Supporting older people in care homes at night

Diana Kerr, Heather Wilkinson and Colm Cunningham

29 April 2008

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:

  • the role of regulatory bodies in night-time care inspection; 
  • the role of managers in supervising and monitoring night-time care; 
  • causes of distress and sleep disturbance amongst residents; 
  • the need to reduce the number of checks that occurs throughout the night; 
  • the training of night staff in areas such as dementia awareness and the management of continence; 
  • guidance on appropriate noise and light levels; and 
  • strategies for developing more person-centred care at night.

Related resources

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.

An audio play based on this work was also commissioned.

Summary

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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 commissioners reported that they do not routinely inspect care homes at night. When they do, it is generally only in response to a complaint or specific cause for concern.
  • Managers in the care homes studied were insufficiently involved in night-time supervision and practice.
  • Night staff often felt undervalued and isolated from the running of care homes.
  • Night staff received less training than day staff – and little or none on responding to people with dementia, supporting continence, recognising and managing pain, or supporting good hydration and nutrition during the night.
  • Where training was available to night staff, it was not specifically focused on night-time issues.
  • Dependence on unfamiliar agency and bank staff increased the workload of regular staff and jeopardised quality of care for residents.
  • Staff carried out routine and indiscriminate 'checking' (for breathing, falls and incontinence) throughout the night, due to a general culture of anxiety.
  • There were often unacceptable levels of noise and light during the night, which affected residents' sleep and caused agitation.
  • The night-time physical environment was disabling rather than enabling, especially for people with dementia.
  • However, the action research part of the study showed that even relatively minor changes in practice could result in considerable improvements to the night-time care experience.

Background

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.

Findings

Care Commission inspections

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."
(Care commissioner)

Night-time culture and experiences

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)

Over-checking

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)

Noise and light levels

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)

The physical environment

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.

Lack of suitable training

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."
(Manager)

Perspective of residents

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)

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."

Perspective of relatives

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."
(Relative)

Management involvement

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:

  • become more individually responsible for residents;
  • to carry out night-time risk assessments; and
  • to develop a more individualised approach to care, including the frequency of checking.

Staffing levels and the use of agency and bank staff

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)

Recommendations

Context

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.

Recommendations for UK regulatory bodies

  • Include night-time inspections as standard, not just as result of complaints. Ensure that remuneration arrangements for inspectors making night time visits are clear.
  • Inspectors must have specific awareness and training on dementia and night-time issues.
  • Inspectors must provide home-specific and informed guidance on staffing levels for night-time care. This is to take account of changes in staffing needs throughout the night.
  • Training modules for everyone must reflect night-specific issues.
  • Minimum qualification requirements must be equally applied to night and day staff.

Recommendations for home management

  • Implement regular communication and support strategies between manager and night-time care staff.
  • Ensure that environmental concerns within the care home setting are addressed and where appropriate relevant technology is used – for example, guidance around noise, light, safety and silent call systems.
  • Put systems in place so that night staff have all the equipment, technology and facilities required to provide good night-time care.
  • Monitor staff training requirements, and ensure appropriate times and conditions for such training is provided.
  • Keep the use of agency and bank staff to a minimum ‐ where possible, staff with a familiarity of the care setting should be used

Recommendations for management in connection with night staff

  • Implement a system of regular communication with, and supervision of, night-time staff. Give clear messages about the expected night-time practices through specific guidance.
  • Ensure a system of training is available to night-time staff and encourage training by ensuring it is night-time specific and at times that do not impact negatively on the night staff. Training content must include dementia awareness.
  • Where required, ensure staff are supported to speak English at a level comprehensible to the resident as a basic requirement. Provide basic training where possible, especially where there are difficulties in recruiting night staff.
  • Develop and provide guidance to night staff on the impact of night working and strategies to support better health – for example, information on nutrition.

Recommendations for care homes in connection with relatives

  • Provide relatives with an information sheet about basic expectations relating to night-time care.
  • Include up-to-date photographs of night staff as part of the information.
  • Inform relatives of the resident's night-time key worker and encourage some form of regular communication between them.
  • Have regular meetings for relatives to improve communication and information sharing.

Recommendations for care homes in connection with residents

  • Each resident to have a night-time key worker who will take responsibility for:
    • the production and review of night-time care plans;
    • the communication to other staff of the resident's needs and any changes; and
    • providing a communication link between the resident and their relatives.
  • Night-time care plans to be used to regularly assess and communicate the needs of the resident throughout the night – information should include regular professional assessments of needs such as continence support and pain needs.
  • Practices that are intrusive, such as checking and changing pads, should be done with minimal disruption, be gender appropriate and be sensitive to communication needs. They should be in response to individual needs, not part of a group 'round'.

About the project

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.

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