Working as a nurse in a care home means many things. Definitions of home vary and are very individual. Here are two broad definitions of home: "the place where one lives permanently, especially as a member of a family or household"; and "an institution for people needing professional care or supervision".

Of course living in a care home is both, the person's permanent residence where they should feel joy and comfort, safe and in control, but additionally where they receive high quality person-centred care that meets their needs.

We know that many people living in care homes have some of the most complex needs of anyone in our society and this includes the need for skilled informed nursing care. We should be proud to say we are nurses and articulate the way in which evidence based nursing care improves quality of life, prevents deterioration and, when the time comes, supports people at the end of life.

The nurse uses clinical skills and evidence based knowledge to assess the resident's needs throughout the day. This might be in general conversations or whilst providing a nursing intervention such as giving medication; alternatively it might be whilst reviewing the residents care plan with them. The "gold standard" of assessment is Comprehensive older age assessment.

Following assessment the nurse will work with the resident and families to ensure the plan of care meets their needs and can guide other staff to deliver the care the person requires. Care plans need to be dynamic and highly personalised to be effective. The need to manage risk but not be risk adverse, the focus should be a balance of risks versus benefits.

Comprehensive geriatric assessment - Comprehensive older age assessment

Comprehensive geriatric assessment (CGA) comprises interdisciplinary and interagency working which places the patient and their supporters at the heart of care. The holistic nature of CGA covering physical, psychological, functional, social and environmental needs of older people may be an encumbrance if not managed effectively. This is particularly true within the community setting where services are affected by local geography and availability.

The assessment process requires co-ordination to ensure that the experience is positive for both the patient and their families. As older people's needs are frequently complex and always unique, those co-ordinating the process must display advanced communication skills in addition to their clinical knowledge to ensure purposeful and timely assessment.

Co-ordinating CGA can be undertaken by any member of the health and social care team but is best carried out by someone the patient and their family trusts to enable open and sensitive discussions.

Nurses are well placed to manage the complexity of assessment in an efficient way, drawing together the different strands to co-ordinate a personalised treatment plan in which the patient and their family share their aspirations and choices. Nurses have a duty to act as patient advocate, empowering people to make shared decisions; these roles are set out within the Nursing and Midwifery Council (NMC) Code for nurses and midwives.

Frequently commissioned for its ability to provide person-centred, cost effective, accessible care, comprehensive older age assessment is congruent with many models of nursing assessment and makes nurses very effective in a co-ordinator role.

Further resources

• NMC. The Code
• NMC. Guidance on the professional duty of candour
• RCN. Raising concerns

Jane and Eileen - planning care

It is Jane and Eileen's anniversary. Eileen tells Sue she would like to take Jane out for some supper and then go to listen to a local operatic evening. Tentatively she also suggests Jane might stay the night at Eileen's. Sue is delighted that Eileen would like to do something special on their anniversary and says she will do everything she can to help. She sets time aside to talk with Jane and Eileen and they are both very keen to go out. Eileen recognises that there needs to be extra preparation for the evening out and they agree a plan, including transport, medication, a short clinical summary in case Jane experiences a seizure and contact numbers should they need help. Sue arranges for Eileen to come in one evening before their anniversary to ensure Eileen is able to support Jane's mobility and manage her medication.

Providing information and advice as well as ensuring family members have the skills to keep a resident safe are an essential part of good nursing care.

Sue then speaks with Jane and Eileen about them staying at Eileen's together. Sue's concerns relate to Jane's mental capacity and she is aware of the legislation around consent to sexual relations, having recently read the RCN's document. Eileen is also concerned about her small home and Jane's safety overnight and they agree that Eileen will come back with Jane and spend the night with Jane at Red Cedars.

Care planning overview

Care planning is a personalised means of supporting the resident, their families and professionals to direct the care received in order to meet their individual needs. Care plans are created following comprehensive assessment, which may include input from a number of professionals.

The majority of residents will be living with multiple pathology and complexity, and frequently experience cognitive impairment. In order to meet their nursing and care needs they require personalised, tailored care planning which recognises:

• the best available clinical evidence
• the personal wishes of the patients/family usually set out as goals of the care
• the patient’s/ family role in self care or self management
• the most appropriate interventions: physical, pharmacological, psychological and educational
• ceilings of care ( the point at which care should not be escalated above)
• proactive management of deterioration (such as acute infection or electrolyte imbalance)
• treatments that have been unsuccessful/unwanted.

The tenets of self care mean that care plans are formed in conjunction with patient/family and other professionals/agencies and draw on the following skills:

• effective /advanced communication
• support /education to make informed choices
• the development of skills in self care
• management of risk.

Care plans should be held by the patient/family with mechanisms in place to ensure that all members of the health and social care team across all settings can access the plan. There are some widely used healthcare systems that can carry diagnosis based care plans within the community/primary care.

Further resources

• GOV.UK. Improving care for people with long term conditions (PDF)

Evaluating care/Managing risk

Following their anniversary Sue and Rachel ask how the evening went for Jane and Eileen and are delighted with the happy response from both who have decided it should be a regular event. Sue and Danilo speak with the rest of the team at their staff meeting to ensure everyone is aware of the arrangements and that the staff have an opportunity to discuss any risks of concerns. Some members of staff are concerned that Eileen staying may pose practical difficulties as they monitor Jane regularly during the night, other staff are concerned that it might be a "safeguarding" issue as Jane has cognitive impairment.

Sue and Danilo work through these concerns using both the RCN led Safeguarding Competency framework and the publication on sexual intimacy (to be published October 2018) to allow staff to discuss their concerns. Both Sue and Danilo acknowledge they will need to monitor the situation but will do this as sensitively as possible. They arrange for the staff to have further training on this area of practice and have informal discussions with their local regulator to ensure they are demonstrating best practice.

Further resources

• RCN. Caring for lesbian, gay, bisexual or trans clients or patients. Guide for nurses and health care support workers on next of kin issues

Below you will find some further links to resources.

• RCN. Neuroscience Forum
• RCN. Bladder and Bowel Learning Resource
• RCN. Medicines management support and guidance
• RCN. Overview of eHealth
• RCN. Forums and networks list. Join one or more of our forums and networks and make a vital contribution to the professional voice of the RCN.