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					Pan Birmingham
Palliative Care Network

Pan Birmingham, Palliative Care Network Care Homes Service Improvement Programme (SIP) for Care at the End of Life
January 2007
Introduction The Pan Birmingham Palliative Care Network (PBPCN) aims to deliver best quality end of life care in every care setting within its area, this being South Staffordshire, Birmingham, Solihull and Sandwell. This of course includes nursing and residential homes within this area. The aim of the SIP is to: 1. To improve end of life care for all residents/patients in Residential and Nursing Homes in the Pan Birmingham Palliative Network area over the next 2 years. 2. To enable residents to stay at home, in their Residential and Nursing Homes at the end of life. 3. To deliver, in this particular setting the vision and aim of the Pan Birmingham Palliative Care Network Strategy, Living Well to the End of Life (see website, or the Care homes SIP pack). Vision The Pan Birmingham Palliative Care Network aims to move towards a situation where any patient, from diagnosis to the advanced non-curative stage of disease, in any setting at any stage, lives well and dies well, in the place and in the manner of their choosing. The thrust of this strategy will be on improving care to the level of the best, with a combined health and social care approach. Specialist teams working with District Nurses, General Practitioners, social care, the community, and voluntary organisations, working to ensure that the Network population receives high quality reliable care at the end of life, and retains control, choice and dignity. To facilitate this aim, the Network organisations will endeavour to support staff who will be delivering the care in the most effective way possible. We will call this whole system Living Well to the End of Life.

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The Pan Birmingham Palliative Care Network envisages a service provision across all its constituent Primary Care Trusts which reflects best clinical practice, delivered by supported, appropriately skilled professionals with access to all required therapeutic drug, equipment and social support when required, in the patient’s chosen place of care. Partner organisations and local communities will be encouraged to join our Campaign to Live Well to the End of Life, declaring our joint intent and actions, set out in a charter format, with 4 levels of activity, as set out below; Level 1 sign up and commitment from Home-Trust/organisation Board, and nomination of a lead. Implementation of care delivery frameworks, including supportive care for staff. Use of Network quality assurance tools and action on outcomes. Organisational excellence in end of life care through innovation


Level 2 -

Level 3 -

Level 4 •

The Network envisages a service, which is centred to the patient and carer needs, and which responds in a consistently high quality, but individual way. The utmost priority will be to involve and inform the patient and carer in all the steps along the journey. This service will be equitable in terms of access to services, place of delivery, quality and timely delivery of service. Patients and carers must feel complete confidence in service delivery quality in any setting to enable real choice of place of death. . Patients and carers must feel supported by the healthcare system along the journey from diagnosis to recovery or death and bereavement.

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How are we going to deliver this? It is important to acknowledge that very often, Care Homes feel excluded from service improvement initiatives and consultation with public bodies, and that with the already robust mechanisms in place for inspection, this strategy aims to put forward an ethos and approach which can only be effectively measured by the monitoring of the patient, carer and staff experience. Even then, this information may often be divergent, but on the whole, organizationally, a picture of quality standard delivered will emerge. There are many caring staff working in residential and nursing homes, and this initiative does not discriminate by qualification or experience, nor by taking up too much time. In fact, the improvement of co ordination of care and relationships with other agencies will save time overall. It may be that the most appropriate end of life lead for the home is a health care assistant, or the home secretary. It will be a fulfilling and inspiring task to undertake. The following standards and implementation plans will tie in with the overall Network Strategy Implementation plan, to ensure that all strands of service delivery across all sectors, are improved in order to support Homes in this initiative. In other words, as a care home, you are not expected to be able to deliver this as a stand alone organization, but as part of a healthcare team, working together in your area. Implementation plan Care Homes , both Nursing and Residential , will be encouraged to join our Campaign declaring our joint intent and actions, set out in a charter format, with four levels of activity, as set out below: The plan will involve four levels of activity within the sector, with nominated leads for the work. Level 1 Sign up the Network Service Improvement programme and commitment from Home Owner/Trust/Organisation Board, and nomination of a lead coordinator within the home. Implementation of care delivery frameworks, Develop links with the Buddy Specialist palliative care team and relevant Palliative Partnership Groups. Use of Network quality assurance tools, and action on outcomes Organisational excellence in end of life care through innovation.

Level 2

Level 3 . Level 4

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Implementation Plan What the Network will do for you • • • Develop a baseline data set for care homes, helping PCTs to ensure GP cover for care homes where there is inadequate or confusing cover Develop a Care Homes support network in response to consultation on needs of Care Homes. Develop a generic toolkit of resources for all care homes to include for example: Newsletter Equipment store and process to access Syringe Driver guidelines Palliative Care reference books Other literature/resources as available eg DVDs and o Information on local education available and contact details o Palliative Care Network directory o o o o o • • • • • •


Develop a roll out plan for care home improvements with the PCT facilitators, so care homes have contact with PCT facilitators. Ensure access to education provided by usual specialist palliative care providers eg from local hospices/CNS teams. Inform Care Homes of SIP activity in primary care teams and other Network End of Life care activities Provide you with pharmacological advice and access, 24 hours. In addition training for staff from our network pharmacist in a three-year rolling programme. Network assistance towards service innovation. We will be available by phone or email to help you with your SIP.

Your Care home SIP – What YOU need to do • Sign up to the Network SIP via email or registering on the phone with Kimberley Treacy on 0121 245 2552 – you will automatically join the campaign roll call on our website, and we will give you a campaign certificate for the Home. Arrange for us to come and speak to you and your staff, it will only take 30 minutes, and we will bring along your pack! Set up a register of patients who you think are nearing the last few weeks of life, and starting them on the supportive care pathway. Let their GP know they are on the list, and ask for their help in ensuring they can die at home. Let your GP and district nurse teams know what you are doing (yes, even if you are a nursing home! cup of tea works wonders again…)

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Call your nearest hospice or specialist team (we will let you know who they are) and ask them over for a cup of tea. Then ask them if they would help you. I think they would be only too pleased. Find out where the nearest network pharmacy is. Have a supportive care board with the specialist pharmacists phone number, the palliative care team’s 24-hour number, and other important information, so new staff, and night staff know where to go for help. Start learning to trust your own skills, you know your residents often better than anyone else, you are their advocate, don’t be afraid to contribute at this really important time. We will give you access to educational DVDs, on site education, booklets on symptom control to help you here, not forgetting telephone access to specialist advice. Hang up your certificate of excellence in End of Life Care with pride, and talk to your residents and families about the steps you are taking to make sure your residents live well to the end of life. Think of how you would want your last weeks of life to be – ask your staff you think about this at a staff meeting… use some of the ideas that come from this conversation. Please tell us your stories, they are very important in encouraging others.

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How do you know your SIP is making a difference? • • You will see a reduction in hospital admissions for your residents at the end of life, we will help you to monitor this, and present this for your inspections. You will notice that your staff are more confident and committed to care at this very personal time. Again, we can help you to record this in a presentation format.

We hope you would like to join us on our campaign. It won’t cost you anything, and we all have much to gain, so we look forward to hearing from you soon. Melanie Young, Zoeta Brown Tel: 0121 245 2552 Email; or

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