“It’s not what staff do but how they make me feel”: Understanding how care home staff influence quality of care from the perspective of residents and their relatives
Understanding “quality” in care homes means recognising that the term means different things to different people. Our study focuses on how staff influence quality in care homes.1
This raises an important question: what is it about the staff who work in care homes that matters most to the people who live there and their relatives? This article summarises our discussion of what matters for residents and relatives.2
At the heart of our discussion is a key message: “love” drives quality. Love was seen as crucial. It promotes friendship, security and trust and shapes how people experience their home.
Obviously, making a concept such as love real in a care home is not without its challenges. Love requires staff to openly demonstrate their kindness, care, confidence and engagement with people living in the home; in some environments this is not always easy. The group shared stories of staff that were genuinely interested in residents; often communicated through the smallest of gestures: simply chatting, asking questions, or just taking an interest in their life, families and friends. Simple gestures that nevertheless build a sense of trust and comfort. It was these “little things” that made a difference.
For example, knowing how a resident likes their cup of tea, or explaining why lunch is a little bit late today can make a big difference for people. Notably, the group emphasised that the ways in which staff conduct themselves, rather than their qualifications, is what matters. Dependability, creating trust and making people feel comfort were not the sole preserve of the registered nurse. If people living in the home feel safe, protected and loved then perhaps it is not surprising that this leads to a better experience of care.
The PPI group acknowledged and praised the hard work of staff. However, they spoke of the organisational problems that shape how staff carry out their work and make “quality” an elusive part of the experience of living in a home. Time – or rather too little of it – was both the enemy and the friend of staff pursuing quality care. Positively, residents appreciated staff taking time with them for everyday activities, chatting and socialising. Less positively, when the care home is short-staffed; when there is a “crisis” in the home; or when one resident requires additional care due to ill-health, then time with other residents is sometimes rationed. This rationing is a problem because residents often rely on contact with care home staff and these may be the only interactions the resident has in a day. Recognising this is not the fault of staff, the group simply wanted to explain personal impacts of a lack of time: feeling overlooked or experiencing a reduced service, such as delayed trips to the bathroom, late mealtimes, or beds unmade; little things that contribute towards the experience of quality for people living in the home. Using agency staff to compensate for a staffing shortfall did not help. Whilst extra staff may help with tasks, they are unable to contribute to the social part of care home life. Staff familiarity and understanding are essential for quality. The group had suggestions of how staff can make a difference.
Flexibility is key to alleviating day-to-day pressures for staff. This flexibility can be at the individual and organisational level. Individually, staff can make the most of limited time for raising quality by socialising whilst engaged in caring activities. Equally, a manager who promotes the ethos of a “home” where care is provided for people is important. The group emphasised the importance of having an understanding manager with a caring approach and who encourages staff to socialise with people living in the home.
A manager sets the tone in the home, therefore a manager who is flexible, pragmatic and understands each person and that every day is different is valued by both residents and relatives. Small things, such as allowing family, friends or visitors the freedom to use their initiative to address urgent matters (rather than following overly rigid protocols) can make for a better quality home life. This can present obvious challenges for home managers. The manager should be firm and not afraid to challenge, while at the same time encouraging a supportive home environment. To do this, managers need to be supported by their employers and have access to opportunities for learning and sharing good practice.
In sum, staff promote quality by being kind, dependable, trustworthy and having (and using) the confidence to advocate for residents. Staff who make the time to really get to know people living in the home and go “the extra mile” to do the little things will make a big difference to how people experience care home life. Firm, fair and flexible managers who create a home ethos focused on the “person” living in the home rather than tasks will help both the quality of life in the home and build the confidence of the staff who work there. Sometimes it’s the little things that help people to do the best job they can for the people who matter most.
Written by: Kirsty Haunch, Theodore Bacon, Rosemary Cox, Tony Dale, Jenny Hill, Pamela Phillips and Karen Spilsbury.
This project is funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 15/144/29).
The views and opinions expressed in this article are those of the authors and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.
1 Relationship between care home staffing and quality of care: a mixed methods approach is funded by the NIHR HSDR (15/144/29) (https://www.journalslibrary.nihr.ac.uk/programmes/hsdr/1514429/#/)
2 Public and Patient Involvement (PPI) Group meeting (25 January 2018) for the NIHR HSDR study (15/144/29). The group is comprised of older people living in a care home and relatives.