Safety culture in care homes is a topic that has not been extensively researched. The review highlights a number of key gaps in the evidence base, which future research into safety culture in care home should attempt to address.

The project leads are looking for suggestions from colleagues who may have worked with domiciliary carers and tested ideas around deterioration. Any advice on measures and impact and data sources is also encouraged.

It recommends that the Government and NHS:

• Urgently increase investment in the District Nursing service to give it the capacity and capability to meet the challenges of the 21st century
• Maintain the post-qualifying District Nurse Specialist Practice Qualification (DNSPQ), which develops DNs’ professional growth and enhances their clinical skills
• Develop a strategy to expand commissioners’, providers’ and the public’s understanding and knowledge of the District Nurse role, enabling them to recognise the added value they bring to the local health economy and particularly to the wider Health and Social Care system
• Develop a standardised data collection system and data set, collecting meaningful data that recognises value for money, promoting a strong economic case for investment in the District Nursing service
• Develop a standardised approach to the assessment of quality, to measure District Nurse effectiveness in England, providing reliable data, enabling innovation and cost-effective practice to be recognised and disseminated
• Explore the co-location of District Nursing teams within Primary Care Networks to provide personalised care, continuity of care and enhanced working relationships across primary and community care teams.

• Analysis of a national linked dataset identifying permanent care home residents aged 65 and older and their hospital found that on average during 2016/17 care home residents went to A&E 0.98 times and were admitted as an emergency 0.70 times.
• Emergency admissions were found to be particularly high in residential care homes compared with nursing care homes.
• A large number of these emergency admissions may be avoidable: 41% were for conditions that are potentially manageable, treatable or preventable outside of a hospital setting, or that could have been caused by poor care or neglect.
• Four evaluations of initiatives to improve health and care in care homes carried out by the Improvement Analytics Unit (IAU) in Rushcliffe, Sutton, Wakefield and Nottingham City show reductions in some measures of emergency hospital use for residents who received enhanced support.
• There are key learnings from these IAU evaluations, including a greater potential to reduce the need for emergency admissions and A&E attendance in residential care homes and the benefit of coproduction between health care professionals and care homes.

• To ascertain the number of people presenting with lower leg ulceration.
• To assess the standard of care provided to people with lower leg ulceration.
• To assess the provision and uptake of training amongst health care professionals.
• To determine if health and social care trusts have policies and documentation in place for the treatment of lower leg ulceration.
• To provide information to assist in establishing regional best practice guideline and care standards for the delivery of lower leg ulceration in Northern Ireland.

Providers of care in care homes should:

• offer staff training regarding recognition of cognitive states including delirium, supporting meaningful activity, end of life care
• have clear processes in place for access to healthcare
• provide information regarding dementia diagnosis and prognosis
• ensure advance care planning takes place
• offer opportunities to take part in meaningful activity.

Commissioners of old peoples’ services should:

• support the delivery of Comprehensive Geriatric Assessment (CGA)
• ensure broad involvement of stakeholders, including care home providers and patients or representatives to ensure services are tailored
• ensure service specifications include interventions such as cognitive reframing
• ensure services are available and coordinated in relation to end of life care
• ensure stable leadership and clear strategy of overall system
• use of specific models of care can have benefit
• do not neglect long term population
• strategies to support healthy ageing and prevent increasing disease burden
• support the development of relationships between care homes and service providers, and ensure clear lines of responsibility
• commission targeted training for staff
• ensure evaluation and monitoring is fed back for continuous improvement.