The night-time care experiences of residents, relatives and staff in three care homes in Scotland.
Although night-time care forms a significant part of care home provision, little research has focused on this. Night staff are a vulnerable group, receiving less training, supervision and support than day staff, but with high levels of responsibility.
This report examines the perspectives of residents, relatives, staff and care home inspectors. It identifies areas of good and poor practice, and recommends ways to make improvements through a series of interventions.
Issues explored in depth include:
Four posters with practical advice for supporting people in care homes at night (PDF, 197KB, A3 format) are available.
Based on this research, the Care Quality Commission (CQC) has published a set of 'prompts' designed to help its inspectors evaluate effective night time care in care homes. The prompts are linked to outcome areas of the national minimum standards. CQC suggests that they could be used as part of a key inspection, and will also help care home providers to think about whether they have the best arrangements in place for night time care.
This study explores the night-time care experiences of residents, relatives and staff in three care homes in Scotland. It identifies good practice and suggests improvements through a series of interventions. These are used to make recommendations for care regulators, commissioners and providers, home managers and night-time care staff.
Care homes provide a 24-hour service. Many research projects have focused on day-time care and provision in care homes, but little is known about night-time care practices and provision, especially the views and experiences of residents and the views and practices of night care staff.
The aim of this action research study was to explore night-time care more closely. The first stage of the study was exploratory, using interviews and observations to identify the main concerns and issues. In stage two, the researchers worked with the night staff to implement and evaluate changes based on stage one. Recommendations are based on the findings from both parts of the study.
CCOs reported that care homes are generally only inspected at night when there has been a complaint or cause for concern. There is a need for night-time practice to be inspected as rigorously as day-time practice. Night time is when staff and residents are most vulnerable and least supported.
"Night might be the very time that some one-to-one time might be most needed."
Night time in care homes is a time of withdrawal from the outside – unlike the day time when the outside world comes in. Night staff are less well-trained and less managed and supervised. They can feel isolated and experience high levels of anxiety – such as what would happen if there was a fire or if someone needed medical attention.
"During the day we have got enough staff … and most of the residents are in one place … they are downstairs … and there is nobody in their rooms … so it is easy to watch over them."
(Member of night staff)
The study found that routine, indiscriminate over-checking led to unnecessary disturbance of residents. Solutions included the implementation of night-time key worker systems; individual risk assessments for night-time care; and greater involvement of management.
"You open the door … Turn the lights on … you are going to wake them up because you are going to check the pad, if it's dry or wet. There are some heavy duty ones [pads], they can actually probably hold up to quite a few litres, so you can probably say some of them won't be that wet, but we have still got to change them and wash them, that's the policy."
(Member of night staff)
The levels of noise and light during the night were too high to support good sleep for residents. Staff talked too loudly close to bedrooms and homes had noisy floorboards, plumbing and buzzer alarm systems. Light levels were not monitored. Bright lights were turned on in bedrooms when people were checked, or left on in the sitting room and corridor areas. Solutions were to reduce light and noise levels and use changes in light to indicate the times for sleeping. These resulted in improved sleep amongst some residents.
"Oh yes, we have been trying our best [to be quieter]. Because before we never really thought about it."
(Member of night staff)
Other aspects of the care home environment were not suitable, particularly for people with dementia. For example, the lack of signage to orientate people led to unnecessary wandering and agitation – and mirrors in bedrooms caused people to believe others were in their room.
A requirement that 50% of all staff in care homes should be trained to at least SVQ level two does not discriminate between day and night staff. This study found that night staff training levels fell below the 50 % level. Where training and modules do exist they are usually directed towards day-time issues and do not specifically address night-time practice.
Problems with releasing night staff for day-time courses and providing extra payment were the main obstacles to adequate training. Training in dementia care, and continence training in particular, were highlighted as inadequate. Training was a key element of the action research stage of this research. The training provided during this stage was person-centred, night-time specific where necessary, and practice-based. In the short term, the result was well-evidenced improvements in practice.
"Since the training on dementia there has been a definite reduction in instances of challenging behaviour and accidents at night."
The views and experiences of residents revealed the impact of night-time practices on their sense of well-being. The checking was seen by some as a reassurance and a source of company through the night. But it was experienced by others as unnecessary, intrusive and a cause of fright and agitation.
"I am fast asleep and then they open the door and put on the light and I jump awake, my heart jumps and then I cannot get back to sleep."
Resident: "Well. They look in and out. They are out so quickly you've not got time to say anything."
Interviewer: "Would you like to?"
Resident: "Yes, well it's a long time since they talked to me."
Relatives knew very little about night-time care or the night staff, and indicated that they were often worried about possible problems. They had not felt able to articulate these concerns or to enquire about night-time staffing levels and competence.
"And that's, that's my worry and again I think maybe that's why we don't ask because we don't want to know really."
Management had little involvement with night staff. This resulted in night staff self-managing, and often implementing inappropriate practices. Increased involvement of the managers during the action research stage reduced staff feelings of isolation and of being undervalued. Night-time key worker systems enabled staff to:
Low staffing ratios at night resulted in a frequent, and in some cases routine, use of agency and bank staff. While this was necessary to meet staffing levels required for care needs, it proved to be a burden for the regular night staff, who had to instruct and supervise agency staff in addition to their own duties. The use of a regular bank of staff could avoid this, but it was difficult to achieve.
"They are always behind you, I have to give them instructions and they are not able to do much on their own … and they get paid much more than I do."
(Member of night staff)
Each recommendation recognises night-time care as a key element in the provision of a 24-hour care service. The recommendations are based on the principle that night-time care is not only about promoting good sleep. Night can also be a time when positive care practices can be carried out and where a resident who is awake can engage in other beneficial activities.
The research team (Heather Wilkinson, Diana Kerr and Colm Cunningham) carried out the work across three care home sites in Scotland. These were a mixture of voluntary, private and statutory provision. Interviews were conducted with Care Commission officers, care home residents, direct care night staff, managers and relatives, and observations were undertaken during night shifts in the homes. A period of action research tried out several changes in practice and resulted in a set of recommendations.