Foot Care in Care Homes – Time for change?

Dementia Care
November 28, 2022

QCS has joined forces with Care Home Podiatry Ltd in a bid to improve foot care in care homes. Here, Thomas Calderbank, Clinical Lead Podiatrist outlines current issues and a possible way forward.

Remember that damning report into the state of oral health in the care home sector by Care Quality Commission (Smiling Matters; CQC, 2019)? Let’s jog your memory on a few of their key findings:

  • Most care homes had no policy to promote and protect people’s oral health (52%)
  • Nearly half of care homes did not train staff to support daily oral healthcare (47%)
  • 73% of care plans reviewed only partly covered or did not cover oral health
  • It could be difficult for residents to access oral care
  • 10% of homes had no way to access emergency oral care treatment for residents
  • Residents perceived a financial barrier to accessing oral care (despite the fact it is offered free of charge courtesy of the NHS)

Now think about your care home, could you substitute “foot health” in place of “oral health” in pretty much every section of this report? We’re guess your answer is most probably yes.

Foot care is an often-overlooked part of care home life, with most care homes happy if someone just turns up to trim their residents’ toe nails. Through this article we explore whether foot care could (or perhaps should) be next on CQC’s radar.

Foot care is important

But why do we want you to take some time to consider your current foot care provision? Because foot care is hugely important to the health and wellbeing of care home residents!

The majority of care home residents will have some foot health concern. A large study of older adults found:

  • A quarter of adults over the age of 65 live with foot pain
  • 75% of older adults suffer a nail condition
  • 60% have toe deformities
  • 58% have problematic callus or corns
  • Bunions, cracked skin, ingrown toe nails, fungal infections and ulcerations (wounds) are also common

You might be thinking some of these sound pretty minor, and yes, they can be, but they can also be early warning signs of more serious problems. For example, corns and calluses are caused by pressure on the skin – exactly the same thing which causes pressure sores and foot ulcers. Having the right professional in place to catch these problems early helps prevent more damaging or dangerous problems for your residents.

Recent scientific studies have shown that having a foot problem greatly increases older people’s chance of having a fall. Foot pain, toe deformities and bunions are particularly linked to an increased falls risk. Because of this link it is strongly recommend that foot checks are part of routine falls assessments carried out by care homes.

Foot problems are also one of the most serious issues faced by people living with Diabetes. This is significant when you consider approximately 25% of care home residents are currently living with Diabetes, with numbers expected to rise significantly over the next 30 years. Poorly controlled Diabetes leads to a range of foot problems which can ultimately result in:

  • Diabetic foot ulcers – wounds that can take months or even years to heal. Diabetic foot ulcerations can lead to infections, sepsis, the need for limb amputations and even death. Diabetic foot ulcerations have a higher mortality rate than breast, prostate and colon cancers7. Mortality rate within 5 years of a foot ulceration can be as high as 75%7
  • Gangrene – caused when there is no longer sufficient blood supply to keep toes or feet alive and they start to turn black. In some causes surgery can be performed to improve circulation, but in most cases surgical removal (amputation) is required

The problem with foot care services

So, considering that foot care is so important to life and limb of care home residents you’d probably assume that there was a robust, well-regulated and organised foot care provision for care home residents. Unfortunately, this couldn’t be further from the truth.

Unlike dentistry, NHS podiatry teams provide only a very small proportion of foot care to care homes, with strict entry criteria and marked geographical variations in what services are available. Most care homes have to seek assistance from the private sector to cover their residents’ foot care needs, this patch work of solutions has some major pitfalls.

There are no rules, regulations or laws on who can offer foot care services to care homes. Currently, there is a confusing array of different people and professions currently providing foot care services to care homes. Literally anyone can turn up to your home, call themselves a foot care specialist, a foot health clinician or whatever else they might like, and charge your residents to cut their toenails, remove callus with a scalpel blade and treat other foot problems… no qualifications, training or criminal record check legally required. As a result, there is huge variation in the quality and safety of care being delivered across the care home industry. This is terrifying, especially when you consider the risks of inadequate foot care we outlined at the beginning of this article.

There is no guidance for care managers on what a foot care provision should look like. How do you recruit a foot care professional for your residents? Where do you look? Who do you choose? What qualifications or experience should you look for? Once you’ve found them – how often should they visit? What should they charge? What level of service should you expect? What is their scope of practice? Care home managers are very much on their own to make these decisions on behalf of their residents with no guidance provided by regulators and policy makers.

Who pays the bill? Normal practice is for private foot care to be paid for directly by care home residents. Not only does this create a financial barrier to residents accessing foot care, but it also means the care home is not directly involved in the transaction between the resident and the clinician. Too often this results in poor sharing of information between the clinician and the care home team, resulting in foot health concerns escalating and ultimately the resident needing treatment that could, and should, have been avoidable.

Should foot care in care homes be next for CQC’s inspectors?

To summarise the key points:

  • Foot care is important to the health and wellbeing of care home residents. Foot care done badly could result in threat to life and limb
  • There are no laws or regulations governing who can provide footcare to care homes. Accessing foot care should not feel like trying to navigate your way through the Wild West. It should not be possible for untrained or undertrained people to pose as foot care professionals
  • There is a lack (or complete absence) of guidance to care home managers on how to set up foot care services in their home
  • There are huge inequalities in the standard of foot care provided to care homes, both between regions of the UK and between individual care homes
  • Foot care for care homes is broadly not provided by the NHS, residents have to pay for this essential service

Regardless of whether CQC choose to inspect foot care services in care homes it is clear there is room for significant improvement. QCS and Care Home Podiatry will be providing more information over the coming days to help you implement a gold standard foot care provision for your residents.

Further information

Care Home Podiatry

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