Background Care homes are increasingly places where older people live and die. The end of life care programme promotes the use of end of life care tools in care homes; however, changing the relatively weak culture of care homes where there is high turnover of staff, a majority of untrained carers, and a lack of multi-disciplinary working, is complex. The Care Home Project Team at St Christopher's Hospice, London became a Regional Centre for the delivery of the GSFCH programme in October 2008. Since this time 132 care homes have completed this programme of which 53 nursing homes are from our own locality.

Methods Four FTE palliative care nurse specialists facilitate the implementation of end of life care tools across five PCTs (population 1 386 076). The team uses high facilitation to empower nursing home staff and visit their specified nursing homes 2/3 times a month to role model monthly coding meetings, advance care plan discussions, LCP training etc. Emphasis is given to supporting staff with monthly reflective-debriefing sessions following a death. Managers collected preprogramme data on all deaths in order to compare to subsequent years.

Results Since 2008, inappropriate hospital deaths have been reduced by 16%. In 2008, 57% residents across 19 nursing homes died in the homes compared to 73% residents across 53 nursing homes in 2010. Sixty per cent of nursing homes (32/53) have gained accreditation compared to a national average of 10%. Commissioners now fund all members of the Care Home Project Team.

Conclusion High facilitation of evidence-based tools in end of life care can develop a palliative care culture in nursing homes. However, sustainability is not without cost. Our sustainability programme consists of nursing home cluster groups within each PCT. Each cluster covers 3 levels: new staff; 4-day training package for regular nurses/carers; action learning for managers.