Title: Relationship between care home staffing and quality of care: a mixed methods approach
Funder: Department of Health and Social Care

Abstract: Staffing is the largest operating cost in care homes and quality of care provided within care homes is contingent on its workforce. In recent years, quality of care in the sector has come under increasing scrutiny, and practice and policy concerns have been raised about staffing levels, recruitment and retention. Beyond broad recognition that ‘staff influence quality’, little is known about the UK care home workforce and its relationship to quality of care. The aim of this study is to provide evidence on the relationship between deployment of the care home workforce (and its skill mix) and: quality of care; outcomes for residents, relatives and staff; and the use of NHS resources. This aim will be achieved by addressing the following objectives; specifically, to: 1. describe variations in the characteristics of the care home nursing and support workforce 2. identify the dependency and needs of residents and relatives in care homes and its impact on care home staffing 3. examine how different care home staffing models (including new roles) may impact on quality of care, resident outcomes and the use of NHS resources 4. explain how the care home workforce (numbers, skill mix and stability) can best meet the dependency and needs of residents 5. explore and understand the contributions of the nursing and support workforce (including innovations in nursing and support roles) in care homes to enhance quality of care 6. translate methods used for modelling the relationships between staffing and quality to provide a platform for sector-wide implementation Our approach explores structures, processes and outcomes associated with quality, using a convergent parallel mixed method design, comprising 5 work packages (WP). Quantitative and qualitative data [WP1-4] will be collected and analysed separately and findings synthesised in WP5. WP1 [Obj 1] builds on existing data and literature to provide depth of understanding of variations in characteristics of the care home workforce (surveys of care home managers and staff) and a realist review. WP2 [Obj 2, 3, 4] will model relationships between national workforce metrics (NMDS-SC) and CQC inspection ratings. These findings will provide important context for WP3. Partnering with Bupa Care Services, WP3 [Obj 2, 3, 4] involves a longitudinal study of relationships between staffing inputs and quality outcomes for residents. We will calculate the incremental staffing requirements necessary for care homes to improve quality, as well as the costs associated with achieving better quality and outcomes in the sector. WP4 [Obj 4, 5] seeks to understand why variations in the relationship between staffing and quality exist through six purposively sampled case studies (homes) using ethnographic methods (observations, interviews and diaries). Six focus groups (with care home vanguards) will seek to explore the case study findings with a broader range of participants and within a broader context: aiding transferability. WP 5 [Obj 6] synthesises the WPs and focuses on translating methods used for modelling to enable the care home sector to learn from this approach and maximise its utility for their particular context. We will produce evidence to inform policy and organisational (care home) level decisions about staffing and best ways to deploy the staffing resource within care homes. The findings will be relevant for residents and relatives, care providers, commissioners, inspectors and policy makers.

Lay abstract: In the UK, 405,000 older people live in 18,000 independently owned care homes (5,153 nursing and 12,525 residential homes). People are entering care homes older, sicker, frailer and have needs that require specialist help, such as dementia. Residents in residential homes today would probably have been cared for in nursing homes 5-10 years ago. These increased demands on care homes will continue as health and social care systems adapt to having less money from government. Staffing is the largest expense in most care homes and quality depends on the staff working in the home. So, to provide high quality we need to understand how to make best use of the staff employed in those homes. In recent years quality of care and staffing in the care homes has often been criticised by professionals, people who live in homes and their relatives, and the policy makers making decisions about how much society can afford to pay for this part of the care system. Beyond recognising that ‘staff influence quality’, we don’t know much about the people who work in care homes and how they affect quality; including how people living in care homes experience care and how much quality costs. The aim of this study is to explore and explain the relationship between use of the care home workforce (and the mix of care home staff) and how this affects quality of care; outcomes for residents, relatives and staff; and how money is used to pay for care and its impact on quality. To meet our aims we have 5 work packages (WP). First, we will better understand how and why the characteristics of the care home workforce vary so much across England. To do this, we will review existing research and survey care home managers and staff (WP1). Having put forward some possible ways in which care home staffing and quality are related, we will use data on quality from two organisations (WP2) - Skills for Care (who help adult social care organisations in England recruit, develop and lead their workforce) and the Care Quality Commission (who regulate quality in services in England and Wales) - to test these ideas and develop understanding of the national picture. Working with Bupa Care Services, we will then use organisational data to further understand the relationship between staffing and quality and costs (WP3). Having explained the associations between staffing and quality, we will explore why quality varies as staffing changes by studying in detail what happens in six care homes (WP4). We will watch care being delivered and gather the views of residents, relatives, care home and NHS staff (WP4). The government has established six care home ‘vanguards’ to improve care for people living in care homes so we will share our findings with a group (staff, residents, relatives) from each site (WP4). Finally, we will identify who and what helps care homes spread new ways of working and use this knowledge alongside a combined picture from the results of all the work packages to encourage all English care homes to consider ways in which they might implement and use the research (WP5). Our findings will be useful for people and organisations making policy on the best ways to make use of staff within care homes. The research findings should help those making decisions about staffing and quality in homes in government, care home organisations and individual care home managers and teams as well as residents and relatives of care homes, and the people who commission and regulate services.

Research activity codes: 8.1 ORGANISATION AND DELIVERY OF SERVICES
Health categories: GENERIC HEALTH RELEVANCE