Bridging the Gap: A Place Called Home

Marianne Walmsley, Head of Quality, & Jane Roberts, Primary Strategy Lead Nurse

Betsi Cadwaladr University Health Board


To ensure a safer, equitable and sustainable care delivery for the needs of residents in care homes. We have identified the need for a new Multi-Disciplinary (MDT) model of support, monitoring and development within care homes across North Wales.

Over the past two years there has been a consistent increase in the number of nursing homes being put under formal escalating concerns, closing due to financial or quality issues as well as a number of homes having increasing quality and safeguarding issues. A recent audit has also shown a high level of admissions form nursing homes that could have been potentially prevented.

A solution to this is for the MDT to support the health and wellbeing of patients by proactively reviewing and initiating new treatment regimes. To enhance the competencies and skills of clinical staff working in the homes by providing training, education and clinical skills. To ensure implementation of evidence based practice delivery by undertaking quality monitoring and structured leadership.


The MDT consisted of ANP, pharmacist, physiotherapist, speech & language, dietetics, practice development nurses and occupational therapists. To influence key health board senior managers data has been collected regarding, admissions, quality concerns, WAST data and district nursing visits, POVA and safeguarding. This data was then used to inform the selection of homes requiring further support and to test the model.

A pilot within four care homes across North Wales is currently being implemented. Funding has been secured from intermediate care funds across two areas.


Patient & Safety experience:

  • Ensure patients are treated with dignity and respect and are properly consulted regarding their care and changes to their treatment plan;

  • Development and promotion of patient-centred care delivered within the patients home; and,

  • Prevention of patient deterioration and improvement of quality of life and increase in delivery of evidence-based safe and effective care.


  • Increased competencies of staff;

  • Access to education and education; and, âAccess to specialist support, advice and leadership.

Efficiency benefits:

  • Contribute to reduction in A/E attendance, hospital admissions and enable earlier discharge to the home;

  • Provide appropriate information, knowledge and support for care home staff in order to enable them to identify early need for intervention; and,

  • Cost savings in medication and consumables.

Regulatory benefits:

  • Reduction in escalation concerns, safeguarding incidents and complaints;

  • Reduction of loss of beds from placements; and âReduction in home closures.


  • The project supports Prudent Healthcare by encouraging collaboration and co -production within care homes , primary, community and secondary care. By sharing the skills and resource of health board staff

  • With the care homes it ensures equitable and consistent practice. The model will ensure the patient is seen by the most appropriate MDT professional rather than requiring an acute admission or GP visit.

Part of cohort Bevan Exemplar Projects 2016-17