The CQC has recognised the impact of implementing Safer Provision and Caring Excellence (SPACE) in Walsall nursing and care homes.

WM PSC SPACEThe SPACE programme (Safer Provision and Caring Excellence) is a large-scale care home improvement programme being undertaken in the West Midlands, which aims to strengthen safety culture and reduce the incidence of adverse safety events. An inspection report published by the Care Quality Commission (CQC) highlighted the input of the WMAHSN’s (West Midlands Academic Health Science Network) West Midlands Patient Safety Collaborative (WM PSC) in Walsall’s community services, gaining a good rating.

On 20 December 2017, the CQC published the report of its inspection of Walsall Healthcare NHS Trust. The CQC paid its visits on 31 May and 20 – 22 June 2017, and while the report shows progress in each service area, a rating of “outstanding” was given to Walsall’s end of life community services, while community health services for adults were rated as good. This makes Walsall Healthcare NHS Trust one of only a handful of community services in the country with this rating.

The CQC acknowledged the input of the WM PSC in contributing to the success of the service, particularly the Safer Provision and Caring Excellence (SPACE) programme and related improvements.

The report found that Walsall Healthcare NHS Trust had developed enhanced case management with staff working in private nursing homes. The Trust successfully achieved additional funding through the WM PSC. Pressure ulcer incidence within the homes had decreased, and increased numbers of people were able to die within their care home where they had staff who knew them, rather than in a hospital setting.

The private nursing home case management service has continued to develop, supported by the WM PSC. New initiatives included: Learning from Excellence and Appreciative Inquiry, reduction in pressure ulcer incidence and implementation of quality boards in care homes.

Aims, objective and scope

Most research into safety culture improvement has focused on hospitals, and the concept has only recently emerged in other areas of health and social care provision such as the care home sector. A recent UK care home census reported that 87% of residents have high support needs, defined as having one or more of dementia, confusion, challenging behaviour, dual incontinence, severe hearing/visual impairment or dependence in mobility.

The care home sector is also characterised by frequent policy and regulatory changes, heavy workloads, high staff turnover and difficulty recruiting and retaining competent staff. These factors make it challenging for positive safety practices to be cascaded to staff and to become embedded within care home organisational culture.

The main objectives of SPACE are to:

  1. Improved safety culture
  2. Reduction in harms – adverse events
  3. Reduction in hospital admission


The overall aim of the programme is to assess the extent to which safety climate in care homes can be improved and the incidence of adverse events reduced, by skilling-up care home staff in service improvement techniques and providing facilitation to enable care homes to implement changes to practice.

Method and approach

WM PSC SPACE Driver diagram for SPACE Project

There are two main elements to the SPACE programme to help achieve the aims of the initiative:

  • Training events and workshops, which help care home staff and managers develop relevant skills and enhance their understanding of safety-related service improvement. Training explores clinical and human risk factors related to safety, alongside techniques for designing and implementing service improvements.
  • Facilitated sessions delivered in participating care homes support staff to implement changes to practice relating to specific safety concerns such as falls prevention and pressure ulcer management.
Measurement plan

The SPACE programme is robustly evaluated to assess its effectiveness. The overall aim of the evaluation is to assess the extent to which safety climate in care homes can be improved and the incidence of adverse events reduced, by skilling-up care home staff in service improvement techniques and providing facilitation to enable care homes to implement changes to practice. It takes a longitudinal approach, using a before and after study design. The protocol outlining how SPACE is measured has been published.

Results and evaluation

The evaluation which will be finalised in Winter 2019 will use a pre-post design with mixed methods.  Quantitative data will focus on care home manager and staff surveys administered at several time points and analysis of adverse event rates.  Data on hospital activity by residents at participating care homes will be compared to matched controls.  Qualitative data on experience of training and the application of learning to practice will be collected via semi-structured interviews with staff (n = 48-64) and programme facilitators (n=6) and staff focus groups (n=36 to 48 staff).  The primary outcome measure is the change in mean score on the safety climate domain of the Safety Attitudes Questionnaire between baseline and programme end. Damery et al BMC Health Services Research (2017) 17:86.

WM PSC SPACE Engagement in QI activity Walsall Nursing Homes

A visitor guide was jointly designed by all care homes to be given out to residents’ families to help keep their loved ones safe and communicate in a uniformed way across the borough.


Learning points

Leadership and culture – The PSC used the National Kitchen table week (linked to the NHS Sign up to Safety campaign) initiative as a driver to engage care home staff that would not normally know about these kinds of events.  A skilled facilitator used Appreciative Inquiry skills to lead this session by reframing a negatively charged situation into a strength based positive listening exercise.  The staff feedback from these events were themed into the 5 CQC domains SAFE; CARING; RESPONSIVE; WELL LED and EFFECTIVE.

Plans for spreading learning and encouraging adoption

The WM PSC has published a Year 1 evaluation report from the NIHR CLAHRC West Midlands which indicate a direction of the learning that can then be spread.

Start and end dates

January 2017 with final evaluation due 2019

Contact us for help and advice

Helen Hunt, Assistant Programme Manager, West Midlands Patient Safety Collaborative Academic Health Science Network
E: helen.hunt@wmahsn.org

More PSC care homes projects

Read about how an international measurement of care home problems is improving quality around the East Midlands.