Discussion of main study findings
We discuss key findings about implementing social distancing and isolation measures for residents – consequences, challenges and solutions; enabling connections and communications; caring for the CH workforce; and supporting the wider CH sector.
Implementing social distancing and isolation measures for residents: challenges, consequences, solutions
Social distancing
Social distancing measures involved residents and staff being required to maintain a 2 m distance from each other.21 We identified negative consequences of social distancing measures, which included confusion for some residents and inhibition of their social interaction. Some residents, notably those living with dementia, found it difficult to understand why they could not sit close to others. These changes to social interaction negatively impacted on resident well-being. Other research has reported similar findings, including that disruptions to residents’ usual care routines and social interactions have negative consequences for their physical and emotional well-being.135
The physical layout of CHs was sometimes a challenge to successfully implementing social distancing, for example in CHs that were not purpose-built where the physical space was not always available. It has been reported elsewhere that space and environment placed constraints on the ability of CHs to respond to the COVID-19 pandemic.136 A key finding of our review was that not all CHs had the space to provide single rooms, create separate zones or ensure sufficient walking space around the home was in line with social distancing measures.33,60,64,78,82,84,103,112,123,129 This was also the case for isolation measures. Our participating CHs implemented different approaches to this, for example one CH established a COVID-19 ward, where people hospitalised with COVID-19 were discharged to recover. Another CH had households of 12 residents that were treated as separate subgroups. A discussion paper in our review suggested that CHs operating with ‘household models’ had improved outcomes for residents, but that more research was required.33 Respondents in another study reported that approaches to cohorting and zoning were only possible if the layout and space in CHs were sufficient.112 A challenge with cohorting shared elsewhere is that it potentially removes residents from the comfort and privacy of their own bedrooms, which can be disruptive and especially so for residents living with dementia.137 Cohorting residents has been described as a type of hard strategy, that is, it is more interventionist and with potential ethical concerns – residents are restricted to a specified place or area and this restriction is monitored by staff.138
Making changes to CHs to enable social distancing and isolation and other COVID-19 interventions will likely have significant cost implications. Design and planning for new CH facilities should embrace the latest IPC evidence; evidence to support care and maximise the quality of life for residents with particular care needs (e.g. residents living with dementia, other cognitive impairments, sensory impairments, conditions requiring residents to use a wheelchair); enable residents to connect socially with their families and friends and to connect with the outdoors and different sensory experiences. There is a need to move away from thinking of CHs as ‘a lot of bedrooms’ and more as ‘spaces and places for living’139 (p1168).
In addition to measures and restrictions within the CH, residents had to comply with restrictions for leaving the CH, for example to visit their own home and other places with staff or family and friends, and for using facilities in the wider CH community, for example gym and cinema. Factors known to enable older people to settle into CH living include being able to continue valued social relationships and establish new relationships.140 These restrictions had negative consequences for residents’ mental health, with staff reporting that residents became withdrawn and introverted, and for residents’ physical health, for example contributing to deconditioning because of a lack of exercise.
Care home staff shared that maintaining a social distance between residents and staff was not always possible, for example, when providing personal care for residents, and that exceptions needed to be made. Similarly, some residents were confused about why they could not have a hug from staff but that staff were permitted to assist with personal washing and dressing. This caused upset for residents and staff alike. For staff who lived alone, not being able to hug residents and colleagues was an additional burden. CHs were perceived by staff as a resident’s home rather than an institution, consequently some staff questioned whether social distancing was appropriate and if abiding by social distancing measures was always in the best interests of residents.
Compounding the challenges of social distancing and isolation for residents was their experience of staff wearing masks and PPE. PPE made it more difficult for residents to recognise and communicate with staff, particularly those residents who were hard of hearing and relied upon lip-reading, or those who had vision problems. This finding resonates with findings in the published literature.137 Sometimes staff had to lift their mask briefly so that residents could understand what they were saying or stand at a distance and talk ‘really loudly’ to residents or write down what they wanted to say on paper. It was felt that seeing staff in full PPE could be ‘scary’ for some residents, especially those with cognitive problems. It could also negatively impact the ability of residents to connect with staff and for the CH setting to feel like ‘home’.
Isolation
In line with government guidance,21 initially residents were asked to stay in their rooms for 14 days, and this was reduced to 10 days from January 2022. During this isolation period, all care and meals were delivered to residents’ private rooms. A key finding was the reported negative consequences of isolation for some residents’ physical, psychological, emotional and cognitive well-being. Staff spoke of some residents being bored, frustrated, confused and distressed, particularly for residents living with dementia or another cognitive impairment. Understanding fully the impact on residents living with dementia was recognised as a challenge and not always possible to achieve. Helping staff to interact meaningfully with residents living with dementia or other cognitive impairment and to be able to assess for signs of distress is paramount. For some residents, isolation was believed to have had contributed to their physical decline, for example, because of reduced physical exercise, and not eating and drinking as well when dining alone, and to a decline in mental health, for example, experiencing disturbing hallucinations. Family members likewise thought that being in isolation had negatively impacted on residents’ physical and psychological health. A rapid review of the psychological impact of quarantine reported that quarantine was often associated with a negative psychological effect and longer quarantine (more than 10 days) was associated with poorer psychological outcomes.23
For those residents who recalled being in isolation, it had been a challenging experience and isolating in every sense of the word. Residents who had recently moved into the CH were considered by staff to have had a particularly difficult experience of isolation regulations. Transitioning to living in a CH was challenging enough without having to isolate alone, not having the opportunity to see the CH as it usually operated, to participate in activities, and to interact freely with and get to know staff and residents. These factors are potential facilitators for older people transitioning well to living in a CH.140 Unintended consequences of isolation measures included potential new residents being put off from moving in because of isolation requirements, reluctance sometimes for residents to attend hospital appointments to avoid having to isolate on their return to the CH, and CH decision-making about potential new residents, for example accepting only older people who are physically and mentally capable of isolating themselves and not those who walk with purpose.
Measures to make isolation less difficult for residents included ensuring that they were entertained purposefully with regular socially distanced visits from staff and various resources to occupy their time, while working with residents’ individual beliefs and values. ‘Activity boxes’ were created. Some CHs gave isolating residents a radio, Echo or Alexa so that they could listen to music; an iPad or tablet so that they could contact family and friends; a TV to keep them entertained; and exercise equipment, such as stretch bands, to keep active. Adequate staffing levels and a skill mix that includes sufficient well-being and activities co-ordinators are vital to an infrastructure that can support these measures. Family members praised the crucial role of these co-ordinators in identifying and acting on signs of low mood for residents in isolation. Engagement of residents in meaningful activities and additional close monitoring were key strategies for supportive isolation in other CH research studies.112,135 Creative approaches to activities for residents not isolating were also evidenced, for example small group indoor gardening, yoga, karaoke, bingo and quizzes. Our toolkit is designed to capture such innovative approaches that are realistic and can be implemented meaningfully in practice.
Purposeful activities alone to support residents isolating are inadequate. Staff sitting with residents regularly to help prevent loneliness and improve well-being was an important study finding. This illustrates the importance of human connection and resonates with reports of the six senses, which are required for outstanding care and include the need for older people to experience a sense of security, continuity and belonging.141 Maintaining good communication with residents throughout their period of isolation was important, with staff comforting residents, explaining the reasons why they needed to isolate and encouraging them to persevere. Most residents shared that the measures and restrictions introduced at the CH were explained well to them by staff, although some shared that staff were not always willing to discuss the measures as fully as they would have liked. Some residents shared that it was likely that staff themselves did not understand the reasons for measures and restrictions, a finding of our interviews with CH staff. Giving as much information as possible to those who are in isolation, their families and friends was a theme in the published literature.23 A pre-COVID-19 study found that best care was evident in CHs where residents, families and staff worked together, and where there was a sense of community.142 Some staff shared with us the importance of maintaining a sense of humour and continuing to ‘banter’ with the residents to raise their spirits. Extra vigilance by staff to ensure residents’ safety while alone in their bedrooms was paramount. The potential contribution of smart technology to support this is worthy of investigation.
Moral dilemmas
Implementing social distancing and isolation measures presented moral dilemmas for CH staff, illuminating potential tensions between risks and benefits and how to balance facilitating person-centred care for residents with a need to implement these measures to help prevent and control any COVID-19 outbreak. This concurs with other research.143,144 One study reported that caregivers were conflicted about incorporating social distancing and infection control into caring for residents living with dementia.143 How to manage social distancing and isolation measures for residents living with dementia or other cognitive impairment was identified in our study as a particular challenge – difficulties for residents to understand, remember and follow instructions. This resonates with other research, where CH staff reported that key challenges to isolating residents were cognitive impairment and language/communication barriers.135 Developing staff knowledge and skills to support the implementation of isolation and social distancing measures to include ethical principles for decision-making warrants further attention. Positively, these authors have developed a Dementia Isolation Toolkit providing ethical guidance on how to isolate people living with dementia safely and with attention to their personhood.135 Others have advocated an approach to care that is ‘principle-based, coupled with case-by-case application of the principles for individual residents’138 (p4). This highlights the need for senior leadership, CH managers and staff to understand key sources of law and their application to resident care, for example the Mental Capacity Act 2005, the Human Rights Act 1998, the Equality Act 2020 and the Coronavirus Act 2020. Helping staff to implement isolation interventions more easily was good teamwork and receiving support from managers and colleagues. A higher level of support from employers and colleagues was also associated with moral resilience in a survey of 962 healthcare workers in Canada.145 They explored links between moral distress, moral resilience and the emergence of mental health symptoms during the COVID-19 pandemic and concluded that moral resilience might be an important target to preserve healthcare workers’ mental health. The consequences, challenges and solutions to implementing social distancing and isolation measures for CH residents illuminate the knowledge, skills and values required to be able to care well for residents and emphasise the need for further investment in the development and recognition of this workforce.
Trauma-informed approaches to caring for residents, families and friends, and care home staff
Social distancing and isolation measures and other restrictions have been a source of distress and trauma for some residents, families and friends, and CH staff during the COVID-19 pandemic and pose a risk to their psychological and physical well-being. Senior health and care leaders shared in our study focus groups that as the pandemic progressed there was a sense of the need to consider the wider health and well-being needs of residents, families, friends and the workforce. Slowly it was recognised that the workforce was traumatised and so a trauma-informed approach was beginning to inform system leaders’ thinking about staff well-being. There are examples of trauma-informed approaches to care, for example for older people in hospital146 and for healthcare workforces,147 and a case is made for widespread implementation of trauma-informed models of care in generalist aged care settings.146 They state ‘Person-centred care provides the foundation of trauma-informed care, wherein collaboration and communication are key. Trauma-informed care extends this philosophy by emphasising the fundamental role of trauma in shaping the person’s experience of care’146 (p426). It is less clear what trauma-informed care might look like for CHs caring for older people, for residents, families and friends, and staff. The potential to translate trauma-informed models of care into the CH sector caring for older people warrants attention.
Enabling connections and communications
An important finding of the study was the creativity and support offered by CH providers, managers and their staff to enable connections and communications between residents, families and friends while residents were isolating, when visiting was not permitted or was permitted with significant restrictions, and for CHs to keep connected and communicate with families and friends. Residents, and family members, highly valued that they were kept safe; they had experienced the difficulties and ill-effects of social distancing, isolation and restrictions but overall understood this and appreciated the safety of implemented measures.
The contributions of families and friends to creating a meaningful life for the older person living in a CH and to creating a sense of community are well known.148–151 An analysis of support networks showed that older people living in CHs valued the support of family members more than any other tie.152 Restrictions to visiting from families and friends had negative consequences for residents and their networks. At times of difficulty, it is normal to want to be with people we love, trust and feel safe with; residents shared that their mental health had deteriorated because of not seeing in person their families and friends and many felt abandoned – a finding that is reflected in other recent research, including a rapid review of the impact of visitor exclusion, which found that residents experienced higher levels of depression, anxiety, isolation and loneliness.153,154 Family members also reported that visiting restrictions had exacerbated their loved one’s physical health decline, for example not being present to encourage, motivate and assist with activities, such as exercise regimens. Positively, the importance of family and friends was recognised in government guidance for England with the introduction of the essential family carer role in March 2021.
Similarly, anxieties and stresses were experienced by families: they were accepting of the need for restrictions to keep residents safe but were not always sure how or why decisions about guidance and implementation were made; many were fearful that they might not get to see their family member in person again; and they were anguished at no longer being involved in the resident’s daily life and the life of the CH community. There were additional feelings of powerlessness for families whose loved ones had moved into the CH during the pandemic, coupled with anger and heartbreak at not being there for this significant life transition. Therefore, enabling connections and communications was key to promoting a sense of security, continuity, belonging, purpose, achievement and significance for residents, families and friends.141 Several innovative and creative approaches were identified to enable contact and communication between residents, families and friends. Stories were shared of how many residents had adjusted to using smartphones and tablets to keep in touch with family and friends through video calls. Others used video calls less often or not at all but made conventional audio calls. Residents with personal access to advanced video-calling technology provided by their relatives – and with the skills to operate it – appreciated the autonomy it afforded them; they did not rely on staff to facilitate calls and so could contact friends and family at times that suited them. This contrasted with those who did not own a mobile phone or could not operate one. Video calls worked less well for those unable to operate mobile technology or without their own devices.
For some family members, remote communication with their loved one was less personal, of variable quality and less private. Remote communication did not give them a complete picture of residents’ condition and well-being, though they did their best to seek out signs, for example the condition of the resident’s skin, and alertness. Others have reported that video-calling was the most helpful technology to mitigate the impact of isolation.135 They reported that barriers to the use of technology in supporting residents during isolation were staff not having enough time to support residents with technology, residents with a sensory impairment, and poor internet connectivity. Despite these drawbacks, family members were keen to continue to have the option of communicating remotely with their loved ones.
Similar findings were reported when families were interviewed and expressed dissatisfaction with remote communications, which were described as infrequent, poorly organised, not private, functioning Wi-Fi or devices for video calls not available, and carers were often too busy to support calls.155 There has been a call for governments and CH providers to prioritise the technological capabilities of CHs and ‘there is a moral urgency to address the digital exclusion of LTC homes’156 (p547). Senior health and care leaders in our focus groups shared that technology imposed an even greater workload on hard-pressed staff, and that there was little time for training and staff development in digital technology. Creative approaches to CHs communicating with families and friends to share information and updates about residents were valued by families. There is the potential to develop further these initiatives, for example applications that enable families to connect for updates about residents’ and their care. This would also be helpful for residents and families who are separated by non-pandemic-related circumstances, such as geographic distance, and family members who are unable to travel. Related to this is the opportunity to develop further in a joined-up way digital technology for CHs to be able to interact meaningfully with LAs, community, primary and hospital settings, and services. A welcome investment is the additional funding of at least £150 million over the next 3 years for technology and digitalisation in the recent White Paper for adult social care reform in England.157
Socially distanced visiting
There was variation in how the different CHs operationalised socially distanced visiting, reflecting the different timelines of their involvement in the study. Families were not always clear about what governed CH protocols and practices. A finding of our review was that good communication and the availability of informational materials, such as brochures, posters and signage on COVID-19 and the associated policies, helped explain the reasons behind restrictions to residents, families and friends.36,50,58,62,97,124
With the introduction of visiting with restrictions, residents preferred meeting in rooms inside the CH. Challenging their ability to exercise choice and control, they disliked rules on time limits for visits, number of visitors and location for visiting. Some complained about a lack of privacy, for example if visits were conducted with a staff member present or if doors were kept open so interactions could be supervised. A key challenge to socially distanced visiting for residents and families was the lack of touch, skin-to-skin contact being replaced by PPE-mediated touch, and other non-verbal forms of communication, such as facial expressions and paralinguistics, which were obscured by mask-wearing. A typology of touch describes ‘good’, ‘bad’ and ‘absent’ touch and discusses how the meaning of touch has changed because of COVID-19.158 For example, pre-pandemic a hug between a resident and a family member was a ‘good’ touch but during the pandemic this became a ‘bad’ touch because of the risk of infecting the resident with the coronavirus.
Caring for the care home workforce
Our study captured evidence of CH managers and staff time and again going above and beyond to care for residents, families and friends, and each other throughout the COVID-19 pandemic. There were several examples of the sacrifices that staff had made. While some staff had left employment due to fears of working in CHs during the pandemic, others had considered leaving but returned to work each day to support their colleagues and to care for residents. For many the ultimate reward was that their CH had remained safe. It was noteworthy that staff expressed great fondness and care for their residents and colleagues, often referring to those within the CH setting as a ‘family’.
Caring for the workforce is intrinsic to high-quality care.159–161 A key study finding is that the CH workforce has experienced trauma and distress. When information was limited at the start of the pandemic, staff talked of how ‘frightening’ they found working with residents who were very poorly with this new, unknown virus. Many had also feared for their own safety at times, with concerns about catching the virus from residents and what would happen to them if they did in a similar way to many other nursing and healthcare staff.162,163 Many staff also had fears for the safety of their families, and some had chosen to separate themselves from their children and vulnerable relatives, which came at significant personal cost. In addition to their stresses at work, staff shared their experience of stresses at home – some CH staff were experiencing family illness and bereavement, partners’ job losses, broken marriages, cancelled healthcare treatment and financial worries as a direct consequence of the pandemic.
Staff in our study spoke about far busier workloads and that initially their roles became more task-focused. Social distancing measures resulted in greater workload for staff as did supporting residents who were isolating. Good support from CH management was considered by staff to make the process of implementing these measures easier. Valuing support from employers is a theme in the published literature.26,137,164 A finding of our review was that workload also increased for staff, due to the new tasks they had to undertake, which had previously been carried out by relatives or other professionals, such as hairdressers;69,95,103,123 as well as the extra preparations staff needed to undertake for the introduction of COVID-19 interventions.25
Pre-pandemic there were staff shortages in the sector.165 Implementing social distancing and isolation measures requires more staff, as does cohorting and visiting restrictions. With numbers further depleted due to sickness, self-isolation and fear during the pandemic, implementation of these measures was challenging. Use of agency staff helped boost the numbers, but even with block booking, this also introduced increased risk of transmission. While the government did introduce infection control grant funding to support the increased staffing costs, this did not help homes find, recruit and retain staff who want to work in CHs. Then and now, this is a significant problem, which the pandemic has highlighted and exacerbated. Our study values and recognises the workforce. It adds weight to the argument that the CH sector needs urgent development and support to grow to meet the needs of older people in the UK.
Staff feel mentally and physically exhausted by changes made to their working practices and the emotional distress they have experienced during the COVID-19 pandemic. These experiences resonate with other research.144,166,167 Respondents in a study of 152 staff working in nursing homes spoke of mental and physical exhaustion and the ‘emotional burden of caring for residents experiencing distress, illness and death’144 (p199). Addressing a lack of pandemic preparedness, resilience training was expressed as a need by hospital employees participating in an intervention in response to the H1N1 pandemic.168 The authors developed a training intervention providing information about normal stress responses, effective coping, and principles of organisational resilience, and allowing for discussion and reflection on anticipated stressors. Employees also identified the importance of visible leadership and the need for reliable, consistent and timely information. The need for longer-term psychological support for CH staff is paramount. A step in the right direction is the new well-being and occupational health offer in the 2022 White Paper for the reform of adult social care in England.157 However, an infrastructure to support the central co-ordination, implementation and evaluation of this is paramount.
Care home staff must feel valued – we were told on more than one occasion that CH working can be a ‘thankless job’. The COVID-19 pandemic can be seized as an opportunity to challenge and eradicate the stigma of CH working being low status. Government investment in the sector is imperative. Key priorities include a review of working conditions and pay scales, and investment in recruitment, retention and development of care staff. On this note, it is encouraging that adult social care in England will benefit from at least £500 million from the Health and Social Care Levy to improve recruitment, retention, progression and staff well-being and that social care will be ‘recognised by the public as a valuable and high-quality service on par with the NHS.’157
Supporting care homes and the care home sector
A key study finding shared by CH staff and senior health and care leaders was the view that the CH sector was abandoned by the government in the early phase of the pandemic and was isolated from the NHS. It has been argued that the deaths of many CH residents were preventable and that one example of the ‘failure to protect life’ (p4) was the UK strategy of prioritising the protection of the NHS.169 It was reported that between 17 March and 15 April 2020 around 25,000 people in England were discharged from hospitals to CHs.170 This is perhaps reflective of systemic issues including the disparity between health and social care systems – as one author wrote: ‘The care system functions in the shadow of the NHS, which enjoys far greater resource allocation and higher cultural and political capital’16 (p2). There are historic imbalances of power between the NHS and social care.171 Our findings underlie that there is a need to ensure that CHs and social care are considered an essential part of integrated care systems.
Care home staff told us that CHs had not been considered or given appropriate guidance early enough in the process. Similarly, our rapid review identified initial reports of a lack of guidance and clarity from governments about when and how interventions should be applied. There was a lack of research evidence about how to manage care in CHs during a pandemic; most of the papers in our review were grey literature, not empirical research. It has been reported that in the pandemic action plan, which was announced on 3 March 2020, there was just one mention of adult social care and a specific action plan for adult social care in England was not issued until 15 April 2020.16
When guidance ensued, this was often long and complicated, with many different policies to consider, it changed frequently and was contradictory, causing confusion and loss of confidence.112,144,172 This was reflected in some of the CH documents related to social distancing and isolation that we reviewed; these were difficult for staff to navigate because of multiple versions, lengthy, repetitive and with links to embedded documents. Time and attention were required to monitor the numerous iterations and to continually update to remain in compliance.144 Further a ‘blanket approach’ to government guidance was criticised for failing to consider the many individual differences between CHs and CH residents. Care home managers had to use their ‘own common sense and … knowledge’ when interpreting the government guidance, rather than simply following it directly, selecting the parts of the guidance that were relevant to the individual CH setting. To this end, CH managers valued the support of their senior leadership to help them interpret and implement government guidance. This is in keeping with recent studies.26,137,144,164
In addition to rapidly changing rules for CHs set by the government, communication of information to the sector from the government was described as chaotic. For example, it was shared that CHs found out about rule changes at the same time as the rest of the population, which meant that homes did not have enough time to implement them appropriately. These findings from CH staff, senior health and care leaders, and CH documents resonate with our review findings that there was a lack of guidance and clarity from governments around when and how interventions should be applied, with policy measures often scarce, flawed or adopted late.43,46,52,56,77,82,84,103,116,128 Our findings are reflected in reported challenges for CHs of dealing with rapidly changing multiple sets of guidance,173,174 the CH sector being ill-prepared to cope with a pandemic173,175 and the sector not being supported well at the outset by governments.18,136,173,176
Care homes need evidence-informed guidance that sets out what and how social distancing and isolation measures should be operationalised, while meeting residents’ individual needs, including their fundamental rights to liberty and security, and with attention to education for residents, families and friends, and staff.175 Our toolkit helps address this need. Our study findings contribute to important lessons for decision-makers about the need for clear, concise and meaningful guidance about social distancing and isolation and related measures that can be translated easily into operational policies for CHs. Our findings also emphasise the importance of social care having a more equitable influence in integrated health care services.
Strengths and limitations
The rapid review (see Chapter 3) is an extensive review of the evidence around social distancing and isolation measures to prevent and control the transmission of COVID-19 and other infectious diseases in CHs caring for older people. Strengths include conducting searches of several primary and specialised databases for peer-reviewed and grey literature and screening of results by several team members to enhance rigour. Because of resource constraints, only papers published in the English language were reviewed, which is a limitation. Using the themes identified in the review to underpin the rest of the study helped ensure this research built upon what was already known and advanced knowledge in the field.
The case study sites were identified using a sampling frame designed to maximise variability, and though we did work with CHs varying in size, geographical location, registration type, ownership and incidence of COVID-19, all the participating homes had a CQC rating of either ‘good’ or ‘outstanding’ (see Chapter 4, ‘Routinely collected care home data’). None of the participating CHs were rated as ‘requires improvement’ or ‘inadequate’ by the CQC limiting the generalisability of the findings. The COVID-19 pandemic has continued to present challenges for CHs over the past 18 months. A potential limitation is that all six CHs were part of larger organisations, although the size of providers ranged from 7 to 114 CHs, the total number of beds ranged from 500 to 5875, and ownership included two family-run CHs. The project team had to work around additional and unforeseeable demands for CHs, for example regarding resident, staff and visitor testing, and vaccination roll-out for residents and staff resulting in some delays in recruitment of CHs, participants and scheduling of interviews. Consequently, fieldwork with the six CHs was conducted at different time points (see Chapter 4, ‘Routinely collected care home data’), which is a potential limitation. Positively, we successfully recruited and retained participants. This sequential approach generated rich data about the experiences of implementing social distancing and isolation measures during different stages of the pandemic, and we present our data analysis by data source across the case sites. Fieldwork was conducted remotely due to COVID-19 restrictions for visitors to CHs; not being physically present in the CHs meant that the researchers were not on-site to promote and discuss the study, to observe and absorb the nuances of the different settings, and to interact directly with the different participant groups. However, despite ongoing pressures during the active phases of the pandemic the study delivered on time. We successfully captured the perceptions and experiences of residents, families, CH staff, and senior health and care leaders to provide a comprehensive view of the experiences of social distancing and isolation measures in CHs, as seen through the lens of those leading, implementing, practising and experiencing these interventions.
Interviews and focus groups were conducted remotely. This helped us to exceed the target sample for CH staff (n = 31/30), and almost to target for the resident (17/18) and families (17/18) samples. We exceeded our target sample of eight participants for the focus groups, successfully recruiting a rich mix of 13 senior health and care leaders from across England. A limitation of remote digital interviewing was that for a minority of interviews the CH Wi-Fi quality was less stable. For 17 of the 31 interviews, participants asked for the project champion to be present, this may have influenced what participants chose to share or not introducing bias.
All CHs shared local policy documents about social distancing and isolation, with a total of 42 included for analysis (see Chapter 4, ‘Document characteristics’), and all completed the proforma for routinely collected data (see Chapter 4, ‘Routinely collected care home data’); some CHs did not answer a small number of questions, which is a limitation. The 31 purposively sampled CH staff participants had a range of roles and varied in terms of length of time working in their current role and in the CH sector, gender and ethnicity. A limitation for the resident and family participant groups is their limited ethnic diversity (all residents and all but one of the family members were white people); this is despite a concerted effort to recruit as per our purposive sampling, but we acknowledge that different experiences, views and meanings may have been missed because of this (see Chapter 6, ‘Participant characteristics’). Residents varied in terms of gender, age, length of time living in the CH, health and care needs, experience of isolation, and experience of testing positive for COVID-19. For 13 of the family participants, the resident was living with dementia or other cognitive impairment. Overall, the participant groups generated a rich account of their experiences and perceptions about the research question. A strength of our study was co-production of a toolkit designed to be meaningful, accessible and for use in practice (see Chapter 2 and 8), we did not conduct a formal evaluation of the co-design process, which we acknowledge as a potential limitation.
Equality, diversity and inclusion
Participant representation
From the outset this study was designed to be inclusive in how we answered the research question. Thus we set out to elicit the voice of a broad range of residents, their families and friends, CH staff, and senior health and care leaders about social distancing, isolation and other restrictions related to caring for older people living in CHs during the COVID-19 pandemic.
Compounding the well-known challenges of conducting research in CHs, the research team was compelled to recruit CHs, participants and to conduct fieldwork remotely due to restrictions owing to the COVID-19 pandemic. These measures prohibited us from immersing ourselves as researcher–observers to gain insights into contexts and cultures and to observe first-hand activities, interactions and communications related to implementing social distancing and isolation measures. Conducting interviews remotely may have excluded some potential participants who may not have felt comfortable with being interviewed using remote technology. However, we adopted a variety of strategies to maximise recruitment and successful fieldwork, for example each CH had a nominated project champion whom we worked closely with to identify and recruit participants and to support participants during the interview process and relatives were given the option of doing their interview in their own home using their own device (e.g. smartphone, laptop, tablet, telephone).
We successfully recruited our target of six CHs in England. CHs were invited purposively, using a sampling frame designed to maximise variability in terms of size of the CH, geographical location, CQC rating, registration (nursing, residential or dual registration), ownership and incidence of COVID-19. The pandemic experience for the CH sector has impacted on CHs being research ready; the team worked hard over a prolonged period to recruit two case study sites with a ‘requires improvement’ CQC; this was not successful. We also managed a key issue around recruitment of participants from BAME groups. At meetings of the Study Steering Committee and Data Monitoring and Ethics Committee, we discussed these challenges and there was agreement that we should prioritise diversity of participants and not focus on recruiting CHs with a CQC rating of requires improvement. This revised plan was shared with NIHR and we were granted permission to proceed with this revised plan.
Staff were purposively recruited to ensure variation (e.g. in age, gender, ethnicity and time in service). Resident participants were also recruited purposively, to ensure a range of genders, ethnicities and different health and care needs. Inclusion criteria were that residents must be over 65 years old and have the capacity to consent. The 31 purposively sampled CH staff participants had a range of roles and were varied in terms of length of time working in their current role and in the CH sector, gender and ethnicity. A limitation for the resident and family participant groups is their limited ethnic diversity (all residents and all but one of the family members were white people); this is despite a concerted effort to recruit as per our purposive sampling.
Reflections on the research team and wider involvement
The project team included senior healthcare professionals who work in the CH sector and established academic researchers with a background in health and/or social care research. JF is a RN with a specialist clinical and academic track record in gerontology with expertise in mixed-methods research to study the organisation and delivery of older people health care in acute and CH settings. SH is a medical demographer and an expert in social care practice and delivery including CHs and the care workforce. AMR is an expert on health workforce policy and experienced in quantitative and qualitative studies of workforce dynamics, including ethnographies of teamwork and deployment policies. RH is a nurse with expertise in evaluating complex interventions, including the organisation of nursing work, interprofessional teamwork and leadership of integrated care systems. AD is a social anthropologist with expertise in the ethnographic study of health and care organisations. SS has expertise in conducting complex multimethod studies in the NHS, project management, and user involvement. SB is lead for service user and public involvement, and for dissemination to service users and public. RA is an experienced executive nurse with strategic development and operational management experience in the independent sector. LR is a specialist nurse with expertise in leadership, clinical governance, quality assurance and quality improvement in CHs.
Our Steering Committee and Data Monitoring and Ethics Committee included experts representing the CH sector, CH nursing and IPC. We established a dedicated study PPI group comprised of 10 members, 2 of whom were also members of the Study Steering Committee. This group comprised mostly of older people, many of whom have extensive personal experience of health and care services, and several are or have been (informal) carers. PPI was an integral part of this study, informing its design, method, analysis and dissemination. PPI contributions included reviewing all participant-facing paperwork for submission to the Research Ethics Committee (e.g. plain language summary, project flyer, participant information sheets, consent forms and interview guides). PPI group members also participated in online workshops to contribute to the co-design of the toolkit.
