UNDERSTANDING THE COMPLEXITY IN CARE HOMES
Introduction
This chapter draws on data from the case study, which set out to explore the experiences and challenges of care staff in managing the healthcare needs of residents, in particular, those living with dementia, and whether the district nursing service was adequately supporting them to manage the healthcare needs they were faced with. Data were collected to deepen
understanding of the context, the care provided in this care home and any challenges facing the care staff. These data included: five interviews (I) conducted with the care home manager (CHM), together with two interviews (I) with team leaders (TL) and a group interview (GI) with 10 care home staff. Documentation (D) was also gathered, including policies, procedures, factual information about the care home and CQC inspection reports.
In PR bias on the part of the researcher may put the credibility of a study at risk (Blythe et al 2013). The researcher may assume that they know the culture, failing to probe for deeper meaning, or overlooking important pieces of data. One way to overcome such bias is through the use of reflexivity. Reflexive field notes (FN), together with a research diary (RD) were kept by the researcher throughout the course of the study and were used as an additional data source. As a district nurse with many years of experience, the researcher used herself as a research instrument, reflecting on the findings from the case study, in relation to her own knowledge and experience of working with care homes, focusing on aspects of practice that were familiar, as well as those that surprised.
As with any case study there are issues with transferability. For this reason rich contextual detail is provided in order that readers can judge if this single case study is of relevance to their own practice. This chapter begins by painting a picture of the case study site, drawing on
observations of the care home made during the period of familiarisation, interviews with the staff and relevant documentation. It then goes on to report on relevant data from the interviews conducted with the care staff, together with data from the reflexive field notes and research diary.
Case study site
The care home that served as the case study site was housed in a building that was relatively new and which was purpose built. It was one of 30 care homes owned by a not-for-profit organisation providing care for older people across the country. In the local authority in which this study took place, described in detail in Chapter 4, five residential care homes were run by this organisation. This care home provided specialist care for people living with dementia.
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The building
The care home was laid out across two floors and comprised six individual units, each caring for up to 10 residents. One entered the building into a central atrium extending over both floors. It was a warm, bright, inviting space, due largely to its large glass ceiling. This atrium served as a central lounge, used by both residents and visitors and was filled with sofas, armchairs and lots of memorabilia. A number of rooms lead off the two floors of the atrium. These included: a reminiscence room, hairdressers and a ‘pub’, complete with bar. There was also a quiet lounge, the manager’s office, a general office housing the bursar, together with the team leader who was on duty for that shift, a staff room, a medical room and the main kitchen. A large garden encircled much of the care home and was accessed from many of the ground floor rooms. The garden was fenced off, giving residents freedom to walk out there as they wished. However, the doors to this outside space were alarmed, to alert staff if a resident was to go out unnoticed.
The units
There were three units on each floor, all leading off the atrium. Outside each unit were pictures of the permanent care staff for that unit. Each unit appeared to function as an individual ‘home’. The door to each unit was opened via a keypad. However, these doors were often left open so that residents could walk around the home as they wished and certain residents were often to be found sitting in the central atrium. The layout of each unit was identical and comprised a central corridor off which lay the bedrooms. Each resident had their own bedroom. Outside each was a picture box holding photos and visual reminders for the resident. All the rooms were individually furnished, each had a profiling bed, unless the family had requested otherwise and all had en-suite facilities comprising a toilet and wet room. There was also a separate bathroom on the unit with a specialised bath, together with a sluice room and communal toilets. At the end of each unit was a lounge with numerous armchairs, a large television, music system and activity items including books, magazines and puzzles.
There was a further seating area for the residents adjacent to the carer’s station, where all information concerning the residents was kept. The corridors had recently been redecorated and along the walls were numerous paintings, as well as photographs of activities and day trips, including residents past and present. Each unit had its own dining room, which included a small kitchen area with fridge, microwave, tea making facilities and toaster. Breakfast was prepared here, with the remaining meals prepared in the main kitchen and sent up on a trolley. As the care home was part of a non-profit making organisation, profits were ploughed back into the care homes. The previous year the manager had been given £80,000 to spend on capital improvements, which had included refurbishment of the main kitchen, new carpets, curtains and furniture in all the rooms, provision of profiling beds for all rooms, as well as refurbishment of the reminiscence room.
Activity
Activity was regarded as an important part of the resident’s day and took place both on and off the units. Informal activities such as exercise, singing or playing games were organised and led
by the staff on the units. Formalised activities such as dances, parties and demonstrations would take place in the central atrium. These were organised and run by the activity co- ordinator, who also spent much of the day working with residents on the individual units. The care home was heavily involved with pet therapy and there were a large number of animals at the home including: rabbits, guinea pigs, cats, chickens and birds.
Staff
When the study commenced the manager had been in post for three years. She had worked for the company for a number of years and had been brought in to improve the care home. She had a wealth of previous experience, working first as a registered nurse and then as a manager in the care home sector for over 25 years. She was supported by 100 care staff, of whom 60 were permanent staff and 40 were employed on the bank, working as needed. There was an administrator/bursar who supported the manager in the day-to-day running of the home, as well as domestic and laundry staff, a chef, kitchen staff, a maintenance person and the activity coordinator. A number of the permanent care staff had worked in this care home for many years. This was particularly true of the team leaders and one had been there since it opened over 10 years previously. The professional backgrounds of care staff were varied and included education, retail, office work, teaching and factory work. Interestingly, a number of the care staff were RNs, mainly from overseas. Although this data was not formally gathered, the majority appeared to have come from the Philippines.
Qualifications and training
In terms of qualifications, 97% of the care staff had either an NVQ level 2 or 3 qualification in social care. All team leaders held an NVQ level 3, which was a prerequisite for this role and some were studying for an NVQ level 4. Mandatory training for care staff included: protection of vulnerable adults, health and safety, fire safety, moving and handling, infection control, a one day first aid course and control of substances hazardous to health. These were all undertaken annually. Other training available to the staff included a one day and four day dementia awareness course, mental capacity act training, food hygiene, food nutrition, training in use of the malnutrition universal screening tool, dietary needs, medicine administration, safeguarding adults, care planning, managing challenging behaviour and person centred care. Care staff also had access to additional training provided by the local NHS trust, local authority and voluntary organisations such as the Alzheimer’s Society.
Staffing levels
In terms of staffing levels there were always at least 13 care staff on a morning and afternoon shift and 6 on a night shift. This comprised two carers on each of the units morning and afternoon, together with a team leader in the office each shift, who would act as a floater if needed anywhere in the care home. There was one carer on each unit overnight, including one who was a team leader. There were no formalised staff/resident ratios; instead these were based on dependency levels and skill mix. So for example, if there was a new member of staff
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they would initially be supernumerary, with the floater making up the numbers. The dependency levels were reviewed monthly as part of the residents’ monthly reviews. Permanent members of care staff were assigned to one unit to ensure continuity for both the residents and their family, but would move between units if needed. They acted as a key worker for up to three residents on their unit and in this role were responsible for the monthly reviewing of the residents’ care plans and monitoring care provision.
Residents
The care home was home to 60 residents, all of whom had a diagnosis of dementia. This number did fluctuate, with 6 residents either already in, or admitted to, hospital during the period of familiarisation. The profile of these residents appears typical of the residents living in
residential care homes today, as shown in Chapter 2. The residents were mainly women. In terms of age, residents were reportedly getting older, with the majority admitted in their 80s or 90s. High levels of healthcare needs and dependency were reportedly present, an issue that will be discussed later in the chapter. Although ethnicity of the residents did not reflect the wider population of the local authority, as nearly all residents were white British.
Inspections
The quality of the care was continually monitored and regular inspections were conducted by their parent organisation and the local authority, in addition to those carried out by the CQC. The parent company required monthly quality audits, together with a large quality audit every six months. There was also regular auditing of the residents’ care plans, the mealtime experience and medication, as well as health and safety assessments. The parent company also conducted a yearly unannounced quality audit. The pharmacy supplying the home conducted a medication audit every six months. As the home had a contract with the local authority, they carried out regular monitoring, together with a yearly inspection.
Regular inspections were also carried out by the CQC. An unannounced inspection had been carried out in 2008 prior to the study commencing, when the care home had been awarded a ‘good’ or two star rating. The next unannounced inspection had taken place in 2011, following a change to the grading and inspection process. At this time the care home was found to be fully compliant on all five outcomes on which they were assessed. The inspection report from 2008 commented that, following the appointment of the present manager, the management of the care home had greatly improved. It was noted that staff members were now working as a team and that training was being implemented. It also went on to report that ‘the residents were receiving personal and healthcare support using a person centred approach’ and as a result ‘the residents’ dignity, rights, independence and respect were maintained at all times’.
Having described the case study site the next section will describe the level of complexity that this care home and their staff were reportedly facing. It will also describe how, as a practitioner researcher, my eyes were opened and I had to acknowledge that, as a district nurse, I had little real idea of the challenges, or the complexity that care staff were routinely dealing with.
Level of complexity at the case study site
As previously described, interviews conducted with the manager and members of the care staff, together with documentation and reflexive field notes provide the data for this chapter. Prior to undertaking this study my knowledge of care homes had developed through my limited
involvement with care homes as a district nurse and from what I had read in the literature. This limited knowledge contributed to a number of surprises that I experienced on analysing the data, often a result of assumptions, or preconceptions that I held, being challenged. A number of issues were of particular surprise (Figure 3) and are summarised as:
Level of need and degree of complexity present The added complexity that dementia brings Level of healthcare skills needed by care staff Level of healthcare support needed by residents
Dissatisfaction with the care home/district nursing relationship Funding pressures
Level of need and degree of complexity
The reflexive field notes recorded a growing realisation on my part, of the degree of complexity reported in the residents, in terms of both their healthcare needs and the level of care required to ensure these needs were met. Working in district nursing for over 19 years I recognised that the residents in residential care homes had changed greatly over the years and had become more dependent. However, I began to realise that as a district nurse I had not given these changes much thought and I certainly had not considered the impact of such changes on the care homes themselves. As the following field note recorded:
..…What is beginning to dawn on me is the level of need and the degree of
complexity that is present amongst many of the residents that these staff are caring for. I was aware from previous experience that they are looking after increasingly ill residents, but I really hadn’t thought about what this meant in practice. And I certainly hadn’t fully appreciated the level of needs that are present, until I was able to spend this time in the care home. Because of this opportunity I am realising that they are looking after people with truly complex needs. Yes, a number of them are mobile and able to feed themselves, but actually all reportedly need support in some form or another and some need assistance to meet all their care needs. And it certainly isn’t limited to only physical needs; the care staff are being asked to provide complex psychological and social support too…..FN 080, p317
Co-morbidity and complex needs were apparently common amongst the residents. Whilst all of the residents had a diagnosis of dementia, many also reportedly had multiple long-term
conditions and health problems, adding to their healthcare needs. Conditions included: Parkinson’s disease, cancer, stroke, arthritis, hypertension, heart disease, diabetes, bladder and urinary problems, depression and general frailty.
113 Figure 3: Reflections from the case study site
A result of such co-morbidity was that the care staff appeared to be providing care that didn’t differ much from the type of nursing care carried out on hospital wards when I worked there. A sentiment echoed by the manager who stated ‘there is a very, very fine line between nursing
and residential’ care (CHM, I, 5). For example care staff were reported to be carrying out
nutritional, risk and continence assessments, and in order to manage the healthcare needs they were faced with were receiving training in regard to tissue viability, recording of baseline
observations, mouth and eye care, management of constipation and end-of-life care.
High levels of dependency were perceived to be present and needs could constantly change. It was reported that residents required support in terms of their mobility, with some immobile, wheelchair bound and requiring hoisting, necessitating the presence of two carers when
providing any care. Over half of residents were supplied with continence pads, suggesting some degree of incontinence, many reportedly required regular toileting, and a small number were catheterised, something that in the past would have necessitated transfer to a nursing home. In terms of nutrition the manager reported that as residents were admitted later in their disease process malnutrition, weight loss and pressure sores were not uncommon at time of admission. Residents often required input from dieticians and/or the speech and language (SALT) team due to nutritional problems, or swallowing difficulties. Many residents reportedly required
support with fluid and food intake. Even when no physical assistance was needed there was still a need to monitor their nutritional intake and to prompt residents to eat and drink. Increasing levels of need and dependency could be the result of the care home caring for residents for as long as they could because the care home was their ‘home’, and the manager would only seek to have them transferred to a nursing home as a last resort if their needs simply became too great for them to manage:
…..but when it is something acute….or anything like that then we can’t. End of life we manage, but then that is supported with the palliative care team and that is brilliant because it is lovely for the residents to die here, because it is their home. But then when you have got somebody acutely ill, they are not weight bearing, they are rigid, they need more allegedly more nursing input then we can’t keep them here, if it is identified…..P23 CHM, I, (3)
The added complexity that dementia brings
Coming from a general nursing background I have, over the years, had very little experience of working with people living with dementia. The opportunity to spend time in a care home
specialising in dementia care gave me greater insight into the care needs of this group of residents, the challenges facing care staff when caring for them and the extent to which
dementia was adding to the complexity that was present. These challenges are summarised as: Importance of ‘knowing’ the person
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Importance of ‘knowing’ the person
Meeting the care needs of residents living with dementia appeared to be a challenge, with many residents reportedly losing the ability to communicate verbally. In the early stages of the disease residents were able to tell care staff if there was a problem, but as the disease progressed communication would reportedly become more of an issue. Understanding what a resident is trying to say was dependent on the person working with that resident having a good