What does ‘good care’ look like? Understanding the complex systems in care homes

Reference # R462/0216
Date January 2017 - April 2019
Funding £132,796
Project lead Dr Al Ross
Organisation University of Glasgow

Published October 2020


Change is a common and necessary part of care environments – but what sort of culture within care homes leads to them adapting well to change? Dr Al Ross and his team wanted to understand what ‘good care’ looks like, discover which aspects of care homes’ systems and culture support this, and share their findings to improve life for older people in care homes.

The idea was to learn the mechanisms by which good care emerges, and then disseminate them

Dr Al Ross

Change in health and care settings is common, and something that must constantly be adapted to. However, we often see a disjunction between the way that some changes are designed and the way that these environments need to actually respond to change in order to be successful.

For example, new guidelines may assume that people behave in a linear fashion – “if you do X, then Y will happen”. But we know that real people and real situations don’t work like that, and care environments must adopt and apply these guidelines in a way that works with their actual, complex environment.

Care homes have many different factors that influence outcomes and success – including the different tasks to be achieved, individuals’ needs, wants and preferences – and these don’t all fit neatly into a simple structure. This can make it hard to understand exactly what contributes to ‘good care’ in any particular care home and replicate it in others.

In this research, we wanted to understand exactly what factors within a care home’s organisational system and culture might support their response to change and help them to deliver good care. The idea was to learn the mechanisms by which good care emerges, and then disseminate them.

Trusting the experts

With this work, we tried to flip the ‘expert’ model upside-down. Crucial to this project was recognising that it is the care home staff who are the experts in what makes good care – not just the academics or consultants producing guidance on what they should be doing.

Ultimately, our work is helping to empower care home staff to do what they’re best at: caring

Dr Al Ross

Our researcher on the project, Dr Santhani Selveindran, engaged with seven care homes in Scotland from across the management models of private, voluntary sector, and local authority-run. Santhani spoke with staff and managers to find out what they think works and what doesn’t. This required gaining people’s trust and getting them to open up about the culture and working practices within their home.

During the course of our research, new care standards were published in Scotland. We decided to extend our project so that we could look at what happened as these standards were implemented and make our findings as relevant as possible. The Dunhill Medical Trust were really helpful, and it was no problem to negotiate an extension.

Researcher smiling and standing in front of scientific poster.
Santhani presenting some of our results at the 2018 Congress of the European Association of Dental Public Health in Palma.
A handbook to help others to develop resilient systems

In order to successfully deliver care alongside a constantly changing environment, these care homes must be ‘resilient’. The findings from this research helped us to identify what makes a ‘resilient system’.

For example, in one care home we saw the use of a new kind of technology for digital care plans and records. Care home staff were able to update these on a hand-held device in real time, recording not just actions against a care plan or daily routine, but also notes on a resident’s mood or energy. Sharing this knowledge is invaluable in tracking and anticipating any changes in the health or comfort of an individual. This is the kind of innovation that develops and supports a resilient system and improves overall care.

We distilled all of our findings from this and similar work in hospitals into a model that others can use to develop the same systems in their environment, and published this as a handbook. This handbook isn’t prescriptive, but it outlines the common factors that we found within care environments that we think lead to good outcomes, flexibility, and resilience to change. The handbook will help those working in health and care environments to identify what those will look like when tailored to their own setting.

Ultimately, our work is helping to empower care home staff to do what they’re best at: caring.

Find out more

You can access the CARe QI handbook that we published as a result of our findings at this link.

The abstract for the work Santhani presented to the European Association of Dental Public Health is available here. I recently presented some results at a resilience methodology conference, the abstract for which can be read here.


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