This review explores the learning from delivery of care in residential services for children and young people, residential services and supported housing for people with learning disabilities and hospice care, and considers how this can be applied in care homes for older people. The report:
- finds that, while evidence of effectiveness is limited, there are promising ideas that could improve the culture of care homes, experiences of care and support for staff;
- presents evidence of how residential care homes in other sectors have created positive organisational cultures and increased relationship-based care to improve the quality of care offered;
- looks at how greater involvement of people who use services and their families can improve experiences of care.
- Evidence from a range of settings suggests that working with people who use services and their families can improve experiences of care. At an individual level, this includes involving residents in planning care and managing personal risks. At an organisational level, this means increased participation in formal inspections (e.g. as peer inspectors), greater links with the community and volunteer working.
- Choice and control are well embedded in services for people with learning disabilities. A person-centred approach to risk focuses more on what can be done than what can’t. Joint risk assessments (involving service users) and advocacy can support this shift.
- Approaches that promote relationship-based care could be applied to care homes to help create a positive organisational culture. Examples include social pedagogy, dignity therapy and Namaste approaches.
- To enhance safeguarding, care homes should be aware of factors that mitigate against abuse, such as strong leadership, robust recruitment practices, information sharing and listening to residents.
- Advance care planning (used in end-of-life care) may improve satisfaction with care received and increase a sense of control. Electronic systems for care co-ordination can be helpful for professionals, but more evidence is needed on impact on quality of care.
- Recruitment of care staff is increasingly focused on values and the ability to build relationships. Care homes also need to be aware of staff stress, which can be mitigated through approaches such as Schwartz Care Rounds and self care.
This study investigated the scope for improving quality of care for older people in residential care homes in the UK by learning from other settings: residential services for children and young people; residential services and supported housing for people with learning disabilities; and hospice care. While evidence of effectiveness is limited, there are promising ideas that could improve the culture of care homes, experiences of care and support for staff.
Increased involvement and personalisation
Evidence from a range of care settings suggests that working with people who use services and their families can improve experiences of care. At an individual level, this includes joint decision-making and involving residents in planning care and managing personal risks. At an organisational level, this means increased participation in formal inspections (e.g. peer inspectors), greater links with the community and volunteer working.
Lack of a consistent or communicated ethos for adult social residential care has potentially damaged its reputation. More research on how hospice care has maintained a positive public understanding could inform strategies for improving perceptions of care homes. Increasing the role of volunteers could increase engagement with the wider community.
Volunteers are integral to the work of hospices and there is increasing policy emphasis on volunteers in other areas of care. But in the current financial climate, there is a danger volunteers could be used inappropriately. Growing evidence on the role of volunteers in end-of–life care will increase understanding of how recruitment, training and support can nurture and sustain their contribution to care quality.
An emphasis on choice and control is particularly well embedded in services for people with learning disabilities. Access to information, good relationships between staff and residents, trained staff who can listen and translate views into action are all important in improving choice and retaining control. Digital technology can play a part in people retaining independence. Care homes are already moving towards a person-centred approach but would benefit from looking at examples from learning disability settings, where greater participation by residents, family and the wider community has a positive impact on the delivery of personalised care.
A positive culture for caring
A positive organisational culture has the potential to positively impact on the lives of residents, families and staff. Features of a positive culture are complex and depend on organisational structures, management arrangements, the physical environment, skilled staff and teamwork, and positive staff-resident relationships. There are a number of holistic and relationship-based approaches that could be applied to care homes for older people:
- Social pedagogy focuses on nurturing residents, treating them as equals and training staff to become risk competent.
- Holding the Space is a model used in residential care for children and young people where relationships are central to fostering a sense of belonging
- Dignity therapy encourages patients nearing the end of life to talk about their lives and what matters to them.
- Namaste (meaning ‘to honour the spirit within’) is an approach developed in the US for end-of-life care and dementia patients that engages people through the stimulation of the five senses. St Christopher’s Hospice is currently working with six care homes to evaluate the approach in this setting.
- There are also innovative examples within residential care for older people: My Home Life focuses on improving the experience of residents while valuing staff through a relationship-based approach.
Regulation, risk management and safeguarding
Regulation and inspection form a core part of social care, but some feel that these processes create tension in the workplace and stifle creativity. To improve regulation, the views of ‘experts by experience’ are increasingly sought. There are opportunities for care homes to build on existing participation mechanisms and for residents to formally feed into inspections (e.g. as peer inspectors). Advocacy provides a collective voice for groups of people with shared interests and can play a role in identifying good or poor practice.
Risk management has tended to be treated in a negative manner, but as part of a person-centred approach the focus is shifting to what can be done rather than what can’t. Joint risk assessments (involving people using services) and advocacy can support this shift. To fully benefit from the personalisation agenda and balance tensions between risk and choice, care homes need practical guidance and shared learning.
Safeguarding is crucial to prevent abuse and reduce the risk of harm to vulnerable adults while supporting them to maintain control over their lives. Safeguarding in adult social care is under scrutiny and recent reviews have set out clear steps for improvement. Learning from others highlights the importance of factors that mitigate against abuse, such as strong leadership, good recruitment processes, effective information sharing and inclusion of the views of residents.
Co-ordination of care
Advance care planning (ACP) is an approach used in end-of-life care that encourages decisions to be taken before a situation or crisis arises, thereby reducing the chances of individuals being treated in a way that does not fit with their desires, values and beliefs. Some evidence indicates ACP can improve satisfaction with care received and increase a sense of control.
Care homes are considering ACP, but to realise the full potential of this approach they need to deliver relationship-based care, train staff adequately, build in sufficient time to fully embrace ACP with residents and ensure organisational values match those underpinning the approach.
There is some evidence that electronic documentation for care co-ordination can improve outcomes for professionals but more research is needed on the impact on quality of care for residents.
Recruitment and staff support
Value-based recruitment is an emerging theme in social care; emphasising the importance of assessing values and attitudes alongside skills and experience. This can be supported by having clear organisational values set out explicitly for residents, staff and potential staff. Staff selection is another area in which there is scope to involve people using care services.
While there is limited evidence on what makes a ‘good’ care worker, the ability to form and maintain relationships is particularly important as the emphasis of care delivery moves towards personalisation, choice and control.
Staff stress and burnout is a real concern for residential care settings. The use of mediators is apparent from the literature, although limited evidence of effectiveness is noted. Self care is an important concept, which requires staff to take care of themselves before expecting them to be able to care effectively for others. It encompasses physical, emotional, relational and spiritual (‘bigger picture’) elements and could help with staff retention and job satisfaction. While it is the responsibility of individuals to care for themselves, employers can highlight the importance of self care, possibly through existing support mechanisms.
Schwartz Care Rounds, an approach originating in the US, gives staff the opportunity to reflect on the emotional and social challenges of their work. Many hospices and hospital wards are embracing this approach and evaluations have shown better team working, lower stress levels, increased engagement with self care and better relationships between staff and patients. There is an opportunity to reap some of these benefits in care homes: a sensible approach would be to use a pilot project and build on the experiences of others who have introduced this model.
Themes emerging from other care settings that could help improve the quality of care in residential homes relate to increased involvement of service users, personalisation of care services, and holistic approaches that help create a positive organisational culture.
The review, by definition, focused on the three comparison settings and did not include a full review of current practice in care homes. There is an argument that other settings could learn from some of the innovative practices being driven forward in residential care, for example My Home Life.
While the research identified interesting ideas for care homes from other settings, a lack of evidence of effectiveness on outcomes made it difficult to extract robust transferable learning. The findings provide a starting point for approaches that need to be explored in more detail with care home providers and partners in the comparison settings.
About the project
A rapid evidence assessment was undertaken between February and July 2013, covering international and national literature, evidence and evaluations from the three residential settings and a ‘sense check’ exercise involving frontline practitioners and managers from six organisations. While evidence was screened for relevance and quality, the project found a lack of evidence on the impact and