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The aim of this work is to reduce avoidable harm, enhance clinical outcomes and improve the experience of deteriorating individuals in the community.

To achieve this, focus will be placed on improving recognition (softer signs and NEWS where appropriate), response and communication by domiciliary carers.  This approach is currently being trialled in care homes building on previous learning from patient safety collaboratives (PSC) and a validated tool successfully used with carers.   Y&H PSC has already a programme of work jointly with Vale of York CCG and Care homes; this will strengthen existing work.   Other PSC’s across the country (e.g. Wessex) have similar work in progress, learning can be shared nationally.

Working in care homes has provided  opportunity to understand barriers and enablers to recognition, response and clear communication, focusing on the needs of residents and staff caring for them.   A significant number of individuals receive care at home,  domiciliary care in the UK (2014/15) was provided to 873,500 people, delivered by 629,400 employed carers, equating to 318 million hours, costing 4.6 billion (United kingdom Homecare association 2016). It is also estimated that 7 million people are informal carers,  1 in 10 people (Carers Trust, 2018).   These carers are pivotal in early recognition of changes in an individual’s condition.

Following on from learning through the initial programme of work in Care Homes, it is a logical progression to engage the domiciliary setting.  This is where many individuals with complex needs would benefit from better recognition  and response across pathways of care improving quality, reduce harm and avoidable hospital admissions.

This project will focus on helping domiciliary care staff, carers and residents to look out for signs of deterioration (softer signs; Stop and Watch Tool) so action can be taken earlier. To improve communication and promote a safety culture in the care team through testing tools such as virtual safety huddles and clear communication tools (SBAR) helping responders assess the situation and take appropriate timely action. The project targets both improving recognition of deterioration (promoting the use of NEWS where possible/ appropriate plus softer signs where not) and developing improvements to structured communication to help ensure an appropriate response.

 The model for improvement will be used to test and implement interventions in domiciliary practice.   Initial testing for proof of concept is being trialled in a number of  care homes (a mix of Nursing, and residential) working with key stakeholders (care home staff, YAS, GPs, Community Nursing staff, residents, carers, ED’s and CCG’s).

Case studies will be developed and the work evaluated for impact.  This will be supported by developing a community of practice between care homes and domiciliary carers to share good practice and address barriers to change.


Key outcomes:

Resident –

improved outcomes through earlier recognition.

Improve adherence to preferred place of treatment/death.

Improved resident satisfaction satisfaction/ QoL score

Domiciliary Carers –

 improved levels of competence and confidence of staff to recognise deterioration and act accordingly.

Improved adherence of individuals wishes re end of life care.

GP’s , YAS, Health Care professional teams including domiciliary agency–

improved accuracy and depth of information being communicated leading to improved appropriateness of response.

Hospital –

Reduce unnecessary ED attendances and unplanned admissions.

Measurement Plan will include the following;

Outcome measures:

·         Hospital: ED attendances and unplanned admissions

·         YAS: Conveyance rates and outcomes

·         Residents preferred place of death             

Process measures include:

·         YAS – calls to 111/999 (volume/ quality)

·         GP’s – calls to GP’s (response/ quality)

·         Care staff: Training competency/rates in recognition

                                    Response calls using structured communication

                                      Embedded  safety huddles focussing on deterioration

Balancing measure:

·         GP/Community Teams – Call out rates

A culture survey will be given to care staff at the start of the project and then repeated once interventions are embedded, to show any changes to the key safety culture domains.   In addition, a simple survey will be used to evaluate confidence by residents and informal carers in their domiciliary care provider relating to recognition and appropriate response following introduction and use of the tools developed.

Responders will  be surveyed to ascertain if there has been a change in the quality of communication being received and the ability to accurately respond.

The learning from this work would be transferable to other domiciliary care settings in other areas.

Learning will be shared to encourage spread once impact is seen and sustainable. Initial stakeholders’ event will link with a Community of practice so the project progress can be communicated and shared with other care agencies in readiness for adoption once tools are available. It is envisaged support for spread to other areas will be provided by the CCG’s care home networks.  The Q community could be an invaluable channel for communication and sharing of learning.

How you can contribute

  • It would be great to have any suggestions from colleagues who may have worked with domiciliary carers and tested ideas around deterioration.
  • Any advice on measures and impact and data sources would be helpful.

Reviewer feedback

This is a great project because…

This is a good opportunity to build on safety models that have been shown to work well and try to apply them to home care, engaging a group of staff who may get relatively little attention and who's status in the system could make structured communication methods helpful. While challenging to implement, if successful this could impact on quality of care and reduce unnecessary demand on other services.

By the time of the event we encourage the project team to think more about…

Further develop your plans for co-developing this with domiciliary staffing.  Stay alert to the potential that approaches developed in other settings may need substantial re-work to achieve outcomes in a different setting. Consider how you will build two way links with others in the Q community to share learning.


  1. Guest

    Adrian Scaife 1 year, 2 months ago

    Hello all,

    I am interested in the use soft signs in scenarios where NEWS is not practical. Were the outcomes and learning from this project published anywhere?

    Many thanks Adrian

  2. Guest

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    Domiciliary care service


  5. At Oxford Patient Safety Collaborative we would certainly agree with the reviewer's comments re co-design as well as many of the others who have commented on the project.
    Similar to WE AHSN we have created short videos, simple tools to copy and train the trainer sessions for our multi-award winning hydration project. Also involving residents (with capacity) and family and making it fun! More information here:

  6. Guest

    caroline maries-tillott 2 years, 9 months ago

    I am leading a QI programme (SPACE) sponsored by the WMAHSN  in nursing homes which is aims to up-skill care home staff with QI tools and techniques.   Improving recognition and escalation has been highlighted as an areas for improvement  and a few care homes care staff are doing some small scale tests of change (PDSA) with the Stop and Watch tool. Initial feedback is positive-  minor amends  have been suggested  and  retrial . We have added a few additional key soft sign prompts into the tool- breathing and urine out put which  have proved to be reflective of deterioration and appear in the Interserve list produced by Wessex

  7. Brilliant to have a project supporting Domicillary Care and if we can help in any way please let me know.

    Would be more than happy to link you in with NELFT team (Geraldine Rodgers) who are currently adapting the Significant 7 Training for Care Home teams in partnership with Waltham Forest CCG to support both Domicillary Care workers. Sarah keep an eye out on twitter for our outputs from yesterday’s session, Geraldine is definitely someone that you should connect with if you haven’t already!

    Have you also been in touch with your local Skills for Care Manager? In one of our London boroughs they have set up a Domicillary Care Clinical Reference Group to support development of ideas locally. Again would be more than happy to make an introduction if this is something that you think would be helpful.

    Good Luck!



  8. If you’re interested in NHS Communities of Practice (CoPs), please join Q’s CoPs special interest group’s Zoom call on 13 July (1pm) to hear about the evaluation of the Health Innovation Network’s CoPs – their challenges and their journey.
    ** More info/to register:  **
    The call will be an opportunity to glean advice and insights to help this project too.

  9. A really good idea. In some situations as patients deteriorate, they are at risk of harm from certain medicines (e.g. medicines that cause acute kidney injury). I wonder if you have considered linking this work to the THINK KIDNEYS work ( i.e. enabling care home staff to withhold certain medicines once a resident begins to become ill. This will reduce risk of AKI and hospital admissions.

    This may be outside the scope of your project but worth linking in with your pharmacy teams? Vale of York are the lead CCG for the NHS England Medicines Optimisation in Care Homes programme for the STP - happy to connect you.

    Good luck.

    1. Thank you, absolutely this needs to be linked to action so if a change is noticed what can the carers act on to prevent deterioration, escalate appropriately but also think fluids etc.  happy to link to progress.

  10. Guest

    Elizabeth Bradbury 2 years, 11 months ago

    Sounds great and a really valuable area to work in and develop. We recognize a real gap in supporting people at home and AQuA may be interested in joining a virtual community to discuss your learning if you are successful. We haven't worked on this specific topic but have done work on the deteriorating patient, sepsis in out of hospital settings etc. Have you thought about aligning this work with the NEWS2 tool as a single common assessment across all health and care settings  incl. home would be wonderful? Good luck!

  11. Hi -- we've done some work upskilling staff in care homes and support workers in community team (Karen Gleave, Q member led on this and has lots of experience in this area). The outputs including a toolkit with our learning and a video for care home workers on SBAR is available at which you are very welcome to use.

    1. Guest

      Many thanks for this!

  12. Great idea, we have done quite a lot of work with Domiciliary Care providers around up skilling care staff and found that a train the trainer model worked best, when delivering training direct to care staff we had very low attendance rates, whereas pitching the training at organisations in house trainers or seniors responsible for training worked better with many incorporating what they learnt into their induction and refresher training programme.  We gave them a training kit of slides, delivery notes and any example equipment they could use when delivering the training.  Quick read guides and tools work best as care staff have little time to read or complete lots of paperwork.  We also asked the Dom Care agencies the best times to hold training sessions and afternoons were preferred.   Hope that helps, kind regards Lesley

    1. Guest

      Thank you.  Your observations are very similar to the learning I have found from implementing react to red in the social care setting.  The real advantage with trialling in this particular company is that they have their own training centre and so an excellent platform to start, the local GPs are also very supportive of the local care homes in the area they associate with.

    2. Guest

      Thank you, yes there is an agency who we work closely with, they have 120 staff.  Discussions have taken place and tools drafted to test.  The domiciliary care group are really supportive and want to get on with preliminary pdsa of the tools which is fantastic.  The company have a plan for how we could capture all the staff and they also have an internal training department who want to help facilitate.

    3. I may shamelessly 'borrow' your approach for any future projects we are undertaking with dom care :)

  13. This sounds like a great idea but I'm not clear how you plan to engage and upskill the domiciliary care staff? Have you identified interested agencies? Are you planning to pay them for releasing their staff to attend training? Hope these comments are helpful as our experience has taught as that the domiciliary care market is difficult to engage with.

    1. Hi


      I have linked with a domiciliary care agency who are engaged and have 120 staff who are collaborating to inform on how they think the tool would work in their setting.  the team are very supportive and keen to pdsa.

  14. The hospice movement may have done some work in this area. Regards Tom

  15. Thank you.  It would be great to explore that element through this work.  I would like to encourage participation by residents and their carers/ significant others.

    1. Sarah, Have a look at the Community Support Project page and the comment from Paul McArdle. Maybe your project and the Community Support project could collaborate in some way if selected for funding. Regards Tom

  16. Hi. This looks like a very valid project. Do you also have a PSM programme? It is also important that patients following self management techniques are also able to recognise health deterioration at an early stage. Regards Tom

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