1. Relationship Activated Care: The 360 Standard Framework Defining and Transforming Care Cultures
Patricia Duff OBE, MSc, BA, RN, RM, PGCEA
Rosemary Hurtley MSc, Dip COT, FRSA
Using measurable outcome standards to exemplify and protect Human Rights in care settings
The 360 SF began as Pat’s brainchild who set out the principles and proposed
framework
in the late 1990’s for care homes. At it’s heart is a range of themes focused
on residents,
staff and relatives (relationship triangle)
At the turn of the millennium Pat began her collaboration with Rosemary Hurtley
to turn the 360 SF from principle and framework into practical tools for delivering
relationship activated person focused care.
Since then the collaboration has resulted in a range of flexible products and services
that help managers and staff adopt the 360 SF
Rosemary Hurtley MSc, Dip COT, FRSA
Royal College of Medicine, Summer School 2013 1 1

2. 360 Forward provides : Diagnostic assessment
Consultancy, education, coaching & training services
Working with managers and staff at all levels
Health and social care
Our aim is to establish dynamic, sustainable person centred cultures in their organisations in line with the philosophy and principles of The 360 Standard Framework.
360 Forward promotes and supports the fundamental tenet that:
positive relationships between the person, their friends and family and health and social care professionals …..
….. is a defining and necessary characteristic of good care in all health and social care settings
The 360 SF began as Pat’s brainchild who set out the principles and proposed framework in the late 1990’s for care homes. At it’s heart is a range of themes focused on residents, staff and relatives (relationship triangle)
At the turn of millennium Pat began her collaboration with Rosemary Hurtley to turn the 360 SF from principle and framework into practical tools for delivering relationship activated person focused care.
Since then the collaboration has resulted in a range of flexible products and services that help managers and staff adopt the 360 SF
The work enshrines Human Rights, issues around privacy, and exemplification of conceptual issues - dignity, compassion, being treated with respect and kindness and to feel included and understood in meaningful relationships in the community in which they live or residing.
Care settings should be viewed as communities in which positive relationships between and among the cared for person, their relatives and staff are essential characteristics of good care.
We realised that it would be possible to measure culture based on evidence, as the basis for continuous improvement taken from the perspective of residents, staff and relatives (relationship triangle) starting from first principles. Combining our MSc theses and literature search for residents.
Highlighting learning needs for sector in leadership and management and practice development
 We have 50 years of combined nursing and therapy experience
Patricia Duff OBE, MSc, BA, RN, RM, PGCEA Rosemary Hurtley MSc, Dip COT, FRSA 2 2

3. What is the 360 Standard Framework?
A diagnostic assessment framework that shows care organisations how to establish and maintain person-centred cultures from the perspective of the cared for person, their families and carers
An outcomes based practice development framework for achieving continuous improvement
The 360 Standard Framework is a quality improvement (change management) framework born out of the desire to improve the quality of care for older people, the experience of visiting family members and staff at work. It comprises three sets of interdependent outcome standards, which together constitute a level of person centred practice as defined by the resident, the staff and the relatives.
A key feature of this methodology is that it is diagnostic. It not only identifies what is happening in the care home/care setting but also seeks to elicit why it is happening and prompts action on findings: it enables the analysis of options for resolving issues and the opportunity to select the best known practice increasingly evidence based practice for achieving improvements.
It can be used at all levels of organisation and practice to identify performance outcomes and ongoing development priorities over time in meeting the requirements of the 360 SF. As such it is both a triad of outcome standards and an assessment framework.
Using measurable outcome standards to exemplify and protect Human Rights in health and social care settings and good practice for a person centred culture.
The 360 Standard Framework is:
Quality improvement and practice development guidance that helps managers and staff in all health and social care settings, and at all levels of organisation, to measure the quality of what they do from the perspective of the person using services, their families and carers
A diagnostic assessment framework that shows health and social care organisations how to establish and maintain positive relationship centred cultures in which the person using services experiences good care and support, family members have confidence in the quality of care, and staff find the work fulfilling
Dignity (DH 2006)
Human Rights (2011)
Relationship-driven person-centred care (2006/8)
Person-centred culture and practice (2007)
Compliance with standards using outcome measures (2008)
Think Local, Act Personal SCIE 2011
National Dementia Strategy / End of Life Strategy 3 3

4. Defining and Transforming
the Care Experience
It is about defining good care from the person perspective – how to use relationships to deliver good care for older people and the culture that enables this
Personalised care is dependent on a partnership approach, creating positive relationships.
Residents will judge their experiences more positively if management and staff are person- centred in attitude and behaviour.
Relatives will judge their experiences more positively if managers and staff recognise their roles and respond with understanding.
Staff will judge their working experiences with older people as more satisfying and worthwhile, and will be more person-centred in their work, if they feel valued and equipped to fulfil their caring roles.
The 360 Standard Framework is achievable where owners, managers and staff are committed to making it happen in partnership with residents and relatives.
Make care homes a positive option for older people and their families where the services of a care home are needed.
The 360 Standard Framework creates cultures where:
people want to live
staff enjoy working
relatives enjoy visiting
…. and where managers and leaders facilitate relationships and community building with high quality care
Success relies on:
Facilitative management and leadership
Continuous on the job support and development
The involvement of residents and family carers
Skilled and knowledgeable committed management
Personalised care is dependent on a partnership approach, creating positive relationships.
Residents will judge their experiences more positively if management and staff are person-centred in attitude and behaviour.
Relatives will judge their experiences more positively if managers and staff recognise their roles and respond with understanding.
Staff will judge their working experiences with older people as more satisfying and worthwhile, and will be more person-centred in their work, if they feel valued and equipped to fulfil their caring roles.
The 360 Standard Framework is achievable where owners, managers and staff are committed to making it happen in partnership with residents and relatives.

5. Assessment Framework –
Residents' Measures
Receiving person-centred care
Opportunities for social/occupational activity
Influencing meals and drink
Meeting spiritual needs
Resolving concerns and complaints
There are 5 standards and three outcome criteria for each section. The example above shows 5 key aspects of being in a care home of particular significance to residents. The audit will provide evidence to demonstrate achievement of the standard, and opportunities to agree and take action on improvements.
So what does dignity look like for a resident?
Person Centred Care and Support
Involvement in decision making
Acceptability of care standards
Confidence in end of life care
Experiencing communication and positive regard
Building positive relationships between and among the resident, their relatives and the staff:  
Home life and occupation
Meaningful occupational activity
Evolving positive relationships between and among resident, staff and relatives
Positive dining experience, companions, level of assistance required
Acknowledgement of spiritual life, someone to talk to
Talk about mapping to CQC essential Standard and how it prevents safeguarding
Communication with empathy, involvement in decision making
Quality care - acceptable standards of care
Prevents negative stereotyping – enabled to use capabilities
Confidence in end of life care and someone to talk with who understands
Positive relationships between residents, staff, managers and relatives
Positive occupational activity and dining experience

6. Staff and Relatives’ Measures
Relative measures
Staff measures
1. Finding the work fulfilling
1. Welcoming ambience of the home
2. Having time to deliver good care
2. Communicating with staff and managers
3. Equipped to do the job
3. Being fully informed
4. Feeling valued as a staff member
4. Seeking to resolve concerns and complaints
The 360 – what does it look like?
Enabled to give Person Centred Care and Support
Integrated member of the resident’s care and support team
Positive relationship building between and among residents, staff and relatives
Pace and work organisation tailored to residents’ needs and abilities
Ability to respond to challenging situations at work- challenging events in the staff-resident relationship
Supported on-the-job learning and practice development for required competences
Relatives visiting experience
Involvement in decisions about the resident’s care and support
Acknowledgement of relative’s feedback role on care quality and home life
Acknowledgement of relative’s involvement in caring tasks
SF applies equally to domiciliary care (slides at end if needed)
LEARNING NEEDS FOR STAFF , Understanding ageism in society, Understanding chronic conditions and their effects on the person –identity, significance, continuity, purposefulness, belonging and being understood, Building positive relationships –the triangle, Specialist communication skills, Understanding transition, loss and adapting, Understanding and preventing institutionalisation, Inter professional co-operation and collaboration
Learning needs in these areas came up in different ways from residents, staff and relatives e.g. ‘I wish I knew more about communicating with people with dementia). Several felt this was not dealt with in enough depth. In fact this concern was voiced about other areas of learning e.g. relationship building, and being able to help people who were grieving, whether residents were grieving the loss of their home or the loss of a loved one with the sometimes stressful changes this brought, and the emotional engagement of staff in coping with the deaths of residents they had become attached to.
Many staff were concerned about he low status that older people have in society and the media at large e.g. language, stereotyping (sweet old thing, old codger etc). Obviously how this expresses itself in care homes is an ever present issue for trainers and training establishments.
Finally the effects of institutionalisation is well documented in research (e.g. Re evaluation of Residential Care, Sheila Peace et al) but insufficiently represented in training curricula for care homes.
Staff benefits
Involvement and integrated member of the staff team
Acknowledgement of the relatives role and their feedback
Acknowledgement of the relatives role in contributing to the community life of the Home and in some caring tasks
Relatives benefits
Positive relationship building
Recognition for level of knowledge/expertise with new qualification
Enhanced status with career development with a pathway
Integrated member of the resident’s care and support team- how to transform and build person centred, compassionate cultures of care and support
Integrated knowledge on promoting function Ability to respond to challenging situations at work (practice and relationships)
Supported on the job learning and on-going practice development enriching job satisfaction
Provide an enhanced practice in prescribing care for a meaningful home life
DOM CARE Main themes for clients:
Control over decisions
Receives consistent care and support
Care and support is delivered in acceptable ways to acceptable standards
Positive relationships
Empathetic and effective communications
Able to resolve concerns and complaints without fear of retribution
5. Contributing to the care of the family member and the community of the home

7. Managers making it happen
Enabling /facilitative management style - clear channels of communication, positive relationship building, collaboration with other professionals and agencies
Pivotal leadership role in change management
Operational management
Practice development
Quality improvement
Business planning
Management Enabling the 360 Standard Framework
requires a model of care management and support for example a named nurse and key worker to provide consistency and continuity
nursing management function strengthened to enable sustained person centred practice
leadership responsibilities strengthened with downward devolution of accountabilities and authority, and systemised individual training plans and programmes
senior staff facilitating practice development and meeting change agenda
facilitating quality of life outcomes by integration of activities into care plans to involve care staff responsibilities
professional and practice continuous quality improvement.
Management role in enabling adoption of the 360 Framework
Managers’ enabling staff to deliver the outcomes
Facilitative management approach
Empathetic communication skills
Pivotal leadership role in establishing the home’s relationship-activated person-centred culture
Infrastructure and processes support delivery of 360 framework for care homes, e.g. staff deployment models and continuity of care, integration of personal care and activities planning enhancing home life.
Quality assessment identifying practice development and learning needs.
 Operational management: demonstrate planning, organising service delivery, developing models for care delivery and the development of community life
Practice development –demonstrate education and training strategy, training methods and evaluation of outcomes.
Quality improvement strategy, QI plans and methods of delivery, involving residents, relatives, staff, informing practice development and training plans.
Business planning incorporating key result areas for service delivery, practice development and training, quality improvement and value added business performance.
What they need to know
Skilled in learning methods
Facilitation and group dynamics, listening, valuing
Knowledge and skilled use of an outcomes framework e.g. The 360 SF
QI action planning and project management
Setting project outcome standards
Open, facilitative pivotal leadership roles
These are the Managers competencies for making it happen

8. Example : Resident Standard 3:1 The resident has a choice of culturally acceptable food and drink that meet his/her dietary requirements
Structure
Process
Outcome
Here is a care home example
Refer to what 360 does – audit ,consultancy advice and training to deliver it
Structure Criteria (The resources) e.g. competence, demonstrable skills, practice development, continuous education, testing new staff adequately, effective organisation, equipment
Process Criteria (What people do): staff action/decision-making involvement of residents and others, best practice method used for need
Outcome Criteria: (What you expect) client perspective - measures of desired effects of care
S- training programmes cover all aspects of nutrition relevant to the health and cultural profile of the resident including physical and mental capacity, empathetic commutation and listening skills, skills in engaging the resident in the decision-making and participation in meeting their nutritional needs
P –Designated staff record the resident’s significant nutritional details in the care plan taking account of a) health needs and b) hydration c) elimination d) requirements for assistance

9. Benefits to the organisation
USE THIS AS HANDOUT with NHS KEY BENEFITS If the resident’s and If the staff outcomes are achieved:
Higher job satisfaction resulting in reduction in sickness, increased recruitment, lower turnover, decreased use of agency and efficiency savings
If the resident’s and relatives outcomes are achieved:
Improved reputation leading to increased occupancy and income
How it helps the organisation:
Promotes self-management of QI
Facilitates analysis of training needs
A blueprint for education and training for self audit, practice development and change management
Helps care providers to meet CQC registration requirements
Makes good care homes visible for older people and their relatives
Benefits to the organisation
Prevents the experiences that bother older people and their relatives (concerns/complaints)
Achieving continuing improvement, meeting statutory requirements and beyond
Able to demonstrate measurable improvements in reputation
Offer nurses a career path – attracting more into the sector as a positive option
Demonstrate efficiency savings, less reliance on agency staffing, lower absence, reduced staff turnover and highly motivated workforce and increased effectiveness of delivering PC outcomes

10. Characteristics of the 360 Standard Framework
Delivers continuous quality improvement and demonstrates measurable change
Involves the cared-for person, relatives and staff
A Standard of excellence in relationship activated care for person-centred outcomes
Underpins all other service and practice standards
Incorporates evidence from research and empirical studies
Diagnostic with measurable outcomes
The adoption of the 360 Standard framework is essential to good care and support in all Care settings for vulnerable adults in whatever settings they are or live
The essential dynamics of quality improvement:
Managers and practice leaders play leading roles in setting and meeting objectives for quality improvement in practice development and operational management.
Managers involve residents, relatives and staff as partners in determining quality improvement priorities and evaluating results.
Managing change requires open, facilitative leadership to motivate staff, empower residents, and support relatives in their caring roles.
Benefits to the organisation
Prevents the experiences that bother older people and their relatives (concerns/complaints)
Achieving continuing improvement, meeting statutory requirements and beyond
Able to demonstrate measurable improvements in reputation
Offer nurses a career path – attracting more into the sector as a positive option
Demonstrate efficiency savings, less reliance on agency staffing, lower absence, reduced staff turnover and highly motivated workforce and increased effectiveness of delivering PC outcomes 10 10 10

11. 1 - Client Decision
Routes : The 10 Step Cycle
2 - Preparing and Planning
8. Internal Evaluation
Foundation Commitment Award
Foundation Outstanding Progress Award
6. Action
Plan
7. Internal Implement Action Plans.
3 - Data Collection
4 - Data Analysis
360 PQ using Talking Mats for hard to reach groups to capture their views for people with moderate dementia
Standard methodology with questionnaires, surveys which have a 4 point scale of agreement with outcome statements:
e.g. for the relative experience
The ambience of the care home gives the relative confidence in the care home staff.
The relative knows the names of the key staff and their role in caring for the resident.
The relative has opportunities to work through any feelings linked to the loss of his/her previous role in caring for the resident.
The relative is able to share his/her knowledge of the resident’s past life, interests, skills and abilities with staff to help them relate to the resident as a unique individual.
The relative receives timely information about changes in the organisation of the resident’s daily life.
The relative receives timely information about any significant changes in the resident’s health, medical treatment and medical care.
The relative’s role in representing the resident is acknowledged and agreed between the relative, the resident and managers
The relative feels confident about helping the resident with personal care tasks agreed between them within the safety guidelines advised by the Home.
5 - Feedback

12. Why is the 360 Standard Framework important to the NHS?
Good patient outcomes - Create a patient-centred NHS
Quality Improvement - Focus on improving their experience and their health outcomes
Value added benefits: effectiveness and efficiency
Leadership and management enabling tools - Empower professionals – end top-down control
Diagnostic tool
Benchmark system
Defined measurable outcomes
Quality improvement methodology
Involves patients, staff and relatives
Measures and drives person centred cultures
Learning support programme
Integrates health and social care

13. Work-based Learning Key topic areas
For delivering quality compassionate care
Understanding ageism in society
Understanding chronic conditions and their effects on the person –identity, significance, continuity, purposefulness, belonging and being understood
Building positive relationships –the triangle
Specialist communication skills
Understanding transition, loss and adapting
Understanding and preventing institutionalisation
Inter professional co-operation and collaboration - INTEGRATION
Dignity challenge – zero tolerance of abuse, treating each person as individual, supporting independence, choice and control, respecting rights to privacy, acting to alleviate loneliness and isolation, enabling complaints without fear.
‘Dignity and respect are low aspirations on which to build a challenging agenda’ – instead base it on citizenship with increased focus on personal identity, self-expression and individual aspirations, rights and circumstances’. JRF Think Local Act Personal – more than personalised budgets
It’s hard to achieve –and much less likely to be recognised
The demand for evidence is wide ranging and multi-layered covering everything from environment and services to the quality of resident’s home life and the expertise required of staff and managers
Statutory regulation and inspection increasingly require care providers to produce evidence of outcomes
Learning outcomes for compassion in care:
1. Staff that can communicate sensitively and acknowledge each individuals, personal experience of dementia.
2. Daily routines, activities and an environment that supports and meet their emotional and social needs.
3. Staff that can apply techniques and strategies to approach situations creatively.
4. Be supported to achieve quality of life in the least restrictive ways.
5.Their experience of care is supported and evaluated through person centred outcomes.

14. The Elizabeth project Justine Cawley Independent Consultant
Associate at Bucks New University

15. Background
Developing a career pathway for people working with older people
From apprenticeship to post-registration nursing
Mid Staffordshire and other incidents of unacceptable care
Over the years older people have been moved out of hospital into residential care and as a result the health input has diminished

16. The Structure of the pathway
Post apprenticeship course
Elizabeth practitioner – Foundation degree
Elizabeth Nurse – Post qualifying degree
The Elizabeth Nurse will be:
A practicing specialist socio-gerontological nurse
Responsible for leading:
The delivery of good care and support to the person
Effective staff learning and development in the workplace
Achievement of demonstrable quality improvement outcomes for the person, their families and staff.
Elizabeth Practitioner - a blend of care giver and everyday living assistant to the Person. The proposals a) to establish the Elizabeth Nurse and b) an enriched care assistant role in care homes. Its focus is on work based learning with demonstrable and measurable positive outcomes for the resident
3. Apprentice Role
This will provide a career pathway for the care sector- from care worker to nurse.

17. Why is this needed?
Increase in complexity of care – dementia, long term conditions
Need to have higher standards in health and social care
No dedicated career pathway for older people
Need to give the sector and their staff more status and recognition
The 360 SF began as Pat’s brainchild who set out the principles and proposed
framework
in the late 1990’s for care homes. At it’s heart is a range of themes focused
on residents,
staff and relatives (relationship triangle)
At the turn of the millennium Pat began her collaboration with Rosemary Hurtley
to turn the 360 SF from principle and framework into practical tools for delivering
relationship activated person focused care.
Since then the collaboration has resulted in a range of flexible products and services
that help managers and staff adopt the 360 SF
Complexity of needs has and is increasing for older people
Predicted increases in demand for health and social care from 2010 to 2030 for people aged 65 and over in England and Wales include people with dementia (moderate or severe cognitive impairment): up by over 80% to 1.96 million (House of Lords, 2013)
Staff require support and training to meet the needs of residents and relatives
Traditionally a Cinderella service - encourage skilled nurses into the workforce and make it a prestigious place to work.
Establishing and sustaining cultures of compassion and dignity and socio healthcare for the person
Inter-professional collaboration and co-operation (partnership approach: nursing and occupational therapy) 17 17

18. Issues in the sector Societal Organisational Operational
Practice- knowledge, skills, behaviours
Lack of funding for socio-health nurse development
No career pathway to higher education qualification in care of older
people

19. Why training is essential:
65% of people in hospital are over % of people in care homes have dementia or cognitive impairment (Alzheimer’s Society, 2013)
Residents of care homes have complex healthcare needs, reflecting multiple long-term conditions, significant disability and frailty.(BGS, 2011)
All health and social care providers need training in the complex management of people with multiple long-term conditions (BGS, 2013)
People living in a care home and suffering from dementia are more likely to go to hospital with avoidable conditions such as urinary infections.(CQC, Care Update)
The social care model is central but insufficient to meet residents’ health needs.(BGS, 2011)

20. Impact More young people coming into the Sector
A more educated and adaptable workforce
A career pathway that young people want to enter
Work based learning and an alternative to University
Less turnover of staff
More profitable sector
Happier staff
More career opportunities
More customer satisfaction
Benefits to the sector:
Provide higher role status and opportunity for specialism that is recognised
Attract good staff and maintain them
Give confidence back to the sector from the public
Demonstrating person centred outcomes
Achieving continuous improvement, meeting statutory requirements and beyond
Able to demonstrate measurable improvements in reputation
Demonstrate efficiency savings, less reliance on agency staffing, lower absence, reduced staff turnover and highly motivated workforce
General consensus that health and social care services do not meet the needs of older people with dementia. However, no co-ordinated model of care has been adopted.
Skills the workforce to meet the needs of older people with dementia and creates a career pathway.
Influences culture- provides a framework that delivers person centred outcomes and has measures to ensure quality improvement.
Focus on nursing older people, maintaining relationships to achieve good care, key elements to achieve a dementia friendly service and leadership.
Piloting a form of training to develop a new nursing speciality and potentially gain national recognition.
Impact on health and social care
Addresses Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry
Fosters a common culture shared by all in the service of putting the patient first
360 Standard Framework offers a set of fundamental standards addressing needs of people using the service, family and friends and healthcare staff.
Provides evidence-based means of compliance with these standards which can be understood and adopted by all staff.
Skills staff to address:
Management of complex health care needs. All health and social care providers need training in the complex management of people with multiple long-term conditions (BGS, 2013) Older people have complex healthcare needs, reflecting multiple long-term conditions, significant disability and frailty. (BGS, 2011)
Avoid unnecessary hospital admission. People living in a care home and suffering from dementia are more likely to go to hospital with avoidable conditions such as urinary infections.(CQC, Care Update)
Reduce dependency on antipsychotic medication. Skill staff to use alternative approaches and strategies to manage challenging situations. (Call for Action, 2012)

21. Enabling the Willis and Francis Report Recommendations
The culture of healthcare provider organisations is routinely assessed
More family and user involvement in education
Streamline communication skills to provide dignity for people with dementia, mental health and chronic disease
Flexible education programmes for nurses and carers, people and their families
Work-based learning
New status of nurse for older people (Francis Report)
Providing the skill sets to develop care homes to deliver enhanced models of community based care - using hub and spoke models, learning and development care homes working with the university to support students in the workplace. Deliver measurable outcomes and reduce admissions, including falls, weight, continence staff time, referrals etc. Human and cost benefit analysis- research

22. Integration
Integration is essential if we are going to give older people the care they deserve.
Partnership is essential – Partnership which are equal
Social Care sector is very fragmented.
NHS have the money and Commissioners have the power
Social care have less qualified staff

23. Social Care Sector Predominantly SMEs who are fighting to survive
High turnover of staff
Lack of awareness of partnership – lose staff to NHS
High drop-out rate with young people

24. Partnership and integration
Partnerships are sustainable
They are equal
They have good foundations and have identified core common goals
They have common training routes

25. Building Bridges
Construction began in 1831 but the project was beset by political and financial difficulties.
By 1843, with only the towers completed, the project was abandoned.
The bridge was finally completed and opened in 1864.

26. Bridges and innovation
Underpin foundations of the weaker side or use strengthening members across it
Victorians great engineers and innovators
We have to be a different sort of innovator by being builders of social structures that work and provide excellent care.

27. Thank you Rosemary Hurtley Rosemary@360fwd.com 01483 275555‘
Thank you
Rosemary Hurtley
Justine Cawley 27 27