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Residents’ quality of life is better in care homes rated as good or outstanding by the Care Quality Commission (CQC). Research found that their quality of life is better in fully-staffed homes, and where staff have better pay and training.

Care providers are obliged to nurture residents’ quality of life, but there is no standard way of measuring quality of life in care homes. The CQC rates whether homes are safe, effective, caring, responsive and well-led. But before this study, it was not known whether CQC ratings were a good reflection of residents' quality of life. It was also not known whether staff numbers, pay and training were linked to CQC ratings. This is important because care workers often have poor pay and little training beyond basic induction training. Staff shortages, which increase time pressures, are common.

Staff need the right tools to gather information about residents’ health and quality of life. Many care home residents have dementia and may find it difficult to tell staff how they are feeling. In the first part of this study, the research team worked with staff, residents and families to develop tools to help care home staff identify pain, anxiety and low mood in residents. These tools are suitable for residents with dementia and those with communication difficulties; staff do not need clinical training to use them.

The study also found that better CQC ratings were linked with higher quality of life among the residents who need most help. Caring and well-led services made a measurable difference, especially for residents who rely on staff to meet their basic needs. Better pay and training for staff were linked to higher CQC ratings. A 10% wage increase was linked to a 7% higher chance of a care home being rated as good or outstanding.

Together, the findings show the link between working conditions, care quality and residents’ quality of life. The researchers say that policies to improve working conditions for staff are essential to improve outcomes for people living in care homes.

What’s the issue?

More than 425,000 older people in England live in care homes. Many have dementia and struggle to communicate about their health or the care they receive.

In England, the Care Quality Commission (CQC) inspects care homes and rates them as ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. Ratings are based on how well the home keeps people safe, meets their health and care needs, responds to concerns, is caring and well-led. Around 1 in 5 care homes are rated ‘inadequate’ or ‘requires improvement’. These ratings are publicly available, and can inform people’s choice of care home. However, there is little research on whether ratings are related to residents’ quality of life.

The UK Care Act 2014 requires care providers to prioritise residents’ quality of life. Quality of life is usually measured using questionnaires, which is not a suitable method for care home residents with cognitive and communication difficulties due to dementia.

The Adult Social Care Outcomes Toolkit (ASCOT) asks people about aspects of their quality of life that are affected by their social care (food and drink, safety, control over daily life, and so on).  Unlike other quality of life tools, it has a version specifically designed for care homes. The care homes tool gathers evidence from different sources, including observations, which means that it can be used to assess all residents, even those with dementia.

Care home residents often have many health conditions. If their symptoms are not well-managed, their quality of life can suffer. There is evidence that pain, anxiety and low mood often go unreported or undetected in care homes. This might be because the tools used to measure them were designed for doctors and researchers, not for care home staff.

Staff, their training, and how they interact with residents, are likely to influence residents’ quality of life, through the quality of care they provide. Care home workers tend to have low pay and some homes do not provide much beyond basic introductory (induction) training. Homes are often short-staffed, which can put the remaining staff under pressure and affect the quality of care they provide.  There is little UK research exploring the link between staff training and pay, and the quality of care provided.

This study aimed to:

  1. develop new tools to measure pain, anxiety and low mood in residents who cannot report their own experience
  2. find out if CQC ratings are linked to residents’ (care-related) quality of life
  3. find out if CQC ratings are linked to care home staff training, pay and turnover.

What’s new?

First, researchers spoke with care home staff, residents and their families. They developed 3 new items for measuring care home residents’ pain, anxiety and low mood. The term ‘low mood’ was used instead of ‘depression’ to fit the language used by staff and residents, rather than medical diagnoses. As many residents cannot self-report, information is collected through observations, as well as interviews with staff, residents and family members. The researcher combines all this information to rate each item.

They tested the new items in 20 care homes, with 182 residents (aged over 65 years). Most participants were female (67%), over 80 years (70%) and just less than half (48%) had dementia. From this initial testing, the researchers concluded that the items captured residents’ pain, anxiety and low mood. Only around 1 in 5 residents could complete the new questions themselves.

Second, the researchers wanted to see whether CQC ratings given to care homes were associated with residents’ quality of life relating to social care (measured by ASCOT). The researchers combined data from the present study with an earlier study of theirs. This meant they could include 475 residents in 54 care homes.

The study found that:

  • care homes generally met the needs of residents in basic aspects of care (such as keeping people safe, well-fed and clean)
  • better quality care homes and particularly those rated ‘good’ or ‘outstanding’ for leadership, were associated with better quality of life for residents with the highest care needs (those who depend on staff most)
  • residents in good and outstanding homes had more control over their daily life, engagement in meaningful activities, social participation, and were treated with dignity
  • the culture of a care home is set by its leaders; good leadership focuses on quality improvement, enabling and encouraging staff to be responsive to residents’ needs and treating residents with compassion.

Third, the team used a large national dataset of care homes to explore the relationship between CQC ratings and workforce issues. These included training, wages, and staff turnover. This part of the study looked at 2,540 care homes over 3 years.

It found that:

  • high wages were linked to higher CQC ratings – a 10% wage increase for care staff was linked with a 7% higher chance of the home being rated as ‘good’ or ‘outstanding’
  • more training in dementia, dignity and person-centred care was linked with higher CQC ratings
  • in general, homes that were short-staffed or struggled to keep staff, had worse CQC ratings.

Why is this important?

The tools developed in this study could be used by care home staff and researchers to assess pain, anxiety and low mood in care home residents, including those who cannot complete interviews and questionnaires. This is the group of people most at risk of having a lower quality of life. The tools could allow staff to identify residents who need extra support.

CQC ratings were linked to residents’ quality of life. This helps validate the CQC’s methods and work. It means that the public can use CQC ratings with confidence to help make decisions about their own, or their relatives, move to a care home. Residents with the most support needs benefitted most from being in ‘good’ or ‘outstanding’ homes.

Quality ratings were linked with working conditions for staff. Investment in improved staff pay, pensions, training and other conditions is likely to improve care quality.

Care homes can improve residents’ quality of life by enabling staff to spend more time with residents (rather than just getting them through basic daily routines). Staff have chosen to enter a caring profession and supporting them to provide good care is likely to increase their quality of life as well as residents’.

What’s next?

Current funding for the social care sector does not reflect the true cost of care. This research suggests that policies which improve staff members’ quality of life will improve care home quality, which is in turn linked to better quality of life for residents.

The part of the study looking at the relationship between CQC ratings and residents’ quality of life was carried out in southeast England, and most residents were White British. Care homes in other parts of the country, and residents of other ethnic groups and cultures, could be studied in future work. In addition, because this study did not include any homes rated ‘inadequate’, further research could explore the impact of a low CQC rating on residents’ quality of life.

You may be interested to read

This Alert is based on: Towers A-M, and others. Care home residents’ quality of life and its association with CQC ratings and workforce issues: the MiCareHQ mixed-methods study. Health Services and Delivery Research 2021;9:19.

A Department of Health and Social Care report - Wellbeing: why it matters to health policy.

A guide on how to improve quality of life: Towers A-M, and others. Quality of life at work. February 2022.

Research on data in care homes: Burton JK, and others. Developing a minimum data set for older adult care homes in the UK: exploring the concept and defining early core principles. Lancet Health Longevity 2022;3:3.

A Health Foundation study on motivating and retaining social care staff: Retention and sustainability of social care workforce.

NIHR Evidence Collection: Improving the quality of care in care homes: what does the evidence tell us?

Funding: This project was funded by the NIHR Health and Social Care Delivery Research programme.

Conflicts of Interest: No relevant conflicts of interest were declared. Full details can be found on the original research.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.


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