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Care homes look after some of the most vulnerable people in our society. In 2020, there were 419,000 people living in care homes. Three in four residents are over the age of 75; almost as many (70%) have dementia. For this and other reasons, many have difficulties with communication, and mental health problems such as depression, apathy and agitation. Reduced cognitive functioning, frailty and multiple long-term health conditions are common among residents.

The COVID pandemic has put the quality of care in care homes in the spotlight.

“The pandemic has been tough for all of us but for people drawing on and working in social care, it has been a time of real challenge and heartache. But we have also seen people using the best of their skills, their incredible creativity, and their compassion to support people in our communities and families during COVID-19.”

Oonagh Smyth, CEO, Skills for Care, The state of the adult social care sector and workforce in England, 2021

Concerns about the care sector have been made worse by growing challenges recruiting staff. Most care staff are paid on or just above the minimum wage and around one in three leave every year. The sector recognises that it needs to nurture and value its workforce and promote the opportunity to work “in a job that has value and a future”. The NIHR funds research on the quality of care in care homes, and how it can be improved. This Collection brings together the latest evidence. The findings are important for those commissioning, regulating, working and living in care homes.

"Care homes remain undervalued and under-resourced. The government has announced major new investment in the care sector. But it is not clear how this will address the key issues of low pay, understaffing and recruitment difficulties throughout the sector. These are major determinants of the quality of provision. Demand for care home services will increase in line with the general population demographic and there is a risk of a widening gulf between public and private provision.

This may seem a depressing situation. But it remains true that care homes have a dedicated workforce putting every effort into appropriate care and improving quality. It is simply that society and government let them get on with it (largely unseen by the general population) without giving sufficient support."

John Chapman, Public Contributor

As a carer, I find not having the time to care and get to know my residents frustrating. How can I deliver the care they deserve if I can’t give them the time they need? At the end of the day, the more staff you have, the more time they have with residents."

Sarah Gray, Care Worker

The quality of care in care homes

The Care Quality Commission is responsible for assessing the quality of care in care homes. It rates care as ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. The CQC's most recent assessment rated around one in five homes as ‘inadequate’ or ‘requires improvement’.

Until recently, it was unclear whether CQC ratings truly reflect people’s experience of care. A new study (MiCareHQ) addressed the question. It found that residents’ quality of life was better in care homes rated ‘good’ or ‘outstanding’. The study also found that the more staff were paid and the more training they received in dementia and person-centred care, the better the home’s care quality rating. Homes that were short-staffed or struggled to keep staff tended to be of poorer quality.

"It is crucial that there is strong, committed and stable senior leadership. In my experience, there are leaders on a career ladder who move on far too soon. There needs to be a valued, well-supported workforce who are appropriately and fairly rewarded. They need ongoing training and professional development to assure their competency and employability. The care home manager should assess staffing needs periodically because a valued workforce is more likely to deliver better care to residents.The staff’s personal circumstances should be taken into account, and part-time and flexible working hours, and assistance with child care needs, offered as required."

Emily Lam, Member of the Public involved in Care Quality Commission inspections of Care Homes

There is evidence that people in care homes may lack adequate health and preventative care. For example, a recent study found that people with cognitive impairment (including those living in care homes) were far less likely to have had their sight checked or visited a dentist. Historically, care homes have struggled to get input from GPs and pharmacists.

How to improve the quality of care in care homes

The importance of leadership in care homes

The MiCareHQ study on social care echoes findings from within healthcare. The evidence suggests that care can be improved with strong leadership, a focus on continued quality improvement and a culture that gives staff time to listen to residents and meet their needs with compassion. MiCareHQ also supports the conclusion of an earlier NIHR review of the evidence which highlighted the pivotal role of the care home manager in creating a culture in homes that enables change.

The importance of leadership is underlined by a study on a tool called Dementia Care Mapping (DCM). The tool aims to improve practices in care homes for people living with dementia. The programme asks staff to put themselves in the place of residents, through watching and assessing residents’ experiences. Their observations are fed back to the staff team who work together to develop action plans to improve care.

The study found that implementation is patchy. Staff and managers’ confidence or skills to lead changes in practice is pivotal. But the success of DCM is undermined by inadequate staffing and funds, and high turnover of staff and managers. How well managers understand, value and engage with DCM has a key influence, as does their leadership style. Managers in homes that had most success with DCM played many crucial supportive roles. For example, some protected staff time to implement DCM, assisted less confident staff, and engaged staff across the home in DCM and the associated changes in practice.

“This paper shows that in order to increase the probability of successfully implementing changes in care homes, you need to gain managerial support, and identify suitable staff to participate. You need to explain and support the change, and be aware of key elements which could disrupt the change process.”

Carol Singleton, Queen’s Nurse

“Training and good leadership are essential in delivering quality care. The initiatives described in this Collection would work really well if staff were given the training, support and time to implement them. Care in care homes does need to improve. But the time and the support to do this isn’t readily available. Care homes are generally run with the minimum number of staff required by law. Staff are therefore over-worked and underpaid. Carers need time to deliver high-quality person-centred care. We can’t do this if we’re short-staffed."

Sarah Gray

"The case for the importance of leadership is well made. It is accepted that the headteacher’s leadership of a school is pivotal to its success or otherwise. It should be recognised this is equally true for care homes."

John Chapman

Tools and techniques to help people with dementia

“In the case of personalised care, we know what to do and yet we can’t make the system deliver what’s needed.”

Clive Ballard, Professor of Age-Related Diseases, University of Exeter, WHELD programme summary

In addition to these general lessons about leadership and culture, there is growing evidence about what works, particularly for people with dementia. The WHELD programme (Well-being and Health for People Living with Dementia) and the MARQUE scheme both provide a framework for high quality care for people with dementia. Their key components are captured below.

The WHELD programme

The WHELD programme supports care home staff to deliver patient-centred interventions for residents with dementia. It seeks to reduce their reliance on antipsychotic drugs and uses social interaction, personalised activities and exercise to improve care. Training in person-centred care is included, along with antipsychotic review by GPs, social interaction, and exercise. Incorporating personalised activities along with more general person-centred care meant there were tangible items to incorporate into care plans. Two ‘care staff champions’ at each home are trained to take simple measures such as talking to residents about their interests.

In a large clinical trial, WHELD improved quality of life for people with dementia. The programme reduced agitation and the overall burden of neuropsychiatric symptoms such as depression or aggression. WHELD was less expensive to deliver than usual care because it reduced the number of hospital and GP visits.

The MARQUE scheme

The MARQUE scheme has been tested (on a relatively small scale) and shown to improve quality of life for residents with dementia. It includes training for staff in new techniques to manage agitation. Each home receives resources and its own action plan, which is agreed with staff and the manager.

MARQUE components included:

  • a game to get to know residents’ preferences and interests (Call To Mind)
  • a technique to investigate causes of residents’ agitation, propose solutions and record the outcomes of those interventions (DICE)
  • the introduction of ‘pleasant events’ in the routine of the home
  • improved communication between staff
  • relaxation techniques for staff.

"A lot of training claims to focus on person-centred care – but the quality is extremely variable and very little is evidence-based. At an early stage of the WHELD programme we reviewed available training programmes in the UK. We found 179, but only 20 met a quality threshold. Only four had clinical trial evidence that they conferred benefit. This is a challenge and we need to move to a framework that emphasises established quality and benefit."

Clive Ballard

"Many dementia homes I have worked in have programmes that are similar to WHELD. Residents have care plans created using information provided by the family and anyone who knows them; care homes could improve by having more input from family members. Each resident must be referred to as an individual and have an individual plan of care. Owners need to step back and not look at care homes so much as businesses, but as a service to those in need."

Joanna Reynolds, Care Worker

"I have seen WHELD and MARQUE initiatives in action and can endorse the benefits. In addition, I would encourage care homes to work more closely with relatives and carers of residents, and the wider community. For instance, during an acute health episode when a resident has fallen ill, the practical help of the resident’s relative or carer at certain periods in the day or week may make a difference to whether the resident needs a hospital admission. In other instances, care home managers have volunteers who come in at mealtimes to help with feeding, or take residents for a walk in the garden or visit a nearby shop.”

Emily Lam

Earlier work in the OPTIMAL study underlined the importance to care homes of support from GPs and the wider healthcare system. Strong relationships and systematic input, such as training for care home staff make a critical difference. They improve the experience of both residents and staff, and reduce crisis admissions to hospital. In England, the Enhanced Health in Care Homes programme aims to improve collaborative working between care homes and wider health and social care services.

"Primary care has its own difficulties and pressures, so it is not surprising that those in care homes do not always get sufficient support from their GP and other primary care services. Care homes are often an added pressure for those services. This is an area where improvement is needed."

John Chapman

Exploiting new technologies

A more recent study showed how simple low-cost video technology allowed residents in different care homes to enjoy taking part in virtual quizzes. Residents felt more connected with each other, and with other care homes. They re-gained a sense of self and purpose and felt less lonely. Care home staff were eager to continue with the sessions, but they outlined barriers such as lack of staff support or time.


Care homes are responsible for a vulnerable group of people with complex health and social care needs. This presents a considerable leadership and care challenge. Care homes need proactive support and engagement from the wider health and care system. And within each home, a well-trained, stable workforce is the key to making improvements. Care homes need to invest in their managers and staff in order to deliver person-centred care, tailored to each individual. Once in place, the evidence shows that this approach can improve the experience of both residents and staff. Importantly, by reducing the involvement of GPs and hospitals, it can be cheaper to deliver.

There is a need to improve the care offered to many residents. Good evidence now exists on approaches that can help care homes effectively manage and care for their residents.

How to cite this Collection: NIHR Evidence; Improving the quality of care in care homes: what does the evidence tell us?; December 2021; doi: 10.3310/collection_48577

Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed 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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