces. The Programme will be focused on developing compassionate, collaborative and inclusive leadership at all levels across the health, social work and social care system.

A range of Leadership support programmes and resources across Scotland are available to care home staff and managers via the SSSC's Step into Leadership website.

Pre-employment

There are different open access resources that introduce people to a career in social care, including care homes, and include tools that help people identify their existing skills and knowledge. The SSSC's Right values, right people: recruitment toolkit offers a range of pre-employment tools both for employers and people interested in working in social care. The College Development Network has launched the Introduction to a Career in Care programme and SSSC has created a mechanism for employers, including care home providers to share employment opportunities directly with local colleges and course participants. The SSSC's network of Careers Ambassadors are supported to work with social care staff, schools, colleges and employability providers, to promote life changing careers in social care.

Induction training

Good induction training is essential to prepare all members of the care home team for their duties and help them to immediately feel valued and supported in their role, which in turn may lead to better staff retention.

Whilst care homes will provide induction training for all new staff, outwith statutory training requirements this can be variable across the sector as it is adapted to the individual requirements of each care home. In addition, previous education and training is not always accepted as being transferable when an employee moves between care homes.

The SSSC and NES have worked in partnership with Scottish Government and employers to deliver a National Induction Framework for adult social care which provides a single point of access to existing NES/SSSC learning materials relevant to adult social care induction as a complement to the induction learning already provided by care home providers. It includes a learning assessment tool and Open Badges that support care home workers work with their managers to plan, record and reflect on their induction. Implementation and widespread consistent use of this induction framework across the sector is recommended.

Education and Career Development Pathway for the integrated community nursing team

The Education and Career Development Pathway for the integrated community nursing team was introduced as part of the Chief Nursing Officer's Transforming roles programme. This supports nurses from care home, district nursing, prison health and general practice nursing teams to develop skills and knowledge to practise confidently and competently from levels 5 to 8 of the NES NMAHP Development Framework and aims to develop a responsive, flexible, community nursing workforce.

Care homes should strive for consistency in providing mandatory training for all staff which addresses the core elements required to deliver safe care, covering a wide range of duties that will increase their knowledge, experience and skill-set. There should also be opportunities for staff to undertake continued professional development and pursue meaningful learning and development and to allow career progression.

Continuous Professional Learning

A requirement of SSSC registration is that individuals either hold or agree to work towards achieving, an approved qualification, usually a SVQ, within a 5-year period. The qualifications are designed from the National Occupation Standards for social care. Both SSSC and registered healthcare professionals are also required to evidence Continuous Professional Development (CPD) to maintain their ongoing registration. It is not unusual for staff to move or change roles during the 5-year period and therefore it can be a challenge to maintain a consistent level of education standards within the workforce. Response to the SSSC's A register for the future consultation have demonstrated an overwhelming support to making qualifications more flexible so people can move more easily to work in different kinds of services.

Although individuals have a professional responsibility to maintain their own training as part of their professional registration, employers have a responsibility to ensure that people living in care homes have suitably trained and qualified staff supporting them. This means that they need to identify relevant general and specialist training and ensure that their care home team delivers safe and effective care in line with all relevant legislation, guidance and best practice.

During our engagement sessions it was evident that there is an abundance of care, compassion, skills and knowledge within the care home team and wider workforce. However, over three quarters (79%) of our online survey responses from care home team members highlighted a lack of protected time for staff to undertake training and practice development. Building on the expertise within the current workforce is essential. Planning protected time, as well as providing opportunities to support the learning and development of the team is required. Everyone in the team should feel supported and valued in their roles, thus, encouraging new people to enter the workforce and experience working in a physical and social environment where they can truthfully say they are satisfied with their role and feel valued.

It is important to support staff and enable them to remain flexible to allow transferability of skills, which will help retain a diverse workforce with different skill sets that all work together to provide the full range of care required.

Availability of training courses, resources and programmes

Lifelong or continuous learning occurs in many different ways. Some high level examples are provided here, but are not exhaustive.

The Scottish Social Services Council have developed digital certificates called 'Open Badges' that help social care staff recognise continuous and informal learning that would otherwise go unrecorded. When applying for an Open Badge, staff need to give evidence of their learning and reflection on practice. Many badges also require endorsement of that evidence by a supervisor or line manager.

The SSSC's Learning Zone and NES Turas Learn are online platforms where all health and social care staff can access health, wellbeing and social care tools and learning resources. Care home staff can select from a wide range of relevant tools and resources developed specifically to meet the education and training needs of those working in the care home environment. These resources support informal learning, specialist training, induction of new staff and the delivery of learning programmes by employers and critically the formal qualifications required for SSSC registration.

Training and education for Registered Nurses and AHPs is also available online through independent and private education providers, with Health Boards also providing training for their employees. Higher Education Institutes provide pre-degree and postgraduate programmes. Many of these support the recommendations of the Chief Nursing Officers Transforming Roles work, in particular the wider role of nurses working in community settings. Following the pandemic, Transforming Roles is being reviewed, with decisions on what shape this will take in the future awaited.

A training package has been developed for pharmacists, doctors and other healthcare professionals to undertake an in-depth review of prescribed medications. This can be accessed on TURAS and is available for anyone who wishes to complete it.

Much of the training takes place online and there is a desire from those we spoke to whilst developing the framework for the sector to introduce more practical support tools, with education and training that is meaningful, consistent, and fit for purpose, to better equip staff and empower them to feel confident in doing their job.

"Most training is now done online however not all of our carers feel confident using computers. This is definitely putting some of them off doing it."

It is recognised that online training solutions can save time, but there needs to be an investment in time to train individuals in digital technology. This is a challenge for an already strained workforce, but it is key that staff have a basic level of digital education to enable access to these resources and opportunities as well as those that are provided face-to-face.

Many areas have successfully developed a HSCP based 'Care Home Liaison Service'. This is a multi-disciplinary team who work alongside the care home team to build competence and confidence in meeting the needs of the people living in the home. This may include focused study sessions on topics such as falls prevention, pressure area care and prevention, use of feeding tubes and palliative care. This should be explored for wider implementation across care homes in Scotland. NHS Lanarkshire for example has developed and built a Care Home Liaison Service over a 20 year period to cover all care homes for older people within the Lanarkshire area.

Evidence from the OPTIMAL study shows that when training includes all members of the care home team (e.g. catering, care and domiciliary team members) there is more likely to be organisational engagement and sustained improvements. This may not always be appropriate as there will be different levels of training required for different roles, where possible this should be encouraged.

There are numerous learning and development opportunities offered via various websites, providers and institutions, in various modes. This can make it difficult to keep track of what is available, relevant and what has been completed. There are also examples of good approaches taking place throughout care homes in Scotland that others are not aware of but could benefit from adapting to use within their own areas. It would therefore be beneficial to explore opportunities to develop and introduce a one-stop repository for tools and resources that everyone can access, which includes courses available as well as highlighting these good approaches for others to draw from.

A single record of education and training for all staff would not only assist to evidence statutory and mandatory training undertaken and promote transferability of learning, it would also help identify educational gaps for an individual. Better promotion of the training resources already available would help staff to know what is available to them and would improve take-up.

As we move forward

The Care Inspectorate have developed new approaches to scrutiny, with the Health and Social Care Standards used in conjunction with the Quality Framework for Care Homes for Adults. The importance of and ability for care homes to self-assess and be subject to scrutiny on the quality and experience of care they provide, to take actions required for improvement or maintenance is required to assure the care provided and experiences of people living in the home. However, it can also add to workforce pressures and capacity.

This framework is not intended to replace these standards, rather to support how care home teams and the wider MDT can meet them. Additionally, in its ambition for a sustainable and skilled care home workforce, the framework echoes the Workforce Strategy's vision and outcomes and aligns its recommendations to the five pillars of the workforce journey.

To meet the direct and indirect care requirements, the care home team is critical, in sufficient numbers, with the right skills and knowledge and the right supports to nurture and retain them. For this, the team requires good leadership and oversight. The roles of the care home manager and the registered nurse are key to this leadership provision.

Care home staff and wider workforce should experience wellbeing support, meaningful work and attractive terms and conditions, which reflect modern society; all helping to deliver the high-quality care that citizens expect.

Recommendations

7.1 Seek to improve the timeous availability of workforce data to support robust workforce planning, recruitment and retention in line with requirements of The Health and Care (Staffing) (Scotland) Act 2019.

7.2 Invest in the development of care home managers and consider access to enhanced leadership training, mentoring and leadership networks.

7.3 Plan and ensure clinical and professional leadership through the provision of registered nurses as key members of the care home team.

7.4 Explore opportunities for recruitment within the community, by placing a greater emphasis on values rather than experience.

7.5 Organisations should take steps to ensure the emotional wellbeing of their staff, and provide access to support and signposting to the range of resources currently available to them.

7.6 Ensure workforce plans include dedicated time for staff to undertake recommended and required education and training.

7.7 Explore opportunities for career and development pathways for support workers, ensuring consistency and transferability of skills and knowledge across the sector.

7.8 When complete, implement the Induction Framework, developed by NES, SSSC & Scottish Government, across the sector in a 'Once for Scotland' approach.

7.9 Identify the mandatory and core elements of training for care staff to ensure the essential knowledge and practical skills are readily available for use in the care home.

7.10 Have meaningful and consistent education and training that is fit for purpose, includes more practical support tools, and is supplemented by online training.

7.11 'Care Home Liaison Service' models should be explored, whereby multi-disciplinary teams work alongside the care home team to build competence and confidence in meeting the needs of the people living in the home.

7.12 Explore opportunities to develop and introduce a one-stop repository for tools and resources, that everyone can access and that will highlight and share good practice already happening for others to draw from.

7.13 Encourage interdisciplinary multi-sector learning and development to develop the skills required to support people living in care homes.