1. Midlothian Gold Standards Framework Care Homes Step Down Sustainability Project (September 2009 - September 2011) Barbara Stevenson CNS Rhona Moyes CNS

2. Background to Sustainability Project Commenced in March 2007 (18 month project led by J. Hockley, J. Watson and S. Murray from the University of Edinburgh) Seven Care Homes in Midlothian, Primary Health Care Teams and specialist palliative care GSFCH framework

3. Education Key champion appointed in each Care Home Attended facilitative learning course and GSFCH network workshops (Foundations in Palliative Care for Care Homes, Macmillan 2004) Responsible for cascading training down to their own Staff Implementation of systems Supportive palliative care register (ABCD register) Adapted Liverpool Care Pathway (LCP) for the last days of life

4. Project Outcomes Significant improvement in: Care of the dying Control of symptoms Continuity of care Carer support Continued learning Increased confidence in: Communicating with relatives about death and dying Caring for a dying person Use of the ABCD Register with the GP

5. Outcomes cont. Increase in DNACPR status (8% to 71%) Increased explicit decision making in end of life care (4% to 55%) Fewer deaths in hospital (15% to 8%) A reduction of inappropriate hospital admissions (>40%)

6. Key Recommendations Advanced care planning discussed early in the admission –Communication and decision should emphasise the appropriateness of allowing a natural death DNACPR status addressed on admission to a Care Home

7. Recommendations cont. Specialist palliative care support for residents with complex needs The use of symptom assessment tools The adapted Liverpool Care Pathway (LCP) used for all residents for end of life care

8. Recommendations cont. Organised reflection times following a death ( Significant Events Analysis tool) Palliative care education for all Care Home staff Accreditation status of Care Home with GSFCH programme

9. The Step Down Project (September 2009 - September 2011) Support Care Home Managers to: Continue palliative care education Consolidate and embed the GSFCH Framework

10. Step Down Project cont. Education Induction Delivery of Macmillan Foundations in Palliative Care programme Develop communication skills Assist in complex family situations

11. Step Down Project cont. Systems Support staff with the ABCD Register and attend the monthly GP reviews Encourage and support staff to use validated symptom assessment tools and adapted LCP Encourage the use of the Significant Events Analysis

12. Step Down Project cont. Evidence Collate end of life data Collate education programme evaluation and attendance data Support Care Home Managers to develop and gain GSFCH accreditation

13. After death data Jan to June 2010 Total number of deaths - 39 Preferred place of death 36 Place of death CH - 30 H - 9 Inappropriate admissions 0 DNACPR 34 Advanced care planning 38 ePCS 36 (Electronic Palliative Care Summary) LCP 21 Anticipatory prescribing 20 Assessment tools 10 External support (CNS) 2 Bereavement support 36 Significant Event Analysis 15

14. Education Data Jan- Aug 2010

15. Challenges To Date Staffing Loss of key champions Staff turnover Management changes Cultural differences

16. More Challenges Education Delivering educational content for trained and untrained staff Time allocated for education Development of communication skills GSFCH systems for use with younger residents Embedding the use of the significant events analysis

17. ......and finally Difficult but achievable Requires commitment from both sides Involves ongoing education