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

3. Prevention

Preventing deterioration in health and wellbeing through good nutrition, hydration continence, movement and activity, cognitive stimulation and social connections.

Prevention can stop the onset of illness through early positive interventions. It can also reverse, stop or delay the progression and impact of a pre-existing condition. Put simply, it involves proactively keeping people well, and maximising their independence to thrive in the most appropriate care setting for their needs. This involves an asset based approach, focusing on what a person can and likes to do rather than where their difficulties are.

People living in care homes must be supported to access any relevant age-specific public health programmes, for example screening for bowel cancer or immunisations against flu, COVID-19, pneumococcal and shingles infections. They should have the opportunity to make an informed decision about whether to take part in these programmes with appropriate information that is tailored to their needs.

Preventing the spread of infections has always been important within care homes, and has been even more apparent during the COVID-19 pandemic. Care homes are not and should not become sterile 'clinical' settings, but they must remain safe environments for people to live in.

The Healthcare Improvement Scotland (HIS) Infection Prevention and Control (IPC) standards are a requisite for safe, high-quality care in all settings. They must be supported by access to relevant IPC guidance, advice, education/training and guidance.

By applying best practice, infections such as respiratory tract, gastrointestinal or wound infections, may be prevented. It is essential that this is part of routine compassionate care in a homely environment. IPC plays a part but so does hydration, mobility and medicines management.

A regularly reviewed personal plan can support a preventative approach to care, and is therefore essential that everyone living in a care home has one. The health and social care standards define a personal plan as:

'A plan of how care and support will be provided, as agreed in writing between an individual and the service provider. The plan will set out how an individual's assessed needs will be met, as well as their wishes and choices.'

Personal plans are currently being produced, often at a very good standard, across the country. However, there is a variation in how they are being written and utilised, particularly in respect to the development and use of online resources. There should be consistency in the approach taken when developing these personal plans, as recommended within the Care Inspectorate's Guide for providers on personal planning.

"The views and wishes of the resident should be sought, considered and implemented to support them to live their lives to the fulfilment."

Preventative care involves a collaborative approach where professionals focus on their knowledge and understanding of the individual to do what is right for them. MyHomeLife Scotland is an initiative to promote quality of life for those living, dying, visiting and working in care homes for older people through relationship-centred and evidence based practice. Together in Dementia Everyday (TIDE) acknowledges and values the experience and skills of carers, and gives them a voice across many aspects of care, including prevention.

Restoring Relationships: The Recovery of Love, Connection and Family

As the Covid-19 pandemic took hold families felt a physical and emotional separation from their relatives living in care homes. Care home staff and managers have also experienced a huge range of emotions, loss and change whilst ensuring the safety of the people they care for.

In response TIDE (Together In Dementia Everyday) have created two Recovering Relationships toolkits, one for families and friends and one for care home staff and managers. These toolkits are for anyone who knows someone living in a care home in Scotland or for anyone who works with care providers in Scotland. Relationships initiative

These toolkits focus on different areas of communication and relationships with lots of practical hints and tips designed to support you to take the first steps to improve and renew your relationships.

Prevention also covers many other aspects of healthcare, including:

Medicines management

Prevention of deterioration or of harm also involves the proactive management of long term health conditions and regular, structured polypharmacy reviews. It has been estimated that 25% to 40% of hospital admissions of older people are related to harm caused by medication errors. In residential care facilities, falls occur at a much higher rate and progress to more severe complications in the presence of polypharmacy and/or inappropriate prescriptions.

The person centred medication review, using the 7-step approach should be initiated by a pharmacist and take place when someone first moves into a care home, and then at least annually thereafter. Certain high-risk drugs, such as antipsychotics, will require more frequent monitoring and review. The aim should be to optimise benefits from medication, and minimise medication related harm.

A suite of prescribing safety indicators are available to help address unwarranted variation and support improvement. In addition, several tools are available to ensure that people and their families are involved in shared decision making at the point of prescribing.

Oral health

Good oral health is crucial to overall wellbeing and helps to promote adequate nutrition and hydration. People living in care homes are at greater risk of oral conditions because of a variety of factors including high levels of dependency, the effects of medication, physical disabilities and cognitive impairment. However, many people are now keeping their natural teeth for much longer than before and so, it is essential that they receive good oral care.

The national Caring for Smiles programme offers training to care staff in oral health. Whilst it is a national programme, there have been some local adaptations. Further useful information can also be found in the Care Inspectorate's 'Supporting better oral care in care homes' quality illustration. This includes details of the oral health programme Open Wide for younger adults with additional care needs who may need support with daily oral care.

Routine and regular dental reviews should continue to be part of an individual's personal care plan when they move to live in a care home. There should be a named dentist / dental practitioner for each care home.

Hearing and eye care

The monitoring and maintenance and proper use of hearing aids, glasses and low vision aids are an important part of preventative care. Uncorrected poor eyesight or poor hearing can significantly impact a person's ability to engage. Low vision or poor hearing impacts on holistic wellbeing and on undertaking the functions of daily living such as eating, dressing, or basic hygiene.

For a person to participate fully within their environment and community, they must be able to see and hear as well as possible. This is particularly important for a person with a cognitive impairment, and can help to reduce distress and prevent falls. With effect from 1^st April 2023, a new national low vision service will roll out across Scotland, which will provide support to those who have low vision or are sight impaired. This service will operate in both practice premises and domiciliary locations, which will include care homes.

Routine sight and hearing reviews should continue to be part of an individual's personal care plan when they move to live in a care home. This is one of the recommendations in the Scottish Government/COSLA See Hear strategy.

Particular attention should be paid to the needs of residents who have both sight and hearing loss (deafblindness). Deafblindness is a unique disability, with prevalence rates increasing sharply from age 70.

Nutrition and hydration

Nutrition and hydration is a part of our everyday life. What and how much we eat and drink has a direct impact on our health and wellbeing. Building nutrition and hydration into everyday practice is important, and should include the proactive identification of anything that might prevent good intake. This includes the ability to see well, ability to hold cutlery and ability to chew food. Dietary choices extend beyond just vegetarianism and veganism. Around 10% of the total UK population may have special dietary requirements because of the beliefs that they hold. These should be respected and supported when someone moves into a care home. An all-party parliamentary group has produced Respect for religious and philosophical beliefs while eating in care with recommendations.

Malnutrition affects every system in the body and results in increased vulnerability to illness and complications, for example, increased risk of chest infections, falls, anxiety and depression or the ability to fight off infection. The Malnutrition universal screening tool (MUST) should be used to identify those at risk. Good hydration is vital for many elements of healthcare for example in the prevention of UTIs; tissue viability and clarity of cognition. A helpful resource about eating and drinking well can be found on the Care Inspectorate website. Further helpful information to support nutrition and hydration can be found on the Royal College of Psychiatrists website and the Scottish palliative care guidelines.

Continence promotion and bowel care

Loss of continence can produce marked reduction of self-esteem and independence. It may be associated with physical problems such as skin breakdown, falls, urine infection and catheter associated urinary tract infection which in turn often causes confusion that in itself can result in injuries that require an acute hospital admission.

Therefore, proactive continence promotion can have multiple benefits for an individual and forms an important part of a person's health and wellbeing. The Care Inspectorate provides a helpful resource for promoting continence for people living with dementia and long term conditions.

Tissue Viability and Wound Care

Tissue viability and wound care is closely connected with hydration, nutrition, continence and mobility. Prevention and early intervention when required are vital as is support from a range of people in a person's care team.

There are a number of resources which can help, for example, the tissue viability toolkit from Health Improvement Scotland. NHS Lothian has a dedicated Care Home Tissue Viability Team who deliver educational packages that build on care home staff's knowledge, skills, and confidence.

Mobility and meaningful activity

Maintaining independence and being engaged in meaningful activity is core to enabling a person to live their best life. Mobility may be how a person moves around. It can be classed as aided (e.g. with a Zimmer frame), or unaided. Being active is how we all help prevent ill health or deterioration. It also has a positive impact on a person's self-esteem, independence, respiratory care, joint pain and tissue viability.

Activity does not have to be a formal exercise or activity programme; it also includes recognising the opportunities to make every moment count throughout a person's day. CAPA Resources | care about physical activity can be used to support physical activity in different ways. Allied Health Professionals may be an important part of a person's care team to help with this area of their wellbeing. For example, a physiotherapist can help an individual maintain their mobility, enabling them to independently engage in their daily activities.

Psychological wellbeing and spiritual support

Upholding people's psychological wellbeing and connections to a spiritual life are fundamental principles of person-centred care. Knowing 'what makes life worth living' and facilitating support for everyone's right to live according to their beliefs and fulfil their emotional, psychological and spiritual needs start from confident conversations with the person and those close to them. Their wishes should be reflected and upheld and regularly reviewed via their plan.

Spiritual care is an integrating aspect of holistic, person-centred care; affirming that fear, anxiety, loss and sadness are all part of the normal range of human experience within health and social care. By supporting individuals to explore challenging questions relating to change, mortality, meaning, purpose and identity we can help individuals to (re)discover core values and beliefs. When such matters are expressed, identified and addressed, people living in care homes can experience a greater sense of enablement, personal wellbeing and resilience in the context of illness, disease and life-changing or other social issues.

Low mood, anxiety and depression

Admission to a care home can be associated with multiple losses and represents a major life transition. It is important to distinguish between the transitory low mood and sadness that may be related to a change in circumstances, compared with enduring depressive disorders.

Agitation is a physical sign of anxiety and can manifest in shouting or other displays of stress and distress, particularly for people living with dementia. Loneliness is a factor in low mood, which is why it is so important to understand what and who are important to a person, and to plan their care and days collaboratively. Low mood and depressive disorders often precede development of dementia and symptoms can be difficult to tell apart. Management begins with a careful assessment to determine cause, followed by a range of therapies which may include activity based interventions, psychological or pharmacological interventions.

Cognitive stimulation and connections with the wider community

Across the sector there are some great examples of cognitive stimulation and active connections within the community, but these do not consistently happen everywhere. The result of this is that for some people, their experiences are limited to 'traditional' activities that may exclude those with declining cognitive health or may not take into account a person's individual preference. Being mindful of a person's life before they have moved into the care home and what connects them to their community should always be part of their care plan. Understanding what matters to the person, whether that be maintaining a spiritual life, family and intergenerational connections or a passion for music is a vital starting point.

In July 2021, Scotland launched a strategy for promoting brain health and dementia research, with the ambition of translating this into health and social care practice. One of the key aims of the strategy is to develop brain health and dementia boards within each NHS board area that will look at dementia research. In addition the Brain health Scotland initiative was developed in partnership with Alzheimer Scotland and funded by the Scottish Government. This initiative provides advice about brain health research and policy, supports the provision of personalised prevention plans and promotes positive brain health in collaboration with Public Health Scotland and other partners.

Communication equipment and support

People who have difficulty speaking and who can be assisted by communication equipment have the right to get the equipment and support they need to use it, when they need it, whoever they are and wherever they live in Scotland, enabling them to participate in their communities and be fully included in society.

Communication equipment, and support in using it, can make a real difference to people's lives and makes sure they have a voice to be heard. From 19 March 2018, NHS boards in Scotland have a duty to provide communication equipment and support to use that equipment.

This duty applies to children and adults, from all care groups who have lost their voice or have difficulty speaking. Health Boards deliver this duty, in the main, through Speech and Language Therapists.

Recommendations

3.1 People living in care homes must be supported to access any relevant age-specific public health programmes with appropriate information to allow an informed decision.

3.2 Application of IPC standards in care homes should be supported by access to relevant IPC advice, education and guidance.

3.3 Everyone living in a care home will have a regularly reviewed personal plan.

3.4 Ensure there are effective systems in place to deliver a consistent approach to the development and implementation of proactive, personal plans.

3.5 A person centred medication review, using the 7-step approach should be initiated by a pharmacist when someone first moves into a care home, and then at least annually thereafter. Certain high-risk drugs, such as antipsychotics, will require more frequent monitoring and review.

3.6 Routine dental, sight, and hearing reviews should continue to be part of an individual's personal care plan when they move to live in a care home.

3.7 There should be a named dentist / dental practitioner for each care home and contracts with local optometry and hearing services.

3.8 There should be a proactive approach to hydration, nutrition, continence promotion, meaningful activity and mobility using appropriate resources and should be considered with the same degree of importance as reactive healthcare.

3.9 Religious and philosophical beliefs in relation to food and diet should be enquired about and catered for.

3.10 Psychological and spiritual aspects of healthcare should be assessed and regularly reviewed within care plans.

3.11 Individuals should be supported to maintain links in their local community which enables cognitive stimulation, mobility, independence and communication.