Is excessive paperwork in care homes undermining care for older people?

Joy Warmington, Asif Afridi and William Foreman  28th Feb 2014

Are older people in care homes missing out on quality time with staff because workers are preoccupied with paperwork?

Care homes have to regularly complete more than
100 separate items of paperwork, often duplicating the same
information, this study found. Researchers visited care homes and spoke
to staff who felt they were judged more on their ability to produce
paperwork than deliver care.

The research recommends that the
sector rethinks its priorities and makes changes to the way it deals
with administration so older people can be given more compassionate,
personalised care.

Key points

  • The
    balance between prevention of poor care and promotion of good care is
    out of kilter. Fuelled by fear and insecurity, care homes spend too much
    time attempting to cover themselves against blame or litigation, often
    at the expense of spending time with residents.
  • Staff can lose
    their sense of vocation if they feel like they are being judged more on
    how they produce paperwork than how they care for people. Some home
    managers spend 20% of their time on paperwork and often have to
    duplicate information for different agencies.
  • Paperwork has
    limited our ability to measure the quality of interactions between staff
    and residents. These day-to-day interactions should be at the heart of
    care home inspections, which should give real weight to resident
    participation, choice, dignity and respect.

Summary

Does
paperwork intended to improve the quality of care in older people’s
care homes make them better places to live, or does it reduce the amount
of time devoted to caring?

This research examines the practical impact of paperwork in care homes and makes suggestions for its improvement.

Key points

  • It
    is a misnomer to talk of a single ‘set’ of paperwork. The research
    identifies more than 100 separate items of paperwork that must be
    completed regularly in care homes, responding to a range of regulatory
    and commissioning requirements. But a shared view of what should be
    valued in care is lacking.
  • Poor co-operation and co-ordination
    between agencies responsible for regulation, monitoring and purchasing
    care results in information being duplicated, often several times with a
    slightly different emphasis each time. This effect is referred to in
    this study as a ‘composite burden’.
  • Staff see some of these
    information demands as bearing little relation to an assessment of the
    quality of care a home provides for its residents.
  • n the care
    homes visited, about half of the paperwork produced was used
    infrequently. Some staff felt that paperwork was inefficiently designed
    or implemented. Providers’ interpretations of the value of regulatory
    paperwork also varied widely.
  • Some managers in care homes
    report spending 20% of their time on paperwork rather than on leadership
    activities that could improve the quality of care for residents.
  • Some
    staff feel they were judged more on an ability to produce quality
    paperwork than an ability to deliver quality care. Paperwork has limited
    our ability to quantify and measure the quality of interactions between
    care staff and residents. Paper offers false assurances in this regard
    and yet it is these interactions that are of ultimate value to residents
    and their relatives.

Background

Public
confidence in the regulatory and inspection regimes that should protect
us when we are at our most vulnerable is plummeting, and government
initiatives to improve care quality and strengthen regulation are being
announced at ever shorter intervals. The Joseph Rowntree Foundation
(JRF) wants to understand how approaches to risk and regulation in care
homes can be developed in ways that support good relationships and
improve people’s quality of life.

This research explores the
role of paperwork in residential care homes for older people. It is
currently estimated that more than 376,000 older people live in around
10,300 care homes in the UK – a population that will increase
significantly over the next 20 years as the number of people in the UK
aged over 85 doubles. Two key beliefs were central to the research
methodology. First, that the purpose of paperwork should be driven from
the perspective of those it is intended to benefit –residents. Second,
that care should be provided in a way that is ‘human’ – focusing on the
creation and maintenance of meaningful relationships between care staff
and residents.

What paperwork is for and who decides this

Care
homes have a list of core ‘must-dos’ based on key legislation and
embodied in 28 standards of quality and care. Yet different agencies
also make requests of care homes and these requests have different
emphases across the country. In addition to this moveable feast of
‘must-dos’, views about how guidance should be interpreted to meet
funding or regulatory requirements also vary. Additionally, some
requests made by inspectors and regulators are seen by care homes as
bearing little relation to the quality of care provided.

It is a
misnomer to talk of a single ‘set’ of paperwork. There is little
co-operation or co-ordination between different regulators and
commissioners and duplication arises when they ask for much the same
information, but tailored to their individual needs. From their point of
view, what is requested is reasonable. However, the impact of several
commissioners asking for similar but slightly different information
places an extraordinary burden on the home. This composite impact is
often what homes are describing when they complain about a ‘paperwork
burden’.

Many interviewees felt that this issue reflected deeper
system-wide uncertainty about what should be valued in care and what
high-quality care should look like. Without this understanding, it is
unlikely that agreement will be reached on the things care homes need to
do, not just to comply with regulatory and commissioning requirements
but to raise the quality of care.

Use and application of paperwork

In
the care homes studied, about half the paperwork was used infrequently.
However, staff still felt they had to produce it, and that the primary
purpose of much of the paperwork was to ensure legal compliance or
prevent litigation. In some cases, staff felt that paperwork was
designed inefficiently. In other cases, paperwork seemed to be
inefficiently implemented, with room to eliminate or streamline wasteful
internal procedures.

Some managers reported spending 20% of
their time on paperwork rather than on leadership activities to help
ensure high-quality care for residents. Some staff reported that they
increasingly feel themselves judged primarily on their ability to
produce quality paperwork rather than quality care. The use and
application of paperwork was explored further in three areas – care
planning and daily records; risk assessments; and staff supervision. The
research found that while care plans are important documents, the
resident’s voice can be lost when he or she is seen as a set of care
needs. In risk assessments, the focus tends to be on avoiding risk
rather than on managing risk and enabling residents, whose wishes and
priorities can be a secondary consideration. Paperwork associated with
staff supervision and performance is rigorously assessed by regulators,
yet does not always result in effective staff development. These are
just some of the areas in which paperwork does not necessarily help
achieve intended outcomes.

Paperwork and its contribution to achieving what residents value

Paperwork
is frequently of limited value in promoting good-quality care. This is
especially true in terms of quantifying and measuring interactions
between care staff and residents in a care home –interactions which
determine care quality and the experience of care. In numerous
conversations with residents and their relatives, the quality of these
interactions emerged as the single most valued and most remembered
aspect of care. However, it is difficult to capture this on paper and
more needs to be done to increase the weight given to observed care
quality in homes. Used in this way – to assess all of the aspects of a
care home’s working culture and care ethos – paperwork could help
contribute to better quality care relationships and to strengthening
residents’ voice in the care process.

Conclusion and recommendations

The
balance between prevention of poor care and promotion of good care is
out of kilter. Care homes spend an inordinate amount of time attempting
to cover themselves against potential blame or litigation for poor care.
Paperwork has become an industry in its own right, fuelled by fear and
insecurity. Instead of being an addition to care quality, paperwork can
lead to ‘subtractions’ – literally taking away from the delivery or
management of care. Five of the most significant subtractions are:

  • Leadership:
    Many interviewees felt that time spent by leaders on paperwork could be
    better spent on leadership activities, being a visible presence in the
    home and demonstrating how to build good relationships with residents
    and staff.
  • Value of care: Interviewees suggested that the
    value placed on paperwork was too high compared to the value placed on
    providing high-quality care.
  • Vocation: Staff are judged more
    on their ability to complete paperwork than on their ability to deliver
    good care, creating unnecessary differentials in ability and divisions
    of labour. This can distance staff from their job and reduce their sense
    of vocation.
  • Co-operation: Paperwork does not drive
    providers, commissioners, contractors and regulators to higher levels of
    co-ordination, nor does it help them establish a shared value system
    for care.
  • Professional autonomy: Regulation can lead to
    regularisation; reinforcing the mechanistic nature of some care
    practice, for example regular bed-rail assessments. Staff in care homes
    need to take action because they recognise that it is the right thing to
    do at the time. Routine should not undermine staff autonomy or be a
    substitute for professional judgement. In the short-term, a number of
    limited steps to improve regulatory paperwork could be taken:
  • Adoption of a single incident reporting form.
  • Alignment of national inspection criteria across agencies such as the Care Quality Commission, NHS and local commissioners.
  • Sharing and use of information across inspectors of care.
  • Geographical
    alignment (improving consistency of approaches to inspection taken by
    commissioners and regulators in specific local areas).
  • Organisation
    of paperwork for different audiences (organising a set of paperwork
    that can be owned and used by the resident and organising paperwork that
    is used more by staff on a day-today basis).

Longer-term systemic improvements will require more ambitious change:

  • Care
    home inspection should involve observed assessment of care, giving real
    weight to choice, participation, dignity and respect. These are
    observable in the day-to-day interactions between residents and staff
    and should be at the heart of any inspection and regulatory regime.
  • The
    primary role of risk management should be to enable residents to live
    their lives in a way that they value as opposed to defending the home
    from potential litigation or reputational loss. This requires additional
    training and a better understanding of risk and enablement among
    regulators and commissioners. Care homes, commissioners and regulators
    should generate more collective approaches to accountability to reduce
    defensiveness and improve shared learning and calculated risk-taking
    across the care home sector.

About the study

The
research was conducted in two care homes in Birmingham and one in York.
As well as examining the current use of paperwork, focus groups and
interviews were conducted with residents, relatives, volunteers,
frontline staff, managers, commissioners, providers and regulators. The
authors would like to thank all those who kindly gave their time and
expertise.

Published by Residential Forum

The Residential Forum is to promote the achievement of high standards of care and support for children and adults living in residential care and nursing homes, supported housing, residential schools and colleges, hospices and hostels. It contributes to improving the quality of service to the public. Members of the Forum are people of standing and experience drawn from the public, private and voluntary sectors, as well as some who can speak for service users and carers.

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