Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study

Abstract

Background Care home staff have a critical bearing on quality. The staff employed, the training they receive and how well they identify and manage residents’ needs are likely to influence outcomes. The Care Act 2014 (Great Britain. The Care Act 2014. London: The Stationery Office; 2014) requires services to improve ‘well-being’, but many residents cannot self-report and are at risk of exclusion from giving their views. The Adult Social Care Outcomes Toolkit enables social care-related quality of life to be measured using a mixed-methods approach. There is currently no equivalent way of measuring aspects of residents’ health-related quality of life. We developed new tools for measuring pain, anxiety and depression using a mixed-methods approach. We also explored the relationship between care home quality, residents’ outcomes, and the skill mix and employment conditions of the workforce who support them. Objectives The objectives were to develop and test measures of pain, anxiety and depression for residents unable to self-report; to assess the extent to which regulator quality ratings reflect residents’ care-related quality of life; and to assess the relationship between aspects of the staffing of care homes and the quality of care homes. Design This was a mixed-methods study. Setting The setting was care homes for older adults in England. Participants Care home residents participated. Results Three measures of pain, anxiety and low mood were developed and tested, using a mixed-methods approach, with 182 care home residents in 20 care homes (nursing and residential). Psychometric testing found that the measures had good construct validity. The mixed-methods approach was both feasible and necessary with this population, as the majority of residents could not self-report. Using a combined data set (n = 475 residents in 54 homes) from this study and the Measuring Outcomes in Care Homes study (Towers AM, Palmer S, Smith N, Collins G, Allan S. A cross-sectional study exploring the relationship between regulator quality ratings and care home residents’ quality of life in England. Health Qual Life Outcomes 2019;17:22) we found a significant positive association between residents’ social care-related quality of life and regulator (i.e. Care Quality Commission) quality ratings. Multivariate regression revealed that homes rated ‘good/outstanding’ are associated with a 12% improvement in mean current social care-related quality of life among residents who have higher levels of dependency. Secondary data analysis of a large, national sample of care homes over time assessed the impact of staffing and employment conditions on Care Quality Commission quality ratings. Higher wages and a higher prevalence of training in both dementia and dignity-/person-centred care were positively associated with care quality, whereas high staff turnover and job vacancy rates had a significant negative association. A 10% increase in the average care worker wage increased the likelihood of a ‘good/outstanding’ rating by 7%. Limitations No care homes rated as inadequate were recruited to the study. Conclusions The most dependent residents gain the most from homes rated ‘good/outstanding’. However, measuring the needs and outcomes of these residents is challenging, as many cannot self-report. A mixed-methods approach can reduce methodological exclusion and an over-reliance on proxies. Improving working conditions and reducing staff turnover may be associated with better outcomes for residents. Future work Further work is required to explore the relationship between pain, anxiety and low mood and other indicators of care homes quality and to examine the relationship between wages, training and social care outcomes. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 19. See the NIHR Journals Library website for further project information.

Supporting the involvement of older adults with complex needs in evaluation of outcomes in long‐term care at home programmes

“…This suggests there is still a further need for methodological innovation to promote their inclusion in service evaluation. One approach that may have merit is the multi‐methods ASCOT CH4 54 —which has been used to promote greater inclusion of the voice of older people with cognitive and communication impairment living in institutional/care home settings but has not yet been feasible in a community setting.…”

Providing long‐term care: Options for a better workforce

“…Concerns also relate to the effect that staff shortages have on providers’ performance. Employees’ turnover and vacancies in LTC are much higher than in other industries and evidence has shown that low staffing levels impact the quality of services (Allan and Vadean, 2021; Towers et al, 2021).…”

“…Turnover requires hiring replacement staff, which entails recruitment costs and generates periods of understaffing. Furthermore, high turnover, as well as high staff vacancies, have proven to negatively impact the quality of care (Allan and Vadean, 2021; Towers et al, 2021).…”

“…A better match between skills, tasks and job roles would be beneficial for LTC workers and for the people receiving care. A higher prevalence of training on dementia and person‐centred care are in fact positively associated with care quality (Towers et al, 2021). Workers in LTC are often confronted by the death of care recipients and may be required to provide end‐of‐life care as patients reach their end of life.…”

Recruitment, retention and employment growth in the long-term care sector in England

“…Studies of turnover rates in the LTC sector have provided valuable insights and highlighted their association with factors such as ownership structure ( 3 – 5 ), management style ( 6 , 7 ), job satisfaction and employment conditions ( 8 , 9 ). Related work has also found that staff turnover is associated with quality of care measures ( 2 , 10 – 14 ). Nevertheless, turnover forms only part of the picture because the impact of staff turnover on the care workforce is mediated by care providers' ability to replace leavers through recruitment.…”