The Promoting Excellence in All Care Homes (PEACH) study focused on the care home workforce, who play a pivotal role in promoting the quality of care provided to older people and are therefore a major influence on residents’ quality of life. This large work-force, of probably over a half a million people, carry out work that is often seen as unattractive, at rates of pay that are seen as under-valuing the contribution made, without a clear career structure, in a sector that is marked by constant change.
The sector itself often attracts unfavourable publicity in relation to reports of abuse and neglect, although estimating the extent of such problems is challenging.
The research aims were to:
- Identify positive and negative factors in relation to abuse, neglect and the provision of dignified care.
- Explore the views and experiences of the care home workforce about best practice, training, job satisfaction and wellbeing.
- Determine organisational, personal, and practice contexts in which abuse, neglect and lack of respect may occur between staff and residents.
- Develop and evaluate an evidence informed training package.
- Make recommendations for policy development, training and regulation in care homes.
Win Tadd – Principal Investigator
Dr Win Tadd spent many years as a nurse and senior lecturer in the UK and Australia. She was awarded an International Fellowship by the Hastings Centre, New York in 1989, a UKCC Scholarship in 1997 and is currently a Reader in Cesagen, School of Social Sciences, at Cardiff University. She chaired the Welsh Government’s National Coordinating Group on Dignity in Care from 2007 – 2011 and is a member of the Advisory Board of Stroke Cymru.
Her research focuses on the ethical aspects of ageing and care of older people. She coordinated the EU project Dignity and Older Europeans, the largest comparative study undertaken in this area. Her other European work explored the information needs of older disabled people (Infopark), Virtues and Chronic Illness and The value of ethical codes in nursing.
Bob Woods – Co-applicant
Professor Bob Woods studied Experimental Psychology at the University of Cambridge, before qualifying as a clinical psychologist at the University of Newcastle-upon-Tyne in 1975. He then worked for several years in the NHS in Newcastle, as a clinical psychologist with older people. There he established groups for carers with Age Concern, as well as developing therapeutic approaches for people with dementia. In 1980, he moved to London, combining extensive clinical work with older people at the Bethlem Royal and Maudsley Hospitals with an academic appointment at the Institute of Psychiatry, London. He worked with the Alzheimer’s Society to develop information for family carers, and undertook a number of research projects on family care-giving, as well as developing new services. In 1992, he moved to University College London, where he continued to be heavily involved in training clinical psychologists in work with older people, as well as in service developments in the NHS and in research on caregiving. He has published widely, from research papers on dementia care and on depression in older people to books for family carers and training packages. He was appointed to the first Chair in Clinical Psychology with Older People in the U.K., at Bangor University in 1996, and continues to work clinically in an NHS Memory Clinic. He is Co-Director of the Dementia Services Development Centre Wales, Director of the Centre for Social Policy Research & Development and a member of the Medical & Scientific Advisory Panels of the Alzheimer’s Society and Alzheimer’s Disease International. Recent research has focused on caring relationships and the evaluation of interventions designed to assist carers.
Tony Bayer – Co-applicant
Professor Tony Bayer is Head of the Section of Geriatric Medicine in Cardiff University and Director of the Memory Team, a long established clinical service for people presenting with dementia and their carers. He has published widely in the field of geriatric medicine, with current research interests centring on epidemiology, assessment and management of cognitive decline and neurodegenerative disease, frailty and ethical issues and older people. He is Editor-in-Chief of Reviews in Clinical Gerontology, a member of the Global Aging Research Network (GARN), the European Collaborative Geriatric Research Network (Geronto-Web) and the Scientific Advisory Panel of Alzheimer Europe.
Diane Seddon – Co-Applicant
Dr Diane Seddon's research interests include: carers and caregiving; assessment and care management; dementia; the health and social care interface; and, nursing and residential care home provision. She has been involved in the development of a successful research programme relating to carers, which has attracted research grants from a wide range of funding bodies, including the Department of Health, Welsh Government and the Big Lottery Fund. Diane has advised on national policy development, including as a Specialist Advisor on domiciliary care to the Welsh Affairs Select Committee, House of Commons. She has also led reviews of national policy implementation, including the evaluation of the National Carers Strategies in England for the Department of Health and in Wales for the Welsh Assembly Government, as well as the Pan-Wales evaluation of the Unified Assessment Process. Current research looks at support for adult survivors of child abuse.
Gill Windle – Co-Applicant
Gill Windle is a Research Fellow based in the Dementia Services Development Centre, Institute of Medical and Social Care Research at Bangor University. She studied psychology at Bangor University and obtained her PhD in 2006. Her research interests are in health promotion, mental health and resilience in later life; the interplay between the individual and their physical, social and environmental contexts and the effects on well-being. She has been considerably involved in policy development in Wales, co-authoring a number of literature reviews to inform the development of the Strategy for Older People in Wales (Welsh Assembly Government 2003) and the Healthy Ageing Action Plan (Welsh Assembly Government, 2005). She was seconded to the Older People’s Strategy Unit at the Welsh Assembly Government during the 2006/07 interim review period and was a member of the Strategy Advisory Group.
Martin O’Neill – Research Associate
Dr Martin O’Neill entered academia following a mid-career change of direction having previously worked in the Health Service. He has worked at the Universities Swansea, Glamorgan and Cardiff and has conducted research in Wales, England, Poland and France. His main areas of research interest are: health inequalities and wellbeing; institutional elderly care; social and economic regeneration particularly in the South Wales valleys; participatory action research; ethnography and visual methods.
Dr. O’Neill has a strong commitment to working with the disadvantaged communities of South Wales to help them tackle some the social and economic problems that they face and is actively involved with the Welsh Government’s Communities First Initiative. In recent years he has become increasingly interested and involved in using film, video, ICT and digital media as a method of engaging hard to reach groups in participatory research and dissemination.
Charlotte Hall – Research Associate
Charlotte Hall’s research interests include: organisational culture; public services; entrepreneurship and innovation. Charlotte conducted ethnographic data collection, data analysis and workshop facilitation for the Promoting Excellence in All Care Homes project.
Simon Read – Research Associate
Simon Read is a Research Associate at Cesagen in Cardiff University, contributing to studies regarding ageing and the ageing society. His work on the Promoting Excellence in All Care Homes project has been primarily focussed on data analysis, workshop facilitation and the piloting of the training package.
A mixed method approach to the study was adopted, including:
- Desk research: to identify existing training materials.
- A postal survey of care workers and managers.
- Ethnographic observation in eight homes from across England, including a mix of urban and rural locations, with and without nursing, independent homes and members of small and large chains, ranging in size from 35 to 106 residents, some specialising in dementia and some not. At least 60 hours of observation was undertaken in each home, over a three to four week period, covering the whole 24 hour period.
- Semi-structured interviews were conducted with a total of 33 staff working in the eight care homes; exploring their views of training and care delivery beliefs about dignified care and work experiences.
- A job satisfaction and well being survey comprising of validated questionnaires was completed by 73 staff working in the eight homes. The measures used assessed burnout, job satisfaction, a sense of mastery and attitudes to ageing and dementia.
- Focus groups were held with 29 care home managers and trainers and (separately) with 15 members of the Relatives & Residents Association. In total,eight groups were held in two waves, before and after the development of the initial version of the training materials, which were then adapted in the light of the feedback obtained.
- A training package was developed, piloted and evaluated in eight training sessions in seven of the care homes, and structured feedback obtained from 77 participating staff.
- Stakeholder workshops with around 85 participants were held at the end of the project where emerging findings were discussed, the training package reviewed and draft recommendations considered.
The Postal Survey
The postal survey results, albeit based on a small sample and therefore not to be taken as definitive, showed that a wide range of available training was taken up in the care home sector. The majority of managers stated that staff in their homes had training on dealing with abuse, but over half reported that staff did not have training on dealing with challenging behaviour in their home. The majority of care workers completing the survey, wanted further dementia training including communicating with people with dementia, managing aggression and performing activities.
Well being and job satisfaction survey
The validated questionnaires completed by 73 staff members, confirmed the relationship between attitudes, aspects of burnout and job satisfaction. Although the majority of staff had low levels of burnout, 29 per cent had a high level of emotional exhaustion and one in five members of care staff reported high levels of depersonalisation, where care recipients begin to be seen as objects rather than people. Significantly, 41 per cent reported a low sense of personal accomplishment, which is associated with a low sense of mastery and negative attitudes to ageing and dementia. Low self-efficacy is clearly prevalent in care workers, and could be an important target for training.
At the macro level, those participating in the research with roles in home management or administration presented the social care sector as being characterised by constant change, e.g. in relation to the inspection framework, training requirements and the paperwork and attendant bureaucracy and by inconsistency, with a lack of standardisation noted in relation to fee structures, staff numbers, inspection, staff training and qualifications and in the interface with the NHS. Thus at the macro organisational level, there is a sense of not being able to keep up with the pace of change and of a potential lack of clarity or even unfairness.
At the micro level, considering the home as an organisation in its own right, the home may be viewed as a physical and emotional space, which may meet residents’ needs for example for privacy, personalisation, choice and control or for support with physical or cognitive needs, to a greater or lesser extent. Some of the homes clearly attempted to create an atmosphere of ‘homeliness’ and assisted residents to feel that they are ‘at home’, and to avoid the more institutional atmosphere still evident in some homes. The physical layout of the home served either as a barrier or facilitator to exchanges and interactions between residents and was an important contributory factor in determining the home atmosphere.
The difficulties in recruiting and retaining staff were evident from this study. These added to the pressure on existing staff, who often worked long hours, and on junior staff who received less supervision than would be desirable. Staff were often recruited from overseas, which in some instances raised issues regarding effective communication in a second language. Staff also reported experiencing racism, and there were clearly tensions between different cultural groups in some homes, which had an impact on teamwork. There were also, tensions in teams between different staff groups, most notably between nursing staff and care staff, and also between older and younger staff. The importance of effective leadership and supervision in fostering good teamwork was clear.
Whatever the staff resource – and staff shortages were repeatedly raised as a major issue – each day there was a job to be done, or rather a whole series of tasks, largely around fundamental care relating to eating and drinking, elimination, washing and dressing and administration of medication. Staff were hampered in achieving these tasks by a lack of information and related resources (e.g. Zimmer frames, adapted cutlery), as well as by shortage of staff. In the homes observed, there were also efforts made to support residents in managing pain and to offer opportunities for social interaction and activities. However, the hours of observation made clear that each home had its own rhythm, its own routines, and that this would often have priority over the rhythm of the individual residents. It was clearly difficult to achieve a move from task-centred care to person- or relationship-centred care.
In each care home, three major groups of actors play key roles, which interact and influence the experience of life in the home. Residents’ attitudes and behaviour have a major impact on other residents and the staff. Positive attitudes to staff were observed as were examples of residents showing empathy and understanding to each other. On the other hand, residents were at times challenging to staff, and occasionally aggressive to staff and to other residents. This often occurred in the context of dementia.
Staff also showed empathy and understanding, and there were many examples of staff empowering residents by offering choices, and providing support so that the resident could retain as much independence as possible. Less often, there were clear examples of staff disempowering residents, most notably through patronising communication, often described as ‘elderspeak’ and through giving priority to routines rather than to individual needs and preferences. No instances of staff being aggressive to residents were observed, although these were reported as having been witnessed by staff when working in other homes. Relatives also had an important, largely positive, role in the homes.
The Training Package
Based on the emerging findings from the study, an evidence-based training package was developed and a preliminary evaluation undertaken. Dissatisfaction with both the content and delivery of much existing training was identified by all parties and topics that were thought to be inadequately covered by current training included dignity, respectful communication, responding appropriately to the needs of people with dementia, and end of life care issues. It was clear that any new package to be developed must demonstrably contribute to excellent care, whilst being low cost and being capable of being delivered ‘in house’ in a variety of ways. The package needed to reflect the day to day realities of life and work in the care home, whilst at the same time comply with and promote the new CQC Essential Standards and Skills for Care Common Induction Standards (2011). Accordingly a vignette based set of materials was developed, engaging staff in considering situations relevant to the identified target topics, where there were not necessarily clear cut answers or solutions. The vignettes were all based on situations that had been observed during the ethnographic research. This approach promotes reflective practice, in contrast to a ‘tick box’, or checklist approach to learning. By using the vignettes in the context of a group discussion, the opportunity for developing team working, group cohesion and a shared, person-centred culture arises, with the opportunity for learning from each other’s experience in a peer group context.
In addition to the vignettes, the package includes material and exercises on attitudes to ageing and a broad conception of dignity. The package has been piloted in seven care homes, and evaluative feedback on the content and the delivery mode has been obtained. This has largely been positive. The materials are capable of development to form the focus for regular group reflective practice supervision sessions in a home, rather than as a one-off training session.
This study is independent research commissioned and funded by the Department of Health Policy Research Programme and Comic Relief under the PANICOA initiative. The research team wish to gratefully acknowledge this support. The views expressed here are the responsibility of the authors and not necessarily those of the NHS or the Department of Health.