Working with Care Home Leaders to Support Integration at Place (Sefton)

A case study from My Home Life England and Sefton Council

This short article describes how a group of care and health leaders have developed new ways of working together at place. The people involved have worked together, built new collaborations and created space to build on the positive practice that occurs every day within care homes.

Background and context

In February 2020 we started to get a glimpse of what COVID-19 might mean. By June 2020 we were starting to understand in more detail that the pandemic was having a profound impact on people living and working in care homes, those who loved them and those who work with them. (1)

As the daily wave of requests for information and requirement to act began, Local Authority and NHS commissioners found themselves being asked to work differently with each other and with the care home sector. Sefton Metropolitan Borough Council and its NHS partners were no different. Virtual meetings with long agendas were set up as a way of informing care homes. The agendas were not set by the council or the clinical commissioning groups, they reflected everything that was happening and what they were being asked to do.

During the summer of 2020, My Home Life England (MHLE) started working with the council to build a programme of support for some of the care home leaders working in Sefton. The programme started virtually in early January 2021, built around the 4 evidence informed frameworks (2) that connect the My Home Life movement. Through appreciative inquiry and action learning sets, the experience and expertise of the participants shaped the learning and development of the programme.

MHLE has a track record for supporting care home leadership, delivering transformational change across more than 2,000 care homes in England. Sometimes as an explicit branch of our work in a local area we are invited to broaden our remit to facilitate stronger connections between care homes and the wider community and across health and social care agencies. We were commissioned to do this in Sefton.

Content, Courage and Collaboration

While the programme was running, we were listening to and working with colleagues in the council and wider care and health system to find out what integration meant to them, coming at a time when structural integration was emerging as a theme from the pandemic. This process of discovery was focused on developing opportunities for care home leaders to support, influence and enhance integrated working across the system, agreeing some realistic and practical changes.

It is worth remembering that it is a ‘mainstream and ordinary’ way of working for people who work in public sector commissioning and delivery of care and health services to have a lot of meetings. They may have different perspectives and priorities at times, but they know each other, can work things out together, fall out sometimes and come back together.

Care home leaders, although often connected together through a great local association or linked through a managers’ network, rarely have the time or opportunity to come together to share ideas and celebrate what is working well and what they value about themselves, each other and the work they do.

The reasons for this are complex, varied and nuanced by local circumstance. However, a consistent factor is the breadth and depth in the role of a care home leader. It is multi-faceted and varied. The registered manager role encompasses leadership in areas that many organisations have whole departments to do. On a daily basis the care home leader is asked to behead of operations, quality, information, human resources, finance, strategy, estates, communications and engagement, contracts, hospitality, safeguarding, training and development, communities, and economic growth.

They also act as a leader of people, leader of change and innovation and leader of day-to-day delivery of complex care. They are an expert practitioner in health and social care, advocate, negotiator and mediator, responder to, writer of and implementer of all policies and procedures affecting registered care homes. They interpret and work with operational policies, procedures and guidelines relating to the multiple agencies that they are engaged with. They area stock taker, equipment checker and health and safety lead. They are the first point of contact for emergencies, out of hours issues, relatives, friends and are the external representative for social and health care meetings.

Commissioning systems for care homes, by definition, create competition, making it hard for people working in care homes to share innovation and positive practice. So, in the time care leaders do have to come together, they often focus on the problems they have in common or the inequalities they feel within the care and health system. For people participating in a My Home Life England programme there is usually:

“the natural creation of a supportive community of managers.” (3) / “I have seen other people on the programme gain in confidence and that has made me feel good, as I hope I have been part of that.” / “I learned that there are many different ways of managing things, and this encouraged me to try out things I wouldn’t have done naturally.” (4)

In Sefton, having a bedrock of collaboration and connections in place, combined with growing confidence in their leadership skills, meant the MHLE participants grabbed the opportunity to contribute to Sefton’s thinking about integration, and the impact it could have to promote quality of life for people who live, die, work in and visit care homes in the area.

In many ways, care homes form little hubs of integration every day. People who live and work in care homes connect the roles of NHS and Local Authority commissioning, whether that’s through debates about funding, supporting positive discharge from hospital or focusing on a strategy for people who have dementia and their families, friends and partners. They also connect the expertise of people working in the care home with that of other health and social care professionals, including general practice, social work, nursing and allied health professionals.

Through discussions with commissioning leaders and the care home leaders about areas we might focus on together, a common agenda emerged to explore what the potential of ‘integration’ might mean in a practical way, what was working well and what people could do more of together to improve everyone’s experience. The title ‘Making It Real’, was used for a summit in which care home leaders worked with the wider system to take the statements of policy and strategy, distilling them into what might feel different and what they could imagine for the future for people living in care homes that integration could support and enhance.

The term ‘summit’ emerged as the airwaves were full of the ‘COP26 summit’ in Glasgow as we were finalising our joint event. Those planning the event liked the definitions we found:

‘Any gathering of people who care deeply about the same topic’ / ‘A meeting or conference to conduct diplomatic negotiations’ / ‘A good summit generates new thinking and many next steps. A successful one can produce a range of outcomes’ / ‘A summit is a strategic conversation that brings different perspectives within a system together to talk about the big picture and the big questions’

The priority areas identified by the care home leaders were also priorities in the care home strategy including:

Developing new ways of working together (a move from consultation to involvement)
The enhanced health in care homes framework and discharge planning from hospital
Using data and information provided by or collected about care homes in a more integrated way for everyone’s benefit

On the day, the summit felt different. The care home leaders were the ‘keynote speakers’, setting the scene. People made an ‘in person connection’ sometimes for the first time and connected with each other. Agreeing ‘ways of working together’ set the tone and style for the rest of our time together.

Everyone in the room engaged and actively listened to each other, a lot of assumptions came to light and some emotional connections were made. For many delegates who attended, spending time listening to the complexity of a care home leader’s role helped them to understand why responding to emails asking for the same (or slightly) different information from 4 different people might not always be a priority.

For care home leaders, it was enlightening to meet people from the local authority or the NHS and listen to the ideas and the commitment they had to support quality of life for people living and working in care homes. It was a very different experience to listening to them speak on a Teams meeting about another piece of guidance or a request to provide information. This time there was a common sense of purpose. Throughout the summit participants focused on being curious, what was real and possible and considered the perspectives of others, building on what was already working well. Delegates made clear promises to each other with a ‘what will happen next and who will do that’ focus.

While not all of the actions agreed on the day may have been followed through, there has been an explicit and real change in the main forum that connects Local Authority /NHS and care home leaders together in Sefton. Renamed the ‘Care Home Strategic Partnership’, the terms of reference have changed substantially with a focus on collaboration, learning together, celebrating positive practice and sharing of information and experience. The partnership is co-chaired by one of the care home leaders who attended the summit and attendance from care homes is developing again. Agendas are co-produced.

People often leave events /workshops or summits with sense that it was a nice day out, but nothing will really change. That’s not the case in Sefton. The word transformational is probably overused and like many words, means different things to different people, but this summit has led to a step change and the beginning of a new relationship between care homes and the wider system in Sefton. ‘It does feel different now’ (4)

So, what helped make this happen?

Clearly it started with a strong commitment from those within the council and wider system partners to support quality of life for people who live, work in and visit care homes. Their investment in the MHLE leadership programme helped support the participants to gain in confidence in their leadership, to connect as a team and develop the professional confidence to engage with wider agencies.

Six months on, the Care Home Strategic Partnership continues to develop and evolve, supported as a collaborative structure with ideas and developments brought by care home managers as well as the wider system.

“The offer from My Home Life England has helped to empower and equip Care Home Managers to face the challenge of delivering high quality effective care and support in the current climate and it’s been amazing to see the journey they have been on, and as part of our integrated Care Home Strategy delivery we hope to continue to build on this in the future.” (5)

– Author: Steph Thompson, My Home Life England, with the involvement of Heather Weekes (new co-chair of the Care Home Strategic Partnership), Neil Watson and Eleanor Moulton (Sefton Metropolitan Borough Council) and Mandy Hetherton, My Home Life England Associate.

Health and Social Care Committee ‘lessons learnt to date’ October 21
My Home Life : Developing Best Practice Together (NCHR&D Forum 2007), Focusing on Relationships (Reference – Nolan, M., Brown, J., Davies, S., Nolan, J., and J. Keady. (2006). The Senses Framework: Improving care for older people through a relationship-centred approach. University of Sheffield.), Being Appreciative (Reed, J (2007) Appreciative Inquiry. Research for Change, London:) Caring Conversations (Dewar B and Nolan M (2013) Caring about caring: Developing a model to implement compassionate relationship centred care in an older people care setting, International Journal of Nursing Studies, 50(9):1247-58)
My Home Life England Leadership Support Programme: Evaluation (Natalie Sanford and Janet Anderson September 2021)
Direct quotes from participants on the Sefton Leadership Support and Development Programme 2020-2021
Eleanor Moulton, Sefton Council Integrated Social Care and Health Manager