Title: Improving the quality of care in care homes by care home staff
Funder: Department of Health and Social Care

Abstract: Background: Over 300,000 older people in England live in care homes due to significant long-term health problems. Many have cognitive impairment. In England, the Care Quality Commission (CQC) regulates care homes to ensure appropriate quality of care. There are, nonetheless, concerns about the quality of some homes, and questions about what ‘quality’ means, and how to measure it. The new Care Act stresses that care services should improve people’s ‘wellbeing’ - their quality of life (QoL) and health. Care home staff have a critical bearing on quality. Issues of pay, training, status, terms and conditions are likely to influence quality. Where staff are specifically trained to focus on the outcomes of care on QoL, this should have a positive effect on quality, as should situations where staff work closely with unpaid carers and volunteers. Aims: 1. Develop new health outcome measures for pain and anxiety/depression that can be used with care home residents unable to communicate their QoL 2. Explore the correlation between CQC's ratings of the home and indicators of residents’ QoL 3. Assess how much staff mix and employment conditions of the care workforce matter for quality: especially staff turnover rates, training provision, different contracts, pay rates. 4. Evaluate (pragmatically) two measures for improving care home quality: a. By training staff to focus on resident quality of life or ‘outcomes-focused care planning’ (OFCP); b. By encouraging staff and care homes to draw on help from local communities e.g. unpaid carers, volunteers, through ‘community engagement’ (CE). Methods: WP1. Conceptual development of two domains (pain and anxiety/depression) and a scoping review of existing measures, with a particular focus on tools that already incorporate observational methods. Focus groups with care home (as selected in WP3) will explore the face and construct validity of the items. WP3 will also provide data to test the reliability and validity of these domains. WP2. Econometric analysis of secondary data to investigate the relationship between CQC quality ratings and workforce characteristics, training provision and community engagement. Care home quality data for all homes for older people (c. 10,000) in England are available from the regulator. Data on staff characteristics and conditions are from the National Minimum Dataset for Social Care, which includes a sample of over 6,000 care homes for older people/dementia, employing about 250,000 staff. WP3. Evaluation of OFCP and CE approaches using data from 20 intervention and 20 matched comparison homes. A filtering survey will be used to identify the sample. After matching, we will assess whether those in intervention homes have better QoL, measuring this using tools from WP1. We will also investigate the relationship between home CQC quality rating and resident QoL. WP4. Case studies and participatory action research will be conducted in 6 homes selected from the WP3 sample to explore how OFCP and CE are implemented and developed, and on how they can have an impact on outcomes. Impact: The project should help care homes, commissioners and regulators understand the impact of workforce policy, training and community engagement, and so improve the quality of care. We will produce academic papers of the results/methods, along with reports and guides for those whose work concerns care homes. Literature for residents and carers will also be produced.

Lay abstract: Over 300,000 older people in England live in care homes due to significant long-term health problems. Many have difficulties with memory and communication as a result of dementia. In England, the Care Quality Commission (CQC) regulates care homes to ensure they provide quality care. There are, nonetheless, concerns about the quality of some homes, and questions about what ‘quality’ means. The new Care Act stresses that care services should improve people’s ‘wellbeing’, meaning their quality of life and health. How well care homes improve wellbeing is an indicator of their quality. But measuring the health and quality of life of people living in care homes can be difficult because they are sometimes unable to express themselves. Care home staff have a major bearing on quality. The types of staff employed, the training they have received and their involvement with their local community (e.g. unpaid carers, volunteers) are likely to have a bearing on care quality. Where staff are specifically trained to focus on the effects of care on people's quality of life, this should have a positive effect on quality. This research aims to: 1. Develop new health outcome measures for pain and anxiety or depression that can be used with care home residents unable to say how they feel because of dementia or very poor health. 2. Explore how closely CQC quality ratings relate to residents’ quality of life. 3. Assess how much staff qualifications (e.g. number of registered nurses) and employment conditions matter for care quality. 4. Assess two ways that quality might be improved: a. By training staff to focus on resident quality of life (called ‘outcomes-focused care planning’ or OFCP); b. By encouraging staff and care homes to draw on help from local communities, e.g. unpaid carers, volunteers and other resources (called ‘community engagement’). We propose four components (work packages) of the study: - To develop a measure for pain and anxiety/depression whereby researchers infer residents’ health aspects from interviews and observations of their everyday life (aim 1). - We will use data on the care homes’ workforce from Skills for Care matched with CQC quality ratings to assess statistically the relationship between care home quality and workforce characteristics/conditions, staff mix, training provision and community engagement (aims 3 and 4). - We will identify 20 care homes who have adopted OFCP or community engagement practices and match these with 20 other homes that do not. Using data collected in the 40 homes on health and care-related quality of life, we will statistically analyse: a) how closely CQC quality ratings relate to residents’ quality of life (aim 2); and b) the relationship between residents’ quality of life and OFCP and community engagement (aims 3 and 4). - To gain a deeper understanding of how these different factors affect residents’ quality of life, we will work closely with volunteers, staff and others in six homes to try and improve care quality over time (aims 3 and 4). The project should help providers, commissioners and regulators to improve quality of care through understanding the impact of workforce policy, training, and community engagement. We will produce: a) academic papers of the results/methods; b) reports/summaries and guides for those whose work concerns care homes; and c) guides for better care for residents and carers in conjunction with participants in the study.

Research activity codes: 7.3 MANAGEMENT AND DECISION MAKING;8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE