Relationship between staff and quality of care in care homes: StaRQ mixed methods study

Data sources

Quality assessment of studies

Studies were quality assessed using the Mixed Methods Appraisal Tool (MMAT). 33 Two reviewers (RD and KH) independently screened and assessed methodological quality. Disagreements were resolved through discussion with a third reviewer (KS). We did not exclude studies based on quality assessment, but we were able to appraise the quality of evidence available to address our question. See Appendix 5.

Data analysis

We used content analysis:34 this approach supports analysis of large amounts of text data. There were four stages to our analysis: (1) familiarisation with the data; (2) organising data into meaning units; (3) coding data to higher level themes; and (4) refining higher level themes. One researcher (RD) iteratively coded data relating to roles and responsibilities and quality of care and life. Coding was developed for different roles: RNs and CAs. Organising data in this way supported comparative analysis so that we could identify similarities, differences and patterns in roles and responsibilities. We ensured an audit trail of the review process to enhance transparency. A team of three researchers was used for analysis and interpretation.

A narrative synthesis of our analysis is presented in Chapter 4.

Stage 1: theory elicitation

Stage 2: theory development and testing

Stage 3: theory refinement

In this final stage, we refined context–mechanism–outcome configurations and examined supporting evidence in three researcher-led discussions during November to December 2019 with our stakeholder groups which included: residents and relatives (group 1) and care home managers (group 2), and our Study Steering Committee (SSC) members (including representatives from provider organisations, policy-makers, regulators, methodologists and members of the public). Stakeholders were invited to comment critically on the resonance, relevance and gaps in our theories. Revision of context–mechanism–outcome configurations after each discussion led to the final set of refined context–mechanism–outcome configurations (presented in Chapter 4).

Latent profile analysis

To examine whether it was possible to discern any patterns in variations in staffing between homes and whether different care home staffing models might be associated with care quality we first examined whether it was possible to detect distinct home/staffing models. Specifically, we attempted to see if it was possible to identify homes with similar workforce characteristics (e.g. similarities/differences in staff-to-bed ratios, patterns of staff experience or temporary staffing use). To do this, we used latent profile analysis (LPA) using the R package tidyLPA. 53,54 LPA is a type of modelling that uses Expected Maximisation algorithms to find maximum likelihood parameters of the statistical model, assuming that it is derived from unobserved latent variables. 55 LPA is a data-driven approach pertinent to a research design in which a number of clusters is not assumed in advance. However, this analysis did not provide any evidence of distinct care home staffing models.

Next, we used multilevel logistic regression to test for relationships between the workforce characteristics described in Table 2 and CQC scores to examine whether differences in workforce characteristics were associated with differences in CQC assessments of quality.

Multilevel logistic regression

We originally planned to treat CQC inspection scores as an ordinal measure of quality. However, 75% of CQC ratings were reported as ‘good’ (see Table 1). However, preliminary analyses suggested that ordered logit analysis was technically inappropriate because the proportional odds assumption was violated. Further confusion matrices derived from ordered logit models found that these models failed to correctly predict both inadequate and outstanding homes. Therefore, we split the CQC score variable into homes rated ‘inadequate’ or ‘requires improvement’ in one category and ‘good’ or ‘outstanding’ in the other and proceeded with logit analysis on this binary outcome.

Local authorities in England act as commissioners and funders of social care for residents and have statutory responsibilities to promote the efficient and effective operation of a market for care services in their locality and must foster workforce development and continuous improvements in service quality. 56 Further, around a fifth of homes in the data set were directly operated by local authorities. Therefore, to account for variations in approach taken by local authorities in managing these homes and in fulfilling their statutory duties, we took a multilevel approach. Where homes are clustered within local authorities, we fitted multilevel logistic regression models using R software environment for statistical programming and data visualisation. The main effects were estimated by multilevel (hierarchical) logistic regression. This is a nested model: care homes represent level one and local authorities with social care responsibilities level two.

Multilevel (hierarchical) regression was appropriate because CQC inspection ratings varied significantly by local authority – as evidenced by the intraclass correlation (ICC) score in regression outputs (ICC score captures the proportion of variation in CQC scores that is due to differences between local authorities). Conditional and marginal R-squared show the proportion of variance explained by fixed effects only and the entire model, respectively. We fitted three separate models. The first is for all homes for older people (nursing and residential), the second is for homes that provide residential care only, and the third is for homes that provide nursing care. This is because relationships between workforce characteristics and quality may differ in these different contexts.

Measures of quality

Quality outcomes were operationalised using nurse-sensitive indicators of care quality. Nurse-sensitive indicators of care quality investigated were: pressure ulcers developed in the care home; falls; falls that result in a fracture; urinary tract infections (UTIs); and chest infections. We also examined reported medication error rates as a broad measure of care quality. These measures all represent adverse incidents within the care home. All outcome measures were transformed to a ‘rate per occupied bed per care-home month’. See Table 3 for statistical description of measures. All these indicators constituted relatively rare events. The most common falls occurred at a rate of ~one per five occupied beds a month. Falls resulting in a fracture were much less common: ~1 per 335 occupied beds per month. Chest infections occurred at rate of ~1 per 20 occupied beds per month, UTIs 1 per 14 occupied beds per month, pressure ulcers 1 per 100 occupied beds per month and medication errors 1 per 62 occupied beds per month. We discuss the limitations of these data sets in Chapter 5.

Measures of workforce

We calculated total care hours (nurses and carers), carer hours and nurse hours per occupied bed per month and a skill mix variable – the proportion of care hours provided by RNs per occupied bed/month. The median number of total care hours per occupied bed per month was 122.5 (interquartile range = 35.5). The median percentage of these hours provided by RNs (skill mix) is 22.5% (interquartile range = 10%). If nurses are off sick or there are unfilled RN vacancies, the care home provider would seek to cover shifts using RN provided by agencies. The median percentage of care hours provided by agency nurses per month was 1.9% (interquartile range = 6.7%). We also have measures of whether nurse and carer hours were at or below their planned levels. We used this to calculate the proportion of planned hours worked each month, providing a combined measure of staff absence due to uncovered shifts arising from sickness and absence. The median percentage of planned hours worked for RN hours worked is 97.3%, although an interquartile range for this variable of 12.3% indicates that shifts where nurse staffing was below target were not uncommon. For carer hours worked as a proportion of planned carer hours worked, the median is higher, 99%, although the interquartile range is slightly larger at 13.4%. See Table 3.

Control variables

Other variables included in the analysis measure aspects of time-varying, home case load, that is changes to demand for care that could therefore affect the processes of care, specifically (see Table 3): (1) ratio of average weekly new residents admitted to available beds (median = 0.02, interquartile range = 0.022); (2) number of occupied beds (median = 44.3, interquartile range = 25.3) and the total number of beds (occupied and unoccupied, median = 52, interquartile range = 29).

We computed the proportion of beds occupied per month (median = 0.9, interquartile range = 0.138) and included this in the regression modelling instead of separate measures of number of beds occupied and total beds. The care home provider shared data constituting proxy measures of potential need: the proportion of residents who were elderly, receiving specialist dementia care and exhibiting challenging behaviours, younger residents with disabilities, receiving specialist care for Parkinson’s or Huntington’s disease and residents receiving specialist end-of-life care. The data were from a single time point (April 2018) and included to examine whether their inclusion affected results.

Social network analysis

The SNA was focused on the advice and influence relationships within the care homes. A roster name generation method95 was used with the care home staff (including managers) in each case site. A blank name slot was added to allow respondents to mention people not included in the roster. The care home managers from the corporate provider were also asked to consider other managers from within the wider corporate network in their responses. All employees were listed, and respondents chose staff in response to three questions asked: (1) Who do you seek advice from on quality of care? (2) Who do you influence on quality of care? (3) Who influences you on quality of care?

This method has the benefit of being efficient; essential in a time-poor environment with competing demands for staff attention. On average, it took staff approximately 10 minutes to answer the survey. Managers took longer (average 39 minutes) to complete the survey as they also completed the NoMaD survey tool (see below).

Staff completed the questionnaire at the care home with the researcher or online. In two homes surveys were left for staff to self-complete and returned to the research team. Most homes had unreliable internet access and so paper-based questionnaires were provided with an optional link to the online questionnaire.

NoMAD

We used the NoMAD survey tool created by Finch et al. ;94 this is based on normalisation process theory (NPT). 96 NoMAD is a 23-item instrument for measuring implementation processes from the perspective of social actors directly involved in the work of implementing an innovation. 97 The manager in each home (n = 11) completed the NoMAD survey. They were asked to imagine (their) ‘ideal’ website bringing together staffing and quality. Care home managers were asked to complete the survey because they would most likely instigate and lead the management of the implementation of any translational technology arising from our study.

Social network analysis

The SNA was used to determine the central players for the flow of advice and influence in home networks. We focused on incoming influence: these responses were more trustworthy than the outgoing influence responses due to the weakness Rogers98 identified in the self-designation method of identifying opinion leaders. We focused on Roger’s sociometric measure of identifying opinion leaders. 98 First, on individuals who have the most connections in the advice network and the influence network: degree centrality. Second, on individuals who serve most often as a bridge in the network: betweenness centrality in SNA. This identifies who serves as connectors between different parts of the network. All respondents were asked about length of service they had in the care home and in the sector, as well as their gender, race, shifts worked and home role.

The responses were processed using UCINET, a SNA software package. 99 The software was used to generate network diagrams and network statistics.

NoMAD

The NoMAD tool has 23 questions to determine readiness for innovation based on four constructs: coherence (the sense-making work that people do individually and collectively when faced with operationalising a set of practices); cognitive participation (the relational work that people do to build and sustain a community of practice around an innovation); collective action (the operational work that people do to enact a set of practices associated with the innovation); and reflexive monitoring (the appraisal work that people do to assess and understand the ways that an innovation and set of practices affect them and others around them). 96

After three general questions on readiness with responses ranging from 1 to 10, 20 Likert scale questions measure the four constructs. Data were analysed descriptively.

Ensuring personalisation of care

Personalisation refers to the focus on the older person’s specific needs, wishes and preferences by care home staff (including RNs and CAs) and using this knowledge and understanding for planning and providing individualised, personally appropriate and respectful care.

Registered nurses and CAs described the importance of establishing close, ‘family-like’ relationships with residents to enhance their knowledge and understanding of the individual. 101,112,125,128,131,135 ‘Getting to know’ the resident required investment of time by RNs and CAs. 104,108,112,122 Work undertaken during and outside of contracted hours; for example, spending time with residents after a shift or on days off. 109,112 Not all CAs prioritised relationship building, focusing instead on task-orientated care. 120,138 Relationships, and ‘knowing’ an individual, were perceived to help staff be responsive in the support and care provided for residents. 101,104,112,122,126,133 RNs reported it supported efficient decision-making to address health and social care needs of residents, whereas infrequent interactions or lack of familiarity with residents negatively impacted on care. 133 CAs perceived personal relationships ensured a ‘human touch’101 and helped them carry out their work,104 for example, recognising signs of pain for a resident and then ensuring adequate pain relief. 128 It also provided strong motivation to provide a level of care that they would for their own family members. 101,103

Staff described using a range of communication methods to build trusting relationships with residents and enhance quality of care and quality of life: greeting a person by name, complimenting a resident, engaging in conversation on topics of resident interest, accepting how a resident is feeling, using humour, or sharing information about hobbies or family as appropriate with residents. 101,104,108,129 While humour was considered an important strategy for building relationships, care home staff emphasised the importance of determining a resident’s reaction or response to humour and adjusting the content and/or tone of this form of communication. 129 Similarly, staff disclosure of information about themselves to a resident needed to be appropriate and acceptable for the resident. 129 Non-verbal communication strategies used included displaying affection, gentle touch or hugging, smiling, being present, not rushing and small gestures aimed at demonstrating understanding of what matters for the resident. 100,101,104,135

Care staff perceived relationship building as important for residents as part of a comfortable and supportive living environment,104,112 and ensuring resident perspectives and experiences were respected. 103,104,129 Building trust was important if residents were able to communicate their needs, such as their physical status or pain or discomfort experienced. 126 CAs described the importance of ‘family-like’ relationships for residents who did not have regular visits from family and friends: CAs described that they fulfilled this role for these residents. 108 RNs had an important role in supporting residents to establish and maintain meaningful relationships with staff, other residents, visiting family and friends. 127 This included assessing any communication difficulties that the resident may be experiencing, for example any difficulties with hearing which could be addressed to support relationship building. 119

Care home staff reported their important role in preserving and promoting personal dignity for residents and involving them in care. RNs played key roles in assessing and planning care,119,122 including finding solutions for, or new ways of addressing, care issues. For example, when a resident refused or resisted assistance with personal care then it was important to find respectful ways to support the resident. 122 RNs also had to clearly communicate any plans for care with CAs. 100 CAs had an important role in supporting residents with personal care to meet personal preferences for maintaining their physical appearance or to ensure their living space was maintained;103,134 this included activities such as timely care to assist someone to maintain their hygiene when incontinent, minimising unpleasant odours by removing wet or soiled linen or clothes, or tidying personal belongings. CAs also perceived it important to provide this personal care with empathy103 and to control non-verbal responses when providing intimate care to not offend an individual resident. 100

Care home staff considered it important to maintain residents’ rights to make choices and decisions about their care, alongside assessing individual capacity to consent:100,104,121 this was promoted by listening to residents, gaining permission from residents, involving residents in decisions and offering information and choices. 114 CAs described that they had an important role in translating complex medical information into lay language for residents,100 and advocating for residents. 100,103,135 RNs described that involving residents in their care required knowledge, competence and effective communication skills, as well as time and opportunities to interact with residents. 114

Assessing, supporting and monitoring resident health and well-being

Care home staff (RNs and CAs) described the importance of their interactions with residents for timely assessment, support and monitoring of residents’ health and well-being. Relationships and ‘knowing’ the resident have been described above. This section provides more depth of how care home staff gather intelligence through these relationships for the purpose of enhancing quality of care and quality of life for residents.

Staff recognised that residents were not always able to articulate when they felt unwell, or when their symptoms were worsening. Therefore, knowing a person helped staff to recognise subtle changes in a resident that may indicate a change in their health status or deterioration and that could promote timely care or interventions;126,128 for example, identifying new or worsening pain for a resident. 102 Examples of observations used by staff for this purpose included changes in resident daily behaviour patterns (e.g. sleep or appetite patterns), body movements or non-verbal gestures (e.g. pointing at or rubbing an affected area), interpersonal interactions (e.g. agitated or not talking) and external appearance (e.g. a bed sore or rash). 102,104,126,128 CAs also described assessing verbal tone or expression of emotions104 as indicators of potential change when a resident could not verbalise their health status. Daily assessment for all residents, and in particular for residents living with cognitive impairment, was considered an important role for all staff to enhance quality of care and quality of life. 126,128

Being able to competently undertake these observations required consistent assignment of staff to build understanding of the person and recognise changes. 133 This could be particularly challenging for RNs who often delegated caring responsibilities to other staff and so had to rely on these staff to report resident changes back to them. 133 RNs perceived it important to direct the care team to ensure these observations were undertaken when providing day-to-day care for, and interacting with, residents. 126 RNs also recognised that particular resident groups (e.g. those being cared for in bed) required careful observation and monitoring. 126 CAs described themselves as ‘proxy reporters’, ‘middle person’, ‘gate-keeper’ and ‘bridging the gap between nurses and residents’. 128 However, some studies reported that some CAs did not consider resident assessment as part of their role, nor their responsibility. 128,133 CAs were cautious and wanted to avoid being responsible for errors so focused on fundamental aspects of care rather than engaging in assessment activities. 128 A task-focused approach, for example CAs focusing on helping a resident to wash and dress but not looking at the condition of their skin, meant that health problems could go unnoticed and untreated, and negatively impact on a resident’s quality of life. 133 Conversely, some CAs reported that when they recognised changes in a resident’s health, for example level of pain being experienced by them, this assessment was not always acknowledged by RNs. 119,128,133 RNs have an important role in supervising and supporting CAs to monitor and report changes in resident status through constant dialogue and engaged teamworking. 113 CAs have not always been adequately trained to assess residents and so without this level of support and supervision by RNs, residents are at increased risk of deteriorating133 or not having their condition or state (such as pain and whether medicines are relieving their pain) reassessed. 128 RNs also have a key responsibility to assess and liaise with other healthcare professionals to ensure the health and care needs of residents are appropriately reported, addressed and managed. 122,133 The importance of team relationships is considered further below (See Leading and co-ordinating care).

Registered nurses described taking actions to ‘nip things in the bud’ and prevent further worsening of a health condition or to minimise deterioration of the resident’s overall health and well-being. 110,115,119,123 RNs described their responsibility to use their knowledge and assessment skills to ensure appropriate care and support for residents, which included for example requesting review and reductions in medicines being administered or obtaining appropriate equipment for assisting residents to move and to prevent pressure area damage. 119 The physical presence of a RN ensured early identification, or anticipation, of problems for residents and so had potential to prevent deterioration of resident health or well-being and also promptly manage acute situations. 119,125

Promoting safety

Registered nurses have an essential role in promoting safety for care home residents, including the delegation and supervision of care provided by CAs. Leading and co-ordinating care is an important aspect of safety and is also considered as a separate theme below (See Leading and co-ordinating care). RNs also interface with external healthcare professionals. Studies highlighted the ways in which RNs work with the range of internal and external staff to ensure appropriate and timely interventions and care by staff to promote quality and safety for residents, as well as to create safe environments.

Registered nurses coach the direct care team and their physical presence is reported to improve care delivery and support teams to reflect on what works well or may need to be improved. 117 The RN has an important role in co-ordinating care and role modelling best practice and professional standards of care. 132 Studies revealed that RNs adapted their ways of working to accommodate best use of the skills set of colleagues for the benefit of residents’ care and to compensate for any perceived deficiencies in staff knowledge, skills and competence, or to accommodate organisational challenges such as staff shortages in the care home or access to other healthcare professionals. 115,123

The RN anticipates care demands, planning work and being responsive and flexible in care delivery and their work to ensure resident safety. Studies highlighted how RNs filled gaps in care while fulfilling their own roles and responsibilities through ‘workarounds’ or adaptations. 115,123 Unintended consequences were identified when RNs were filling gaps in care over extended periods while fulfilling their own role and responsibilities: higher workloads for RNs were perceived to increase errors in care delivery. 123

Record keeping was considered an important source of information about care ‘done’ or ‘not done’ by the care team; CAs recognised their role in supporting the maintenance of accurate care records. 100 RNs audit these care records and following up on any missed care or ensuring accurate records to reflect the care provided. 116 Deficiencies in care records were perceived by all staff (RNs and CAs) as neglectful and opening opportunities for criticism or blame cultures. 100 Learning from adverse incidents (such as medicine administration errors) was also used by RNs to support the care team and to develop a more open culture and climate that would benefit residents’ care and promote safety. 113

Knowledge of, and adherence to, policies and protocols were considered a prerequisite for achieving safety for residents, but RNs acknowledged that these did not always accommodate the challenges and realities of working in a care home environment. 113 This led staff to find workarounds to ensure safe care delivery, for example to ensure the administration of medicines when short-staffed. 110,123

Registered nurses were considered essential for creating safe environments for resident care. 119 Examples of ways in which nurses contributed to safe environments included carrying out risk assessments, documenting and recording care, minimising potential harms/hazards, using protocols to help prevent falls, obtaining appropriate equipment for moving and handling of residents, and preventing pressure area damage,119 and preventing medication errors. 110,116,125 Decisions related to creating safe environments had to be balanced with the RN’s ambition to promote resident choice and freedom within the context of a shared residential environment meeting the needs of a varied resident population. 122

Leading and co-ordinating care

The importance of RNs leading and co-ordinating care has already been raised in the themes above. We develop understanding specific to leadership and co-ordination in this section. In particular, we consider the ways that RNs work collaboratively to promote good quality care, support planning activities and ensure safe delegation of care.

Studies described RNs working collaboratively with members of the care home team, relatives and external healthcare professionals. This collaboration was perceived to improve resident’s health status and quality of life. 119,125,132 Collaboration required RNs to effectively listen to others and gather information about the resident and their needs and preferences from residents themselves, their relatives and the care team. 107,110,114,115,125 RNs translated this intelligence into a care plan that promoted personalisation of care (discussed above), and then played an important role in ensuring the right people were involved at the right time to support the resident.

A significant proportion of personal care and support is provided by CAs in care home settings. CAs had a pivotal role in monitoring residents and reporting changes in residents’ health and well-being to RNs125 and to initiate additional care or services, for example from the medical team. 100 RNs reinforced this perception: CAs were described as their ‘eyes and ears’115 but it was the RN who led and co-ordinated care.

Registered nurses were described as having a key role in liaising with medical and allied health professionals. These services – medical care, physiotherapy, occupational therapy and dietetics – are often provided for care home residents by external services. RNs liaised with relevant professionals to ensure timely inputs to meet residents’ health, care and support needs. This requires RNs knowledge of the resident and a comprehensive assessment to help inform decision-making about care and to guide these inputs. 110,114,133 Involving the resident and family with these services and care was also deemed the role of the RN. 125 Despite being pivotal for collaboration and co-ordination, it is important to highlight that RNs reported that they often worked alone in the care home setting:106,107,115,116 they described themselves as a ‘solitary worker’. 116 This highlights a distinction between RNs working in this context to, for example, in an acute care environment where there are often more RNs working at one time and access to medical staff.

The RN had a role in planning activities, which was closely linked with ensuring leadership and co-ordination of care for residents’ benefit. Planning activities occurred at a number of levels; for example, to ensure adequate resourcing and staff rostering (facility level), to prioritise, plan and delegate daily work and activities for the team (team level) and to respond to residents changing needs (individual level). 122,123,132 Delegation of care activities by RNs to CAs required:105,113,115,116,119,125,132

• The RN to clearly communicate with CAs and to have understanding of the knowledge and skills of the care team for appropriate delegation.

• RN and CA relationships based on trust so that the RN had confidence that delegated care would be carried out appropriately and the CA would report if they did not feel capable to perform, or did not understand, the delegated care.

• The CA to report any concerns about the resident to the RN and the RN to follow up on delegated tasks with the CA, monitor residents and outcomes and any unintended consequences of delegation for residents or the care team.

As leaders and co-ordinators of care, the RNs required an understanding of the care team for safe delegation. When delegating, RNs had to ensure they maintained a level of engagement with residents and their care so that they could review and respond to any changes in care needs for the resident. 133 RNs also had to minimise task-based approaches to care when delegating: while carrying out delegated care tasks (e.g. bathing), CAs needed flexibility in their work (and the organisation of this work) to be able to respond to immediate needs of residents. 109 Task-based approaches or routines were perceived by care home staff to have a negative impact on residents and their experiences of care. 109

Supporting residents to live with purpose

In this final theme, we acknowledge that the roles and responsibilities of care home staff are carried out in the residents’ home. Therefore, in addition to meeting the personal and healthcare needs of residents, staff have an important role in supporting residents to live with purpose and to promote their quality of life and well-being. In many ways, this theme overlaps with our consideration of the ways in which care home staff ensure personalisation of care. However, we considered it important to also consider how care home staff support residents to ‘live with purpose’, alongside the tensions in their work that may inhibit this ambition.

Registered nurses described their role in helping residents with their personal well-being and quality of life. 119,127 This was perceived by care home staff as ensuring residents: felt safe and secure; established and maintained meaningful relationships (including intimate relationships); fulfilled their spiritual needs; had time to reminisce; had physical or emotional needs addressed; and maintained their functional and/or cognitive abilities for as long as possible. 100–102,104,108,112,118–121,124,125,127,130,131,138

Importantly, care home staff helped create a ‘home’ environment. Recognising individual residents within a communal living arrangement was a key concern for care home staff. 131 Care home staff liaised with residents and their families and friends to promote a sense of home for the residents. This included surrounding the resident with familiar possessions,127 or encouraging residents to maintain routines or do tasks they may have previously done. 124 Promoting residents’ choice and control about how they spent their time was also highlighted by care home staff as important. 119 RNs identified their role in maintaining balance and harmony within the communal living environment: this included supporting residents in distress or behaving in ways that may upset or disrupt other residents. 119,122 A range of strategies and approaches used by care home staff to promote resident well-being were identified in the literature, and included: providing one-to-one company; engaging in activities of the resident’s choice and promoting diverse activities, both social and recreational; and promoting a home-like environment with opportunities to engage in household tasks. 103,104,112,118–120,122,124,125,130,131,135,138 However, studies revealed the challenges for care home staff when supporting residents in the care home environment.

Staff shortages, alongside workload demands and pressures which included the administrative burden of care, limited available time for care home staff in these more supportive activities. 111,120,131,135 Physical care was often prioritised over psychosocial care130,134 and the organisation of care, particularly task-based approaches, could limit the engagement of CAs with residents’ social, spiritual and emotional care needs. 109,120,135 Cultural differences also impacted on whether CAs considered psychosocial care as within their roles and responsibilities. 129 Leadership played an important role in creating cultures that balanced the range of residents’ needs to support both quality of care and quality of life.

Philosophy of care that promotes staff–resident relationships

Philosophies of care promoting relationships between staff and residents support staff behaviours that foster individualised resident care. 139–145 Philosophies should include an explicit care-focused mission statement,139,142,146 clearly articulated and enacted through the everyday behaviours of managers/supervisors. 139,140,142,143,147 Philosophies should go beyond assisting residents with physical tasks, and address residents’ social and emotional needs through relationships. 143,144 To be effective, work needs to be organised around such philosophies. 144,145,147 For example, a core number of staff who are a ‘good fit’ with the philosophy of the care environment, who engage consistently with the same group of residents and with sufficient resources will better meet residents’ needs and preferences. 148–153 Staff who are a ‘good fit’ with the philosophy of the care environment, were those that actively valued older people:45,144,154–161 displaying or willing to learn empathy, compassion and kindness45,144,153,155,156,162–167 and enacting these attributes through behaviours; performing duties beyond the bare minimum specified in contracts, helping others45,144,155,156 and working well with coworkers. 153 Sufficient staff subscribing and enacting the philosophy meant it was reinforced, sustained and relationships developed. 153,154,159

Cross-sectional50 and longitudinal studies27,167 were inconsistent and contradictory, but revealed no critical number of staff. Numbers varied from 5 to 15 residents per staff member. 148,150–152 Relative criteria were more useful: sufficient staff for timely care, such as, avoiding residents crying out for help with no care workers around to notice,140 and consistent staff with regular contact with a group of residents and families. 168 Small groups of linked residents and staff promoted familiarity, communication and a familial environment for cultivating relationships111,150,152 with more time for residents, families168 and coworkers. 111,149,152

Managerial behaviours encouraged relationship building:139,140,146 clearly communicating role expectations and responsibilities;140,146,153,169,170 reinforcing individual staff contribution to collective care;144,146,163 physically helping out with resident needs and supporting staff;139,146,171–173 actively listening to staff, resident and families’ concerns;139,141,146 and openly discussing challenges faced. 139,141,143,147,171–174 Staff that feel supported, valued and with (managerial) ‘permission’ to prioritise residents’ needs adapt and adopt behaviours that foster expression of residents’ preferences while providing care144,147,157 and experimentation of novel ways of engaging residents. 136,153,175 A relationships-focus enables greater appropriateness in behaviours given resident preferences. 45,136,139,144,155,176,177 Strategies employed included associating residents’ stories to their own experiences, stimulating empathy and taking more responsibility for putting ‘learning’ (about individual residents) into practice. 45,156,177 Unsupported staff provided less support to colleagues,147 weakening the generative mechanisms behind quality.

Developing close bonds with residents is not without risks: relationships developed over time can increase the emotional burden of care,156,176,178 feelings of helplessness and distress when unable to reduce suffering;144 not always mitigated by caring experience. 178 Accordingly, some workplaces discouraged relationship-building with residents157,178 to reduce the emotional burden for staff. 147,176,178

Expert families

Family members are an important and valuable source of information and understanding for residents’ needs and preferences. 140,153,164,166,173,179–181 Staff engagement with family members – if desired – leads to family acting as experts in their relative’s care. 166,172,179,180 In a philosophically and behaviourally supportive context, these roles positively influence staff behaviours and create opportunities for relationship-centred care140,164,182,183 – especially for residents living with de5mentia. 179

Family involvement is legitimised via formal mechanisms for involvement. This also encourages relationship building168,179,182,184 built around ‘informing staff’ and ‘consulting with staff’ through to ‘co-deciding with staff’. 179 Mechanisms for meaningful participation include: invitations to care planning meetings,166,179,182,185 support groups for family members,184 formal introductions to staff members at the facility,179,182 and regular family information meetings. 182,185

Relationships between staff and family members should be reciprocal and act as a vehicle for sharing information about residents,144,164,168,172,179,181,182 their preferences and other personal information for informed care164,179–181 and care planning. 179 Practical manifestations can be seen in staff avoiding foods that a resident dislikes and using personal belongings to create homely environments. 164,172 Family may demonstrate successful behavioural strategies and interpretation with residents. 144,179,184 In turn, staff feel rewarded from positive relationships with families. 144 Establishing relationships with family members takes time. 140,144,153,164,181,182 Once established, communicating care plan changes,182 health,144 and participation in activities can be sustained,164 generating a greater sense of shared caring responsibilities and mutual respect. 144,164,172,173

Risks for staff associated with greater familial involvement include feelings of stress and anxiety arising from unrealistic demands and expectations on care provided140,144,178,179,183 or an unwillingness from family to accept a resident’s deterioration178 or challenging behaviours. 144 One consequence is negative feedback loops of poor staff experience and negative attitudes towards families, diminishing recognition of continued importance of staff–family relationships,140,179,183 and subsequent relationship breakdown. 140,144,178,183

Team reciprocity

Companionship is important in care work; being seen, needed and supported by reciprocating colleagues provides satisfaction and meaning in work. 157,158 Expressions of reciprocity included, ‘we depend on each other’,157,172 ‘show respect for one another’,146,173 ‘we take turns’,186 and ‘we are a part of each other’s decision-making’. 146 Sometimes reciprocity was implicit in teamwork,143 meaningful relationships with colleagues,144,171 shared values,141,143,158,170,172 mutual respect,141 a mutual understanding of each other’s work,144,171 strong group relations142 and unified commitment. 142,157,187 Whether explicit or implicit, reciprocity was linked with information exchange and the ability to draw on each other’s knowledge and skills to promote individualised care and enhance quality. 139,141–144,146,153,157,170–173,188,189 Teams with high degrees of reciprocity were more open to advice seeking and collaborating. 158,189

Leaders – at unit level – exhibited various behaviours designed to foster reciprocity:

• Clearly communicating expectations of staff, ways of working and their behaviours. 139,146,153,170

• Promoting shared goals and mutual respect. 141,170

• Helping out ‘on the floor’. 139,146,172,173

• Holding regular meetings inclusive of all staff. 139,146,170

• Openly discussing and resolving problems as a team. 139,141,146

• Flexible working structures for staff. 143,145,147,153,171,173

• Encouraging the sharing of ideas. 139,141,143,146,171

• Bringing staff together as a close-knit group bound together by common interests and experiences. 141,170,172

• Regular staff supervision. 139,143,171

Role experience was a modifier of reciprocity-reinforcing behaviours. Experienced staff often used reciprocal behaviours to build confidence with less experienced/confident staff. 147,153,155,158,159,190–194 Such behaviours were nested in relationships built on open communication and respect for the less experienced. 193,195 Managerial support meant experienced staff shared greater knowledge and experiences;147,155,157,192,196 especially among staff caring for people living with dementia. 157,165,180,197 Units that discouraged coworker relationships often lacked team reciprocity,178 and were of poorer quality. Unit-level supervisors that minimise conflict and role model relationship-building behaviours provide the context in this context–mechanism–outcome configuration.

Role modelling and reciprocity do not always coexist. Negative outcomes include complacent staff generating and sustaining power imbalances or bullying – particularly in chronically short-staffed homes. Examples included ignoring or excluding team members or withholding information about resident care. 198 Understaffed care teams have higher workloads, less time available for interpersonal discussions and less time for defusing frustrations, leading to conflict. 198 Effective leadership and management are crucial for minimising such unintended outcomes. 149,178,194,198

Autonomy in everyday work

Greater perceived autonomy means greater staff engagement with work140,144,169,199 or role empowerment. 140,189,194,200 Autonomy is a positive and necessary feature of delivering individualised resident care. 140,144,166,199,200 Flexibility in staff responses to needs is highly valued, leading to higher perceived quality among family and residents. 142,180,199 Increasing autonomy is easier in smaller teams of staff, working consistently with the same group of residents and colleagues. 152

Autonomy, behavioural enactment and leadership coexist in a positive feedback loop. Collective agreement resulting from reciprocity strengthens collective knowledge and shared values/mission, which in turn gives staff greater confidence to act independently. 158 Shared values are vital to developing professional values and integrity, refining staff skills, supporting further learning and development of skills and satisfaction with work. 158 These leadership elements constitute the context in this context–mechanism–outcome configuration. In such long-term care facilities, management practices foster staff with the skills, knowledge,140 opportunity139 and confidence to become autonomous workers. 197

Staff exhibit active autonomy in resident care in various ways that promote quality of care: reporting they are involved in care planning,45,140,199,200 asking for advice,45,140 being encouraged to innovate with different ways of providing care or undertaking work,140,144,169,171 meeting residents’ needs flexibly157,171 and being consulted for their views, ideas and opinions,140,150,156,189,200,201 and feeling valued for such input. 45,140,159,189

Staff who see themselves as equal partners in care experienced a sense of shared responsibility45 and mutual respect. 140 Staff capacities and capabilities when recognised and used efficiently result in work geared to meeting individual resident needs, rather than institutional routines. 45,140,156,159,171,199,200 Autonomy allowed staff time to ‘do the little extra’s’. 158 As a result, staff were more likely to be independent in their work,169 considered themselves able to make decisions,189,200,201 and shared work. 140,159,169 A high degree of flexibility in their work plans makes it easier for staff to collaborate and consult with each other in short informal meetings and, further, to support and help each other during the shift. 158

Reward and recognition

Rewarding and recognising staff influenced how staff felt about their work and shaped behaviours. Reward and recognition happen formally and informally. Formal endorsement arises from:

• the senior executive team (organisational level) and/or care home leaders;200

• the organisational mission statement (placing as much value on staff as residents);45,139,156

• training and education;45,140,142,145,160,169,196,200,202,203

• career advancement opportunities;43,45,145,160,200,202

• adequate pay;43,140

• coaching and mentoring;43,139,146,156,160,161 and

• involvement in decision-making about resident care for the resident’s they knew well. 45,156,202

Surprisingly, little evidence exists regarding the influence of pay on perceptions of work and staff behaviours.

Informally, recognition can be:

• Managers addressing staff by first or preferred name and praising staff for their contribution. 139,140,146,163,200

• Utilising the unique knowledge staff have about individual residents by asking them for their opinions on how best to support the resident population. 140,146

• Managers ‘pitching in’ with the day-to-day work, such as making beds and assisting at mealtimes, to support staff;139,146 and

• Providing emotional support for any anxieties staff experience as a result of providing care. 147,148

Rewards are wide-ranging but included offering small gifts or arranging social gatherings to demonstrate appreciation for a job well done. 139,170 The investment in staff through rewards and recognition had a positive impact on how staff felt about their work, enhanced staff–manager relationships and led to behaviours that promoted quality in the long-term care facility and for the benefit of residents. 45,139,142,148,156,159,163,200

Cultural competence

Cultural competence, the ability to understand, communicate and effectively interact with people of different cultures, helps staff meet residents’ needs and promote quality of care and life. 140,147,184,204 Manifestations of cultural competence included:

• Employing staff from different backgrounds, which was identified as valuable for promoting cross-cultural relationships with residents, family and coworkers. 140,147,162,177,184,193

• Respecting religious beliefs,147,177,193 cultural norms,140,154,162,193,205 and sexual orientation,204,206 made a positive difference to daily lives of residents. 140,147,154,162,193

• Knowing how to provide culturally appropriate personal care – such as meal preparation,162,205 honouring rituals,140,147,162,169 greeting residents using their first language,193 being in tune with local dialects,207 touching a resident in a culturally appropriate manner,140,193 and/or using appropriate non-verbal communication. 147,162,184,193

These factors all helped develop and maintain (cross-cultural) relationships between staff and residents. 140,162,193

Quality-promoting relationships are hindered184,193 when staff experience discriminatory behaviour from residents, for example, verbal abuse on the basis of skin colour,162 accent,162 sexual orientation204,206 and language difficulties. 162,180,184,189,193,206 Management intervention is essential to repair relationships. 147

Cultural competence is developed on the job147,180,193,204 and reinforced through team reciprocity,162,193 exhibited as respect and tolerance of each other’s cultures, effective cross-cultural communication and learning,193,206 and promotion of relationships between coworkers. 162,180

Falls

The pooled OLS model suggests a higher skill mix is associated with a reduced rate of falls. However, this result was not statistically significant in fixed effects and our preferred multilevel growth model. The results of this model also suggested that falls were higher in homes with more residents in specialist dementia units, although none of the workforce measures were associated with statistically significant changes in the rate of falls (Table 12).

Falls with fractures

A higher skill mix was associated with a lower risk of falls with fractures, with the size of the relationship stable across different model specifications (a coefficient of −0.008). However, the effect size itself was small and the models were only able to explain a very small proportion of the variation in the incidence of falls. No other workforce characteristics were associated with rates of falls with fractures, although once again there was an association between more residents in dementia units and a higher rate of falls (Table 13).

Marginal effects analysis suggests that for an average care home with 48 occupied beds, if the proportion of care provided by RNs increased from a mean of 0.2 to 0.3 (one standard deviation above the mean) – equivalent to an increase in full-time nursing posts of around 3.5, from 7 to 10.5 – the increase might lead to a reduction in the number of 0.5 falls per year for that home 1.7 (95% CI 1.54 to 1.87) to 1.2 (95% CI 0.89 to 1.5).

Urinary tract infections

A higher skill mix was associated with lower rates of UTIs in all three models, although the size of the association was smaller in the fixed effects and multilevel growth models. Marginal effects suggest that a one standard deviation increase in skill mix equivalent to 3.5 extra full-time equivalent nursing posts in an average home with 48 occupied beds, would be associated with a fall in UTIs from 41 a year (95% CI 35.3 to 46.7) to 32.1 a year (95% CI 24 to 40.3). The rate of UTIs was higher when the proportion of planned nursing hours worked was higher and lower when the proportion of planned carer hours worked was higher (Table 14).

Chest infections

There was no statistically significant relationship between skill mix and the rate of chest infections in our preferred multilevel growth model. Once again, the rate of chest infections was higher the greater the proportion of planned nursing hours worked and lower the greater the proportion of carer hours worked (Table 15).

Pressure ulcers

The only relationship between staffing measures and pressure ulcers in our (preferred) multilevel growth model was that more hours worked (RN plus carer) was associated with a greater risk of pressure ulcers. However, the size of this relationship was small, and only a low proportion of the variance in incidence of pressure ulcers was explained. Which is not surprising given the rare occurence of pressure ulcers in our data. Risk of pressure ulcers increases as the number of care hours provided increases. This could reflect more care hours being provided in homes where residents have more acute care needs which reflect frailty, ill-health and co-morbidities that put residents at increased risk of developing pressure ulcers. (Table 16).

Medication errors

We observe a number of statistically significant relationships between medication errors and staffing measures. A higher skill mix was associated with a lower rate of medication errors, with the coefficients stable across all three models. Medication errors were also more likely when a greater proportion of care hours were provided by agency nurses. We also see the same pattern of results that we observed with UTIs and chest infections; medication errors are higher where a higher proportion of planned nursing hours are worked and lower where a higher proportion of carer hours are worked. The consistency of this result across all three measures lends credence to the idea that this may reflect how staffing affects the accuracy of record keeping (Table 17).

Examining marginal effects, an average home of 48 occupied beds, a one standard deviation increase in skill mix – equivalent to around 3.5 additional full-time equivalent nursing posts – would be associated with that home having an annual fall in medication errors of around 5, from 12.5 per year (95% CI 3 to 22) to 7.6 (95% CI −2.6 to 17.1).

Additional nursing costs

We reported above, that a one standard deviation increase in skill mix would result in the percentage of care being provided by RNs increasing from 20% to 30%. In an average care home with 48 occupied beds, this would equate to an increase in nursing hours of 598 hours per month. In the absence of any care home specific nursing unit costs, data from PSSRU Unit Costs of Health and Social Care were used to determine costs of nursing hours. 208 These estimates are derived from Agenda for Change pay scales and other indirect costs, including overheads and are assumed to be broadly indicative of appropriate unit costs. This gives an hourly cost for a Band 5 community-based nurse of £39.23, equating to a cost of £23,460 per month or £281,520 per year for an average home.

Cost of falls resulting in fractures

A one standard deviation increase in nursing hours would be associated with a reduction in falls with fractures of 0.5 per year in an average home. This suggested an annual treatment cost saving of £2123.50.

Costs of urinary tract infections

The results reported above suggested that a one standard deviation in skill mix would be associated with a reduction in UTIs of 41 per year in an average home, suggesting a treatment cost saving of £13,817.

Cost of medication errors

Our results suggested that increasing skill mix by one standard deviation would be associated with a reduction of five medication errors per year in an average care home. This equates to an annual saving of £15.35.

Our cost–benefit analysis reveals that an expensive increase in nursing care (a total cost of £281,520 per year for an average-sized home of 48 beds) would be associated with total treatment cost savings of around £35,058 that is a net additional cost of £246,462. There is of course a degree of uncertainty around both the costs of treatment and the estimates of reductions in falls with fractures, medication errors and UTIs. It would be possible to compute upper and lower bound estimates of the net additional cost but given the small size of the marginal effects of skill mix increases on the incidence of nurse-sensitive indicators of care quality, more nuanced estimates would not change the big picture: additional staff costs are likely to substantially outweigh reduced treatment costs.

‘Enough’ staff

Care Quality Commission reports did not provide details of staff numbers, skill mix or deployment within the care home. This omission applied to all care homes in our sample (which included care homes of differing size and ownership). However, our analyses offered qualitative insights into how staff numbers may influence ‘quality’ in the care home. All care homes rated outstanding were considered to have ‘enough staff’ or ‘sufficient staff’ with the skills, knowledge and experience to ‘meet residents’ needs’, or ‘keep people safe’:

All of the residents said there were enough staff available to them and they never had to wait for support.

Care Home 18

Residents were supported by enough staff with the skills, experience and knowledge to meet their needs.

Care Home 14

Perceived adequate numbers of staff were positively appraised by residents and their relatives for providing individualised care in a timely manner, and by staff to feel supported and to be able to spend time with residents:

A person we spoke with told us there were enough staff to support them if needed, they said, ‘There is always someone151 here. If I use the call bell they come quickly’.

Care Home 19

We saw staff had enough time to sit and talk to people and ensure their emotional and social needs were also being met.

Care Home 21

Staff felt there were enough staff to meet people’s needs. One explained, ‘If we have a resident who needs more care, [registered manager] will make sure there’s enough staff to meet their needs’.

Care Home 2

For care homes rated inadequate, staff numbers were often considered to be below the number required to meet residents’ needs and to ensure care was safe and this had an impact on workload for staff, their ability to meet demands and staff well-being:

Relatives we spoke with told us there were rarely enough staff. One relative said, ‘There just never seemed to be enough staff there.’ Staff we spoke with told us there weren’t enough staff. One staff member said, ‘Staffing is a bit dodgy, it’s hit and miss if there are enough staff or not.’ A different staff member said, ‘There is a lot of staff sickness, it’s because staff are so overworked.’ Another staff member said, ‘We are short staffed and it’s a safety issue.’

Care Home 24

Lower staffing levels were of particular concern at the weekend and at night. Staff sickness was higher in those care homes with lower staffing levels. The reports of care homes rated inadequate highlighted system deficiencies related to (1) calculating staffing levels and (2) effectively managing staffing in these care homes:

Systems were either not in place or robust enough to demonstrate staffing levels were effectively managed. This placed people at risk of harm.

Care Home 25

In care homes rated as outstanding, registered managers were reported to have the authority to secure the workforce that they judged necessary to meet demand and to ensure safety for residents.

Care home manager: judgement and authority for staffing levels

When the care home was rated as outstanding, there were examples that highlighted the pivotal role of the care home manager for judging staffing requirements to meet residents’ needs and promote safe care, coupled with the authority to enact these decisions within the care home. This was highlighted across the sample rated as outstanding and not specific to characteristics, such as ownership or size. These reports indicated that a degree of flexibility and judgement by the manager about staffing in these care homes was considered essential for promoting quality. Good working relationships between the care home manager and the provider senior management team in care homes rated as outstanding were reported to support the care home manager when determining staffing levels and structures:

The registered manager told us that although the provider was a ‘corporate brand’, the provider worked with them and gave them flexibility to manage and run the home. For example, to vary staffing levels and arrange specific activities.

Care Home 11

The manager was therefore afforded authority based on confidence and trust in their abilities to manage their care home. Some managers were given authority by the provider organisation or owner to consistently staff the service slightly above the ‘required’ levels to ensure that staff had more time to spend with residents. Staffing above required levels had additional benefits:

We were advised the service was staffed 10% over the estimated required levels, in order to allow for annual leave, training and unplanned absence.

Care Home 15

There was minimal detail in the reports as to how care home managers made judgements about staffing levels. In some homes rated as outstanding, it was reported that the manager used a dependency tool to calculate staffing levels based on resident need, while others were considering the utility of a dependency tool for better predicting staffing levels. For many of these managers, they used professional judgement and understanding about the needs of residents.

The reports of care homes rated as inadequate did not refer to the use of any tools for calculating staffing levels, nor how managers determined these levels using their judgement:

There was no evidence to demonstrate how staffing levels were calculated.

Care Home 28

In addition, our analyses revealed that senior management teams in large and medium provider organisations were reported as largely ‘absent’ from the care home or involved with care home managers when deficiencies in care were identified. In some cases, provider senior management teams were ineffective: this created a ripple effect where inadequacies of senior teams were associated with poorer quality:

We had concerns about the quality of the provider’s response when issues were raised with them … we found the response of the services senior management team was not robust.

Care Home 23

‘At our last inspection the provider had failed to ensure there were sufficient numbers of care staff deployed to meet peoples assessed care and support need’ … ‘At this inspection the provider had not made enough improvement and was still in breach of regulations’

Care Home 25

Proactive and cohesive relationships between the manager of the care home and the provider senior management team (or owner) therefore appeared important to support the manager with making decisions about staffing and to empower them to staff as they determined most suitable for the people living in the care home and to ensure quality of service. For independently owned single-care home operators, where there was no access to a provider senior management team, then managers (and owners) sought external support from larger organisations (such as the local authority) or healthcare professionals.

Transparency, oversight and monitoring of decisions about staffing levels were identified as important for assessing, planning and maintaining the contribution of care home staff to quality. However, our analyses revealed that staffing numbers only partially explained the relationship between staffing and quality.

Quality is more than staff numbers

We identified other factors related to care home staffing that had an influence on quality. Stability of staffing and low levels of use of agency or temporary staff, coupled with a skilled and competent care workforce, were clearly necessary for promoting quality:

There was a stable staff team and people and relatives told us they knew staff well. The service had low levels of use of agency staff and had high levels of staff retention due to the positive and supportive culture. The registered manager told us they and the head of care would work a care shift rather than use agency staff. The service had the lowest staff turnover of the eight homes in the provider’s local region.

Care Home 5

Stability of the care home workforce was linked to appropriate induction for all staff, and enabled opportunities to address training to support staff and promote skill and competence. Stability of the workforce ensured that residents were supported by a consistent team of staff and staff were able to develop understanding of the needs and preferences of the people living in the care home to provide personalised care. Stability was also reported to promote teamworking which had benefits for staff and their day-to-day work:

The registered manager had a strong focus on developing a permanent staff group and teamwork. They valued their staff team and provided opportunities for continuous learning and development for staff. The registered manager told us how they had worked hard to employ permanent staff and reduce the number of hours that agency staff were used to cover shifts.

Care Home 4

Staff working in care homes where there was stability within the team reported their job satisfaction and well-being at work. Staff at a care home rated as outstanding provided the following comments: ‘It’s a really nice place to work’, ‘I love my job’ and ‘I’ve worked here for 20 years, I must be happy’ (Care Home 15). Care home managers had a key role in providing environments for these important factors associated with staffing and quality to flourish. However, the presence of the provider senior management team (or owner) was also important and to reinforce staff were valued for their role and contribution. Examples of how this was achieved were offered. Some organisations offered induction days for new staff to learn about the organisation and its values, as well as providing opportunity for staff to meet the senior executive team (such as the Director and Chairman) and the senior management team. A staff member reported:

This really makes you feel you are part of [organisation name].

Care Home 17

Another example was provider senior managers spending time at the care home so that they got to know staff, could offer opportunities for staff to promote quality in the care home, or to address barriers for promoting quality:

The provider tried to engage with members of staff through planned ‘surgeries’ by the human resources department. This was so staff could talk through any concerns they had to drive progress. It was also so the provider could share any benefits staff got working for the company. This was to promote staff retention and provide consistency for the people living at the home.

Care Home 16

Provider senior management involvement in care homes rated as inadequate was often lacking or, if present, ineffectual for creating staff stability, minimising use of agency staff, or ensuring the skills and competence of the care home workforce.

Realising and supporting the potential of the staffing resource

Opportunities for the continuing professional development and training of staff were extensive in care homes rated as outstanding. This was linked to developing skilled and competent staff which impacted positively on quality for care home residents. The care home manager had a key role in supporting staff to develop and to help realise their potential to benefit residents. New staff were supported through induction and mandatory training that supported staff to obtain the nationally recognised Care Certificate, and some care homes offered a period of shadowing of a more experienced member of staff:

In addition to completing the induction training, staff were provided with opportunities to shadow more experienced staff. This enabled them to get to know people and learn how they liked to be cared for as well as developing their knowledge and skills.

Care Home 17

In care homes rated outstanding development opportunities included skills development to support role extension, bespoke training through an extensive library of courses, targeted development to accelerate staff development for more senior roles, experiential learning to enhance understanding for delivering compassionate care, formal health and social care qualifications, and support for RNs for revalidation. In addition, there were opportunities for staff to become a champion for a particular aspect of care and enhance service delivery or to change roles within the care home to make better use of an individual staff member’s skill set. In these care homes, mandatory training for staff was maintained and regularly updated. The records of staff in these care homes were up to date, with plans for their training and development identified. In addition, there was evidence of supervision and appraisals for staff:

Supervision sessions enabled staff to discuss their personal development objectives and goals. We also saw records confirming that staff had received annual appraisals of their individual performance and had an opportunity to review their personal development and progress. A member of staff told us, ‘I am always more confident after supervision’.

Care Home 17

Encouragement by the manager for development and training was valued by staff and a motivating force for quality and excellence in the service:

Staff told us, ‘The manager has continued to encourage us to [strive for excellence] and is so enthusiastic. I think we are doing even more things with the residents than we did in the past. We haven’t stopped. We want this place to be as good as it can be’.

Care Home 20

While the importance of continuing professional development was recognised and actively promoted by managers of small independent care homes, there were less structured opportunities for staff and on occasion staff had to leave to pursue development opportunities:

We always encourage staff to achieve their own potential. If that means they leave us to move forward, that’s fine. We’re happy that social care in general is benefitting from their development.

(Care Home 19)

In care homes rated inadequate, opportunities for staff training and continuing professional development were limited (regardless of size or ownership), as well as limited supervision arrangements to ensure staff were supported in their roles:

The management team were not routinely assessing the competency of all staff and responding to shortfalls in their knowledge in an effective and proactive way.

Care Home 23

Staff told us they had received training although the amount of training varied and we could not establish from the records we reviewed that staff had received training that would equip them with the skills and knowledge to carry out their role and responsibilities.

Care Home 29

In these organisations, specific concerns were raised across the CQC reports about limited knowledge, skills and competence for staff in the following areas: safeguarding; infection prevention and control; falls prevention; oral health; end-of-life care; fire safety; management and administration of medicines; and moving and handling.

In addition to continuing professional development, training and supervision, other mechanisms to reward and recognise staff were considered important to ensure staff felt valued by the management team. Feeling valued was linked with enhancing staff commitment and supporting their potential contribution to quality:

Staff felt constantly supported, valued and praised. They told us, ‘There is no shortage of praise, and we get thanked for all we do’, ‘I feel valued by everyone I work with’ and ‘Teamwork is essential and we have no problems there’.

Care Home 14

Reward and recognition varied in care homes of different sizes and ownership and relied on the available resources for the care home manager. Examples of the ways in which staff were rewarded and recognised are provided in Box 4. Reward and recognition by smaller providers were often less structured and involved smaller gestures, such as thanking staff or listening to staff. For example, one care home invested in refurbishing a staff room based on staff input and feedback. This highlights that reward and recognition were not always financial, in terms of monetary rewards for staff, but involved other approaches to promote staff satisfaction and well-being, and to realise and support the potential of the staffing resource.

Person (not system) focused

In care homes rated as outstanding, the focus on the person living in the care home was evident. Our analyses highlighted the ways in which staff engaged positively with residents, offered choice, attended to diverse personal, social or cultural needs, promoted dignity, focused on abilities of the individual and promoted independence. By working in these ways, staff were described as being ‘present’ or ‘visible’ for residents, were able to develop relationships with residents, gained in-depth understanding of individual residents and their needs and preferences, and as a result were able to recognise and respond to changes in their presentation or condition. This had a positive impact on residents because it enabled tailored care and interventions, promoted individual purpose and well-being, ensured residents were involved in daily decisions, created a sense of personal security and safety and promoted resident and relative satisfaction:

People told us they thought the staff were ‘excellent’. Relatives told us how they thought the care and the management were ‘excellent’. One relative told us, ‘It [the care home], is fantastic.’ They went on to say, ‘It is not a home, it is my family member’s home.’ One relative had written a compliment thanking staff for the ‘Love and passion they provided.’ They went on to say, ‘The work staff did was amazing’.

Care Home 21

Developing relationships to support the person living in the care home was an important aspect of ways of working in care homes rated as outstanding. Residents and families were consulted to ensure that their views on personal support needed, as well as their preferences, were included in plans for care and ongoing reviews of care. Some care homes had a rolling programme of ‘resident of the day’ where the resident and their family met with a range of staff from the care home to provide feedback on the service they received and to review their care plan to make sure it fully reflected their current needs and preferences:

One person described their ‘resident of the day’ experience as ‘An extra special day’.

Care Home 18

Care home staff in these homes consulted with relevant health and social care professionals to ensure support for residents was sought in an appropriate and timely manner. Advice offered by external health and social care professionals was incorporated into care plans:

‘We do have people with some complex needs here so want to ensure all carers have knowledge of the issues and needs that people have, especially new care staff.’ Relatives agreed, ‘[The family member] has better access here to health services than she did at home in the community’.

Care Home 1

Care homes rated as inadequate reported staff working in ways which displayed some of these person-focused aspects. However, the reports also highlighted when these aspects were not fulfilled and where care was systems-focused:

We found examples of institutionalised practices where staff had not considered people’s feelings or if they were promoting their dignity. These practices were neglectful and could cause emotional harm.

Care Home 23

We found pre-admission assessments to make sure the service could meet people’s care and support needs, lacked detail about people’s physical, mental, social needs and preferences, with no information about identified risks.

Care Home 26

A person-focused approach required effective mechanisms for staff to work together and share information for resident care and quality assurance.

Working together

The combined action of staff to effectively and efficiently support and care for people living in a care home constituted teamwork. CQC inspectors described teamwork in care homes as outstanding when staff: ‘worked together’, ‘were on the same page’, ‘had shared values’ and ‘valued each other’.

In care homes rated outstanding, working together and supporting each other in the collective endeavour of care was highlighted: ‘It’s really good. Everyone is supportive, friendly and professional.’ (Care Home 13). In addition, there was acknowledgement that within the team there were individuals with different skills and that each team member should be able to make a contribution and flourish in their role:

A staff member said: ‘We all have different skills and can offer something different’.

Care Home 11

Working together was often underpinned by a clear philosophy of care that staff were keen to deliver:

Staff were driven by the philosophy that ‘every individual at the care home should receive an outstanding service’.

Care Home 2

Staff in care homes rated as outstanding displayed compassion, kindness and empathy towards each other. Teams were described as motivated, passionate and committed to improving residents’ lives. A shared philosophy of care and values led staff to share information with one another, ask their colleagues for advice and support, and to learn from each other. Leadership was key for promoting teamwork and staff reported that they valued teamworking, and enjoyed working in these environments and with their colleagues:

A staff member said: ‘The manager works with us as a team, that’s how it works, there is no them and us’.

Care Home 15

One staff member said, ‘I absolutely love it here, I like working with older people and all the staff are very nice. It is like one big family’.

Care Home 21

The care homes rated outstanding were also characterised by open and honest cultures that also supported learning from incidents and reflective practice:

The manager said: ‘getting things wrong makes us learn and get better as a team. We should never be afraid to fail, it is what we learn from it that is so important’.

Care Home 3

There was evidence of staff working as a team in some reports of care homes rated as inadequate: ‘We have a good staff team and create a nice working and living environment for everyone. It really is a home’ (Care Home 29). However, staff at these care homes described their day-to-day work as disorganised, that there was poor communication between staff, that their workloads were burdensome and they did not feel supported by colleagues or the manager. Therefore, despite acknowledging being part of a team, teamworking (as described above) was not apparent.

Structure in teams was also an important feature of care homes rated as outstanding. The registered manager was responsible for the overall service but was supported by leaders working in clinical areas and support services (such as laundry, kitchen and maintenance). These ‘unit level’ leaders were essential for cascading information to staff, delegating work and supervising staff, and monitoring service delivery. In a number of care homes rated outstanding in our sample, unit leaders did regular checks to ensure quality practices were thoroughly embedded in the service, for example medicines management procedures, confidentiality processes, responding promptly to call bells and treating residents with care with dignity.

Information sharing to benefit residents

Information sharing involved but was not limited to: giving and receiving details about the physical and psychosocial needs and preferences of individual residents; acting on information received; and sharing experiences, expertise and insights to benefit resident care. This required systems for comprehensive recording of individual residents and their circumstances and included written and verbal communication with the purpose of enhancing quality of service received by residents and their families.

Information sharing in care homes rated outstanding included staff in close consultation with residents, families and health and social care professionals. Systems for information sharing in these homes were reported as comprehensive and robust, and staff engaged in both written and verbal forms of communication. Written forms of communication provided staff with the knowledge, instruction and awareness to meet resident’s needs safely and effectively. These also provided a formal record of care for people living in or visiting the care home, and for internal and external reviews and audits of care within the home. Verbal communication supplemented written forms of communication and had the potential to promote effective discussions between staff, or between staff and residents and relatives, or other professionals involved with care. Conversely, information sharing in care homes rated inadequate was described as ineffective, lacked managerial oversight and there was an over reliance by care staff on verbal handover or informal communication rather than a mix of verbal and written communication. This resulted in missed opportunities to mitigate risks and promote safety.

While systems for written communication varied between care homes, there were some that were common to all outstanding homes including: policies and procedures; and care plans and risk assessments. Verbal communication included (but was not limited to) staff handover between shifts, team meetings and informal conversations.

Policies and procedures

In care homes rated as outstanding, there were detailed policies and procedures in place that were evidence-informed and reflected current legislation to guide staff with best practice. Documents identified in our analyses included policies on safeguarding, the Mental Capacity Act (2005), health and safety, infection prevention and control and medicines management. Staff were reported to be engaged with these policies and procedures and this was linked to promoting safer care for residents. Examples in these outstanding reports included accurate medicines administration records and evidence of adherence to infection prevention policies:

Protocols were in place that clearly described when medicines prescribed for use ‘as required’ should be administered. Staff had excellent knowledge of people’s medicines and the signs or indicators of when medication would be required.

Care Home 15

In inadequate care homes, while the provider had policies and procedures in place, many did not reflect current legislation or best practice. These policies and procedures were therefore not fit for purpose and created potential risks to safety and quality of care within the care home:

We concluded the provider was not evaluating and improving their practice sufficiently to meet regulation. They did not operate effective systems and processes, and the systems and processes did not enable the provider to assess, monitor and improve the service or assess, monitor and mitigate risk.

Care Home 29

Care plans and risk assessments

In care homes rated as outstanding, care plans were reported as comprehensive and person-focused and included a resident’s preferences: ‘I prefer a small snack before bed like a yoghurt or a banana and to watch some television. I like to have my bedroom light off with the door half open’ (Care Home 14). Staff engaged with these plans, which were also regularly reviewed and updated to reflect changing needs of residents. Whereas in care homes rated as inadequate, care plans were reported as often not reflective of current care needs of residents, lacked specific detail, were not well presented or organised and were often not used by care staff:

Although we found no impact on people’s care, not all staff spoken with had read people’s care plans. Staff referred to not having the time to do this and stated they were solely reliant on senior members of staff providing key information at handover meetings.

Care Home 22

Some care plans lacked detail instructing staff how to meet people’s needs. One person’s care plan referred to ‘regular repositioning’ to reduce the risk of developing pressure sores but did not specify how often the person required this.

Care Home 30

Some care homes in our sample had transitioned to electronic care planning to enhance quality. Electronic care planning supported ‘real time’ information recording by staff about the care and support of residents. Electronic systems were considered to raise staff awareness of residents’ needs and any changes to prompt timely interventions. Finally, these systems enabled efficient audits to improve resident care. Staff perceived that electronic care plans freed up time for them to spend with residents.

Risk assessments were completed by care home staff to help identify potential risks specific to an individual, for example mobility and risk of falls, continence, nutrition and hydration, or skin integrity, or as a result of the environment, such as fire and safety, infection prevention and control. The care plan addressed how these personal risks should be mitigated for an individual. Plans to manage environmental risks, for example how to evacuate residents in the event of an emergency, were also documented. In outstanding care homes, effective risk assessments supported staff to balance potential risks and resident’s choice, and to support and maintain residents’ safety or report concerns or incidents through appropriate routes. Risk assessments were regularly reviewed, and care plans were updated in these homes:

We saw that all potential risks were recorded and used to inform changes to people’s care plans.

Care Home 19

In care homes rated as inadequate, there was a lack of engagement with risk assessments by both management and staff. Validated risk assessment tools were not always used in these environments. Where risk assessments had been completed, some were generic and not always reflective of the needs and preferences of the resident. Planned care did not always reflect identified risk for an individual and not all risks to people’s safety and well-being were recorded or monitored:

Risks associated with the stoma had not been considered or recorded, for example, the risk of skin irritation, leakage, retraction or prolapse and dehydration.

Care Home 22

Verbal communication

Verbal communication – such as handover, team meetings and informal conversations – complemented written communication that guided or recorded care delivery. In care homes rated as outstanding, handovers were considered effective for catching up about resident care, listening to the views and concerns of care colleagues and promoting the involvement of all staff in supporting resident care decisions:

Staff worked well as a team to provide effective care to people. There was a handover every morning with nurses and care staff. Staff ensured that any changes to people’s needs were mentioned and known about. One member of staff said, ‘When I’m not here for a few days I get a handover from a nurse. I catch up with the care staff and talk to people too.’ Another member of staff said, ‘We have good relationships, we all work together.’ A third said, ‘We support each other. It’s a positive team and one thing I like about working here is that they are all people orientated’.

Care Home 1

However, in care homes rated as inadequate there was often an over-reliance on verbal reports about care during handover and neglect of the written documents detailed above which had an important role in promoting quality and safety within the care home environment.

Team meetings were reported to have a range of important functions associated with resident care (such as reinforcing the home’s philosophy of care, reviewing care plans and/or risk assessments, or revising work organisation to benefit residents) and staff development and recognition (e.g. learning from incidents, taking time to recognise and value staff contributions and achievements). The extent to which these functions were achieved varied depending on whether the care home was rated outstanding or inadequate, and whether there was strong relational leadership of the care home.

In addition to handovers and team meetings, managers of care homes rated outstanding engaged in informal conversations on a regular basis with staff. Many had ‘open door’ policies and did regular ‘walk around’ the care home. Other homes used afternoon ‘huddles’ so staff could meet and discuss events of the day. These strategies were considered to support and encourage staff to informally discuss their work and encouraged recognition of staff, as well as opportunities for ongoing problem solving:

Staff felt listened to and clear about their roles and responsibilities towards people living at the home. Staff felt confident to raise issues, concerns and ideas with the registered manager and were given regular opportunities to do so.

Care Home 19

The combined use of both written and verbal communication using the systems described above contributed to effective information sharing that benefited resident care. These systems were observed more frequently in care homes rated as outstanding. In addition, these homes had effective leaders that led the care teams. Working together and information sharing enhanced team cohesiveness and were important foundations for staff to ensure quality of support and care for residents.

Network characteristics

Advice and influence networks can be described as radial (Figure 7: Care Home 1 a and b). At the centre were a single respondent who felt they influenced, and were influenced by, everyone and a second respondent who was influenced by everyone. The relatively low reciprocity in the home suggests that while these two individuals may feel as if they are influential, it may not be reciprocated: advice and influence flowed to these two individuals, but they may not provide good targets for messaging around innovation.

FIGURE 7.

Advice network and influence network across 11 care homes.

Staff were mainly drawn from the local area, with multiple families providing care home employees. Social relationships – formed in the local community – existed between staff and were maintained in the home. These mutual connections may provide some network cohesion, which in turn may help with sustaining adopted innovations. The advice and influence networks reflect relationships formed in the outside community being present in the care home: both networks have a large number of relationships and cliques. The relatively high clustering coefficient suggests tendencies for network clusters to form. However, network densities are low – possibly because the more people in the network the lower the density.

The low-density and low-reciprocity nature of the networks mean fewer connections and a barrier to spreading innovation.

Implementation of innovation

The manager felt a website on staffing and quality would feel somewhat familiar and largely ambivalent regarding the chances of such a resource becoming a normal component of current or future work (Table 18). Implementing innovations is helped by harnessing the power of the most central players in the network: those providing the most advice and influence. The manager (PBCM01) and deputy manager (PBCM02) were the ones providing advice and influence. The deputy manager was the most used bridge in the influence network. Perhaps surprisingly, a CA was the most used bridge in the advice network (receiving advice and passing it on) (Table 19).

It was very possible that a considerable degree of homophily had developed in Care Home 1 due to (1) staff mainly living in the area local to the care home and (2) multiple families who had multiple members employed by the care home. Homophily is the tendency to form strong social connections among those who share something in common – including living in the same area or being from the same family. 213 This should lead to more cohesion in the network due to increased number of connections, but also creates more cliques and clusters in the care home network. Care Home 1 had higher than average cliques and clustering, especially in the influence network. Staff relationships outside the care home influenced the networks within it. Any weak bridging ties between the network clusters and cliques would provide routes for moving innovation-related knowledge (and behaviours) from one group to another.

Network characteristics

The home has core–periphery structure advice and influences social networks (see Figure 7: Care Home 2 a and b). Most of the relationships are either within the core, or between the core and the periphery.

This care home had the highest number of advice and incoming influence relationships and the most reciprocity between staff. It was also the densest, with above-average numbers of cliques. The networks’ tendency to form clusters was also higher than average (Table 19). The overall picture is one of heavily interconnected care home staff with strong reciprocal advice and influence relationships. These characteristics suggest innovation is more likely to spread – relative to homes such as #1 or #3 – widely and quickly.

Implementation of innovation

The manager was ambivalent towards a website on staffing and quality in terms of familiarity and chances of incorporation into normal work (Table 18). The care home manager was the key central player in both networks serving both as a bridge and providing the most advice and influence. The care home manager was the key opinion leader: they also received influence and advice, making them a significant bridge in these networks. Their support for any implementation of an innovation would be crucial.

Care Home 2 (and see also Care Home 10) had low numbers of staff living near the care home, but both homes had a high number of cliques and clustering. The networks were denser, making them more cohesive and with weak bridging ties connecting the clusters and cliques. The cohesion of these networks was most likely due to management efforts at increasing the sense of belonging (to the home and subteams) among staff. Dense and cohesive networks should encourage the transfer of innovations within these networks.

Network characteristics

Like Care Home 2, both networks in this care home had star-shaped core–periphery structures (see Figure 7: Care Home 3 a and b), with just a handful of relationships not involving the core. One manager (BKM01) in the influence network was the biggest receiver of influence but also provided the most influence. This individual was a natural bridge between influence-based cliques.

While the number of relationships based on advice and influence was relatively small, there was a fair degree of reciprocity (advice network was slightly above average and for influence, double the average). The ability to cluster in both networks was above average, but the number of cliques formed was well below average. Both advice network and influence network densities were above average but limited connectivity in these networks may inhibit the spread of new ideas.

Implementation of innovation

The manager felt a website on staffing and quality would likely feel new and were moderately positive regarding the chances of such a resource becoming a normal component of current or future work (see Table 18). The care home manager (BKM01) was most sought after for advice and the strongest influencer. The unit manager (BKM03) held a clear bridge role in the influence network – bringing less connected groups together through influence. Surprisingly, one of the most connected staff was an estate maintenance employee who sought advice from almost everyone in the home (reflected in their betweenness centrality score). The extent to which this individual would be a good opinion leader is unknown.

Care Home 3 provided the perfect example of a network bridge. The unit manager received the most influence in the influence network and was also the person who influenced the most staff members. This individual would therefore be the most logical choice for an opinion leader given their influence in the care home.

Network characteristics

Care Home 4 differed from the previously described networks as there were no obvious focal points (see Figure 7: Care Home 4 a and b) for advice and influence. Spreading innovation-related messages/information from one side of the network to the other would need several intermediate members to co-operate. There were no ‘bridges’ to enable the efficient spread of information (using people) from one side to the other in a couple of steps.

The number of advice and influence relationships were below average. And reciprocity, the number of cliques within the networks and potential for clustering were also low. The densities of both networks were about average (Table 19). Relative to other care homes’ network structures these networks would not represent a supportive context for the diffusion of innovation.

Implementation of innovation

The manager felt a website on staffing and quality would feel very familiar and was strongly positive regarding the chances of such a resource becoming a normal component of current or future work (Table 18). The care home manager had the highest betweenness centrality in the advice network. A carer – with 3–5 years of care sector experience – was highest in the influence network. Both roles would be potential knowledge brokers. The highest out-degree centrality in the advice network was the care home manager, while in the influence network it was another carer who had been employed in the care home industry for over 15 years. All the centrality scores were similar – representing no clear advantages in trying to identify potential brokers/influencers for innovation (Table 19).

There was no obvious central point in the network structure of Care Home 4. It did not have either a core–periphery or radial structure. This meant there was danger of blockages of best practice intervention or innovations within this network (see also Care Home 5 for another example of network structure impacting on function). For this network, the ties were not evenly distributed. Because the relationships are clustered on the left-hand side of the network, the benefits of these relationships (including social capital, influence and innovations) will go to the left-hand side first.

Network characteristics

The influence network had a clear bifurcation (see Figure 7: Care Home 5 b). The network component to the left of node WPS31 is focused on six caregivers who receive a lot of influence from managers, nurses and other CAs. The component on the right had no influence from nurses or managers – with just two exceptions: CAs WPS31 and WPS45 influenced by the deputy general manager (WPM02). The deputy general was a bridge in the influence network. These structures suggest that the spread and adoption of an innovation is more likely in the left-hand part of the network because influential people and those they influence are more closely connected. In the right-hand component, CA WPS45 (influenced by the deputy general manager) influenced only one other person. Unlike the influence network, the advice network was less divided. Most of those receiving advice had a manager or a nurse involved.

Reciprocity in both networks was low. The number of cliques formed, the ability to cluster, and the density of each network was below average-reflecting fragmentation.

Implementation of innovation

The manager felt a website on staffing and quality would feel somewhat new and was largely positive regarding the chances of such a resource becoming a normal component of current or future work (see Table 18). The deputy manager (WPM02) was the most influential and the most sought-after person for advice. But the difference between them and others was not large. A senior CA had the highest betweenness centrality in the advice network, and a CA had the highest betweenness centrality in the influence network. See Table 19. Given that lack of a single clear source of advice in the care home, the safest strategy would be channel innovation messages to the home via the nurses and managers.

Network characteristics

Of the nine largest recipients of advice, seven had reciprocal ties with each other (see Figure 7: Care Home 6 a). The care home manager advised eight (of the nine) biggest recipients. Like the advice network, the influence network structure is focused on those most influenced (see Figure 7: Care Home 6 b). However, unlike the advice network, there were fewer reciprocal ties and thus fewer interconnections among members.

Reciprocity and numbers of cliques in both networks were below average. The clustering coefficient was well above average, suggesting strong potential for clusters to form – especially the case in the advice network. The network densities were higher than average probably because these were relatively small networks (see Table 19).

Implementation of innovation

The manager felt a website on staffing and quality would feel new and were ‘cautious’ regarding the chances of such a resource becoming a normal component of current or future work (see Table 18). The most central players in a network are an obvious target for implementation efforts. If the home manager targeted the nine most likely recipients of advice (who then advised a handful of others), then the chances of spread and adoption of something new may be improved. Perhaps unsurprisingly, the manager providing the most advice was also influential. While the nurse serving as the most used bridge in the advice network had only been employed by this particular care home for less than a year, they had more than 15 years of care home sector experience. Of note, was the housekeeping assistant acting as the most used bridge in the influence network. While she said everyone influenced her on quality of care, she in turn only influenced two other people – suggesting her usefulness as a bridge in knowledge translational terms was limited. The structure of the two networks suggests that diffusion of an innovation will be more successful if focused on providing and encouraging the use of advice.

The advice and influence network structures of Care Home 6 (and also 11) have a small number of central players with reciprocal ties with each other. This structure facilitated an easier flow from one side of the network to the other than those networks that did not have this feature.

Network characteristics

The advice network resembled spokes on a wheel. The hub was the deputy manager who received advice from everyone (see Figure 7: Care Home 7 a) and yet was at the heart of the reciprocal ties in this network. Outside of the reciprocal ties, there were very few interconnections in this network. The influence network was much smaller and unlike the advice network, lacked an obvious individual as focal point (see Figure 7: Care Home 7 b).

Both the advice and influence networks were small in terms of connections, with clear reciprocity in the advice network (above average) but not in the influence network. There were relatively few cliques in both networks. The reciprocal ties with the deputy manager meant clear potential for clustering in the advice network. However, in the absence of such reciprocity in the influence network, there was little potential for clustering. The density of the advice network was about average, while the density of the (small) influence network was well above average (see Table 19).

Implementation of innovation

The manager felt a website on staffing and quality would feel somewhat familiar and largely ambivalent regarding the chances of such a resource becoming a normal component of current or future work (see Table 18). The potential opinion leader in the advice and influence networks was the deputy manager (BRS05). This individual had the highest betweenness and degree of centrality in both networks. She was at the centre of a cluster of reciprocal relationships through which advice flowed. The manager influenced the same number of people as the deputy manager giving her the same level of degree centrality (see Table 19).

Network characteristics

In the advice network, the focus was on the care home manager and deputy managers who tied together the network while in the influence network, the focus was on two individuals who received the most influence (see Figure 7: Care Home 8 a and b). The small number of employees at this care home had an impact on the characteristics of these two networks: not surprisingly, the number of relationships in both networks was below average. The level of reciprocity and cliques was well below average in both networks. But having the fewest possible connections – because it was a small home with few staff – meant clustering was just below average, and density well above average (see Table 19). This was due to the small number of people in the networks which means fewer possible connections.

Implementation of innovation

Despite the manager feeling a website on staffing and quality would be reasonably new, the manager was positive regarding the chances of a web resource becoming a normal component of current or future work (see Table 18). The care home manager was an obvious choice as a potential opinion leader. She had the highest betweenness centrality in the advice network – providing the most advice and was a clearly influential figure. One of the support workers (WSS05) had the highest betweenness centrality in the influence network. However, with 12 people influencing her and her only influencing one other person, she was unlikely to succeed as a key bridge in the influence network.

Network characteristics

Despite some overlaps, there was segmentation among the advice givers in this network. Some of those receiving advice get it from those where it was not shared with others (see Figure 7: Care Home 9 a). On the other hand, the influence network had a generally radial structure focused on the carer receiving the most advice (SGS34). The radial nature comes from the fact that the carer in the centre was influenced by almost everyone (see Figure 7: Care Home 9 b).

Numbers of relationships and cliques, reciprocity, clustering and density were all lower than average (see Table 19).

Implementation of innovation

The manager felt a website on staffing and quality would feel completely familiar and were extremely positive regarding the chances of such a resource becoming a normal component of current or future work (see Table 18: note they were a pilot site and had lots of experience working with Skills for Care infrastructure). Two CAs with almost 30 years’ experience had the highest betweenness centrality in the advice network and one of those also had the highest betweenness centrality in the influence network. However, while they received the most advice and influence, they connected outwardly to only a couple of others who were not well connected. These two CAs would not make great candidates for roles as opinion leaders. The care home manager was the most sought-after for advice and a CA was seen as the biggest influencer. The number of people advised and influenced by the manager was small, suggesting more people may be needed for a sense of critical mass in influence and spread of behaviours. See Table 19. In the advice network, those targeted for innovation diffusion would need to be selected carefully – based on their cliques – because of the segmentation of advice givers.

Network characteristics

This was a strongly interconnected home with equally strong levels of reciprocity. This drives the increased number of cliques and makes it possible for this network to form more clusters. This was another broadly radial structure with one staff member being influenced by everyone. But the relationships and interconnections in the influence network meant that cliques and reciprocal ties were dispersed. (see Figure 7: Care Home 10 a and b). Both advice and influence networks were conducive to diffusing innovations.

Relationship numbers were above average in both networks while clustering coefficients and the densities of both networks were below average. This was likely due to the size of the network as a whole – and therefore a higher denominator for the measures (see Table 19).

Implementation of innovation

The manager felt a website on staffing and quality would feel familiar but were ambivalent regarding the chances of such a resource becoming a normal component of current or future work (see Table 18). Top providers of advice and influence were a nurse and the care home manager, suggesting suitability as opinion leaders. The best bridges in this advice network were a team leader and a staff member who was both a nurse and the unit manager. Both these bridges provided as much advice as they received – confirming their value as bridging connections. The two staff with the highest betweenness centrality as influencers network were influenced by many more people than they influenced, limiting their roles as bridges for implementation or brokers for knowledge/messaging in the network (see Table 19).

Network characteristics

This well-connected home’s advice network was radial in nature and driven by the three staff who took advice from almost everyone. The reciprocal relationships in the advice network of these three people formed a clique. It was similar structure for the influence network: four people were influenced by everyone (see Figure 7: Care Home 11 a and b). There were multiple cliques of reciprocal relationships between people. With some overlap in their connections, each member is also connected to unique people. This makes these cliques a solid target for diffusing innovations.

This care home had network characteristics that were well above average for both networks, indicative of its well-connected nature (see Table 19).

Implementation of innovation

The manager felt a website on staffing and quality would be very new. However, they were also positive regarding the chances of a web resource becoming a normal component of current or future work (see Table 18). Advice network reflected hierarchy and roles in the home: top advice providers included 4 (of 5) managers, 2 (of 8) senior CAs and 1 nurse (of 8). The staff member connecting the most people in this advice network was the care home manager (see Figure 7: Care Home 11 a). The top influencers at this care home were the care home manager and three of the other four remaining managers: a senior CA and a single assistant (see Figure 7: Care Home 11 b).

The care home manager was connected to the most influencers and so served as the biggest connector in this network of influence. The managers were prime candidates for opinion leadership roles (see Table 19). In both the advice and influence networks, the cliques identified above would be a good entry point for innovations, due to the breadth of their reach.