Care home residents were vulnerable to severe effects from Covid-19 infection and experienced high mortality, especially early in the pandemic. In response, many countries introduced visiting restrictions to limit transmission. These often proved extensive and prolonged, drawing fresh attention to issues of autonomy and human rights in long-term care. We conducted in-depth interviews with 27 family carers in England with relatives living in a care home during the pandemic. Adopting a relational autonomy lens, conceptualised using the capability approach, we examined how family carers considered their relatives’ capabilities to have been impacted by visiting restrictions and how relational support could be strengthened. Family carers were concerned for their relative’s fundamental capabilities, including physical health, emotional well-being, and feeling connected to significant others. Capability deprivations were associated with family separation, ‘adapted’ visits that were inappropriate for their relative’s needs, and lack of opportunity for family carers’ to provide emotional support, help staff identify their relative’s emotional and physical needs, monitor care standards or advocate for their relative. Optimising relational support during a public health emergency requires effective collaboration between care homes and family carers. Specific measures include (1) ensuring there is clarity, a sense of shared purpose, clear accountability and confidence in visiting restrictions, (2) providing family carers regular, personalised updates about their relative using a range of digital communication tools, (3) allowing choice about visiting arrangements where possible, and ensuring visits are appropriate for residents with dementia and (4) ensuring that family carers feel welcomed, involved and enabled to resume in-person visits at the earliest opportunity. Consultation with care homes, families and residents, and workforce and digital readiness should be prioritised.

Residents of long-term care facilities (LTCFs) were disproportionately affected by the COVID-19 pandemic. We assessed the extent to which hospital-associated infections contributed to COVID-19 LTCF outbreaks in England. We matched addresses of cases between March 2020 and June 2021 to reference databases to identify LTCF residents. Linkage to health service records identified hospital-associated infections, with the number of days spent in hospital before positive specimen date used to classify these as definite or probable. Of 149,129 cases in LTCF residents during the study period, 3,748 (2.5%) were definite or probable hospital-associated and discharged to an LTCF. Overall, 431 (0.3%) were identified as index cases of potentially nosocomial-seeded outbreaks (2.7% (431/15,797) of all identified LTCF outbreaks). These outbreaks involved 4,521 resident cases and 1,335 deaths, representing 3.0% and 3.6% of all cases and deaths in LTCF residents, respectively. The proportion of outbreaks that were potentially nosocomial-seeded peaked in late June 2020, early December 2020, mid-January 2021, and mid-April 2021. Nosocomial seeding contributed to COVID-19 LTCF outbreaks but is unlikely to have accounted for a substantial proportion. The continued identification of such outbreaks after the implementation of preventative policies highlights the challenges of preventing their occurrence.

Increased physical activity is widely promoted as beneficial for older people, but previous research indicates this may be difficult to implement in care homes, especially for people with dementia who form an increasing proportion of residents. Care home cultures can mitigate against physical activity for residents, but there is also scope for them to embed personalised physical activity. They are under-researched, but significant in terms of outcomes and quality of life for residents. This paper builds understanding of care home cultures of physical activity through qualitative, empirical research in five care homes. Key findings are that culturally framed views about physical activity, sometimes reflecting stereotypical views of dependency, can be seen in care homes. Managers, staff and residents may be invested in or resistant to physical activity and dominant managerial or societal views may be reflected or contested. The relatively closed boundaries of care homes reinforce sedentariness, and resident involvement in either chosen or enforced physical activity is varied. Interactions demonstrate potential to negotiate physical activity more or less effectively in any given care home. Rigid routines, external regulations and pressure on staffing can be negative, but management commitment has positive potential. In conclusion, the paper identifies that to increase physical activity in a sustainable manner, any intervention needs to address issues of culture change and individual needs and preferences.

A grounded theory approach, consistent with the work of Strauss and Corbin, was used to undertake semi-structured interviews with 17 older people, to explore their experiences of living in a care home, during the four- to six-week period following the move. Purposive sampling was initially adopted, thereafter, theoretical sampling was employed to recruit individuals identified by care managers within older peoples’ community teams and care home managers within a large Health and Social Care Trust in the United Kingdom. Consistent with grounded theory methodology, data collection and analysis occurred simultaneously. Constant comparative analysis underpinned data analysis and data management techniques. Data analysis revealed five distinct categories that captured these experiences. These were: (a) wanting to connect – ‘I am so lost here’, (b) wanting to adapt – ‘Well mentally you have to make the best of it’, (c) waiting for assistance – ‘it's a frustration for me’, (d) ‘waiting on the end’ – I am making no plans’ and (e) wanting to re-establish links with family and home – ‘I love getting home and I like getting out to the town’. Together these five categories formed the basis of the core category, ‘Waiting and Wanting’, which encapsulates the initial adaptation experiences of the men and women in the study. Findings indicate that individuals were dependent on others to create a sense of belonging, independence and wellbeing. Moreover, risk aversive practices were perceived as a threat to individuals’ independence and autonomy. Recommendations include the need to amend policy and practice for the development of a bespoke induction programme for each resident facilitated by a senior member of the care home staff working in partnership with individuals and families, in addition to the health and social care team, to support a more positive transition for new residents, relatives and care home staff.

Transition to a care home often follows a hospital admission and can be distressing. Care home settings play an important role in the care of many people at the end of life. This longitudinal study employed a narrative approach, aiming to explore the perspectives of older care home residents on transitions to, and life and death within, care homes. Five participants, aged 85 years and over, were recruited from two privately owned care homes in the South-West of England. All participants had a diagnosis of an advanced progressive condition (excluding advanced dementia), or were thought to be frail. Longitudinal interviews (19 in total) were conducted over a ten-month period. A structural narrative analysis was performed and participants’ narratives are presented under three headings, with one participant's story chosen to illustrate each narrative type: ‘becoming a care home resident’, ‘living in a care home’ and ‘death and dying’. Findings revealed that care home residents experience a loss of autonomy and a lack of agency; they are often excluded from decision-making. Older care home residents have few choices with regard to care at the end of life. Further work is required to improve transition into care homes, including support and advocacy during decision-making, which often takes place in hospitals at a time of crisis.

Care-home residents with dementia can experience behavioural and psychological symptoms such as aggression, agitation, anxiety, wandering, calling out and sexual disinhibition. Care-home staff have a duty to keep residents safe. However, residents with dementia can pose particular challenges in this area. In this paper, we draw on a study which explored how care-home staff manage dementia-related behaviours. In-depth ethnographic case studies at four separate care homes were conducted in England. These involved interviews with 40 care-home staff and 384 hours of participant observation. Our analysis showed that some residents with dementia experience behaviours which can either create risks for, or negatively impact on, themselves and/or other residents or staff members. It emerged that the consequences of the behaviours, rather than the behaviours themselves, created difficulties for staff. To cope with the risk and impact of behaviours, staff employed multiple strategies such as surveillance, resident placement, restrictions and forced care. Using the data, we explore how actions taken by staff to manage the risk and impact of behaviours in these communal settings relate to residents’ human rights. Our findings have particular relevance for care-home staff who need support and guidance in this area, for service development worldwide and for the global ageing population whose valued human rights may become under threat, if they require long-term care.

This paper examines some demographic and medical factors associated with the likelihood of residing in a care home during the last month of life for persons aged 70 and over in France and, if so, of remaining in the care home throughout or being transferred to hospital. The data are from the Fin de vie en France (End of Life in France) survey undertaken in 2010. During the last month of life, very old people are more likely to be living in a care home but are not less likely to be transferred to hospital. Medical conditions and residential trajectories are closely related. People with dementia or mental disorders are more likely to live in a care home and, if so, to stay there until they die. Compared to care homes, a more technical and medication-based approach is taken in hospitals and care home residents who are transferred to hospital more often receive medication while those remaining in care homes more often receive support from a psychologist. In hospitals as in care homes, few older persons had recourse to advance directives and hospice programmes were not widespread. Promoting these two factors may help to increase the quality of end of life and facilitate an ethical approach to end-of-life care.

The construction of a meaningful life depends upon satisfying ‘fundamental human needs’. These are broadly categorised as: physical, social and self-actualisation needs that every human experiences. Some fundamental human needs satisfiers, such as ‘home’, are synergic, addressing more than one need. For an older person, the move to a care home compromises their ontological security (through disruption of identification with place and control over environment) that one's own ‘home’ provides. This paper explores the complex issues surrounding the residential status of care home residents in terms of fundamental human needs. The methodology utilised was hermeneutic phenomenology. Eight older residents participated in the study, and each resident was interviewed up to eight times over a period of six months. Narrative analysis was used to interpret how participants viewed their experiences and environment. Five themes emerged from the narratives that collectively demonstrate that residents wanted their residential status to involve ‘living with care’ rather than ‘existing in care’. The five themes were: ‘caring for oneself/being cared for’; ‘being in control/losing control’; ‘relating to others/putting up with others’; ‘active choosers and users of space/occupying space’ and ‘engaging in meaningful activity/lacking meaningful activity’. This study indicates that if care homes are to achieve synergic qualities so residents are able to regard care homes as ‘home’, then care home staff may need to be more focused on recognising, acknowledging and supporting residents' aspirations regarding their future lives, and their status as residents.

Background: Elder abuse in care homes is probably common but inherently difficult to detect. We developed the first questionnaire to ask care home workers to report abuse anonymously.

Method: We held qualitative focus groups with 36 care workers from four London care homes, asking about abuse they had witnessed or perpetrated.

Results: The participants reported that situations with potentially abusive consequences were a common occurrence, but deliberate abuse was rare. Residents waited too long for personal care, or were denied care they needed to ensure they had enough to eat, were moved safely, or were not emotionally neglected. Some care workers acted in potentially abusive ways because they did not know of a better strategy or understand the resident's illness; care workers made threats to coerce residents to accept care, or restrained them; a resident at high risk of falls was required to walk as care workers thought otherwise he would forget the skill. Most care workers said that they would be willing to report abuse anonymously. Care workers were sent the newly developed Care Home Conflict Scale to comment on but not to complete and to report whether it was acceptable and relevant to them. Several completed it and reported abusive behavior.

Conclusion: Lack of resources, especially care worker time and knowledge about managing challenging behavior and dementia were judged to underlie much of the abuse described. We describe the first instrument designed to measure abuse by care home workers anonymously; field-testing is the logical next step.

Background: Using a representative secondary care survey for the first time, we explored family carers’ reasons for providing care. We hypothesized that carers with a positive rather than negative motivation for caring would be less abusive towards the care recipient and more likely to be caring for someone still living at home a year later.

Methods: We interviewed 220 consecutively referred dementia family/friend carers from UK Community Mental Health Teams. We asked non-spousal carers why they were the main carer. Our main outcomes were the revised Modified Conflict Tactics Scale scores, measuring abusive behavior by the carer, and admission of the person with dementia to a care home.

Results: Nineteen (17.1%) said they were the main carer due to the high quality of their relationship with the care recipient, their willingness to take on or their suitability for the carer role. A further 22 (19.8%) said they were the main carer due to other potential carers’ negative relationship with the care recipient, unwillingness or lack of suitability for the role. Carers who gave the latter explanation tended to be more anxious at baseline (F = 3.0, p = 0.055), reported higher abusive behavior towards the care recipient a year later after controlling for sociodemographic variables (t = 2.0, p = 0.05), and their care recipient was more likely to be admitted to a care home in the following year (hazards ratio 9.9, p = 0.040).

Conclusions: We found preliminary evidence that carers’ reasons for providing care predict the well-being of the care recipient. Future studies involving dementia family carers should consider asking why the main carer assumed this role.

Benevolent, long-term care can threaten older adults' sense of autonomy in a residential home environment. Increasing reliance on a hotel style of living has been seen to erode social identity, life satisfaction and even survival or lifespan. Drawing on evidence from both gerontological and social psychological literature, this paper examines the links between the empowerment of residents and their subsequent quality of life in the context of a move into a new care facility in a medium-sized town in South-West England. A longitudinal experiment was conducted during which 27 residents on one floor of a new facility were involved in decisions surrounding its décor, while those on another floor were not. The residents' attitudes and behaviour were monitored at three points over five months (four weeks pre-move, four weeks post-move, and four months post-move). Consistent with the social identity literature, members of the empowered group reported increased identification with staff and fellow residents in the new home, displayed enhanced citizenship, reported improved wellbeing, and made more use of the communal space. Moreover the staff found the empowered residents to be more engaged with their environment and the people around them, to be generally happier and to have better health. These patterns were observed one month after the move and remained four months later. Some implications for theory and practice are discussed.

In 2007, the estimated cost of disease-related malnutrition in the UK was in excess of £13×109. At any point in time, only about 2% of over 3 million individuals at risk of malnutrition were in hospital, 5% in care homes and the remainder in the community (2–3% in sheltered housing). Some government statistics (England) grossly underestimated the prevalence of malnutrition on admission and discharge from hospital (1000–3000 annually between 1998 and 2008), which is less than 1% of the prevalence (about 3 million in 2007–2008) established by national surveys using criteria based on the ‘Malnutrition Universal Screening Tool’ (‘MUST’). The incidence of malnutrition-related deaths in hospitals, according to government statistics (242 deaths in England in 2007), was also <1% of an independent estimate, which was as high as 100 000/year. Recent healthcare policies have reduced the number of hospital and care home beds and encouraged care closer to home. Such policies have raised issues about education and training of the homecare workforce, including 6 million insufficiently supported informal carers (10% of the population), the commissioning process, and difficulties in implementing nutritional policies in a widely distributed population. The four devolved nations in the UK (England, Scotland, Northern Ireland and Wales) have developed their own healthcare polices to deal with malnutrition. These generally aim to span across all care settings and various government departments in a co-ordinated manner, but their effectiveness remains to be properly evaluated.

Older people living in residential and nursing care homes spend a large proportion of their time within the boundaries of the home, and may depend on the environment to compensate for their physical or cognitive frailties. Regulations and guidelines on the design of care buildings have accumulated over time with little knowledge of their impact on the quality of life of building users. The Design in Caring Environments Study (DICE) collected cross-sectional data on building design and quality of life in 38 care homes in and near Sheffield, Yorkshire. Quality of life was assessed using methods which included all residents regardless of their frailty, and staff morale was also assessed. The physical environment was measured on 11 user-related domains using a new tool, the Sheffield Care Environment Assessment Matrix (SCEAM). Significant positive associations were found between several aspects of the built environment and the residents' quality of life. There was evidence that a focus on safety and health requirements could be creating risk-averse environments which act against quality of life, particularly for the least frail residents. Staff morale was associated with attributes of a non-institutional environment for residents rather than with the facilities provided for the staff. The new tool for assessing building design has potential applications in further research and for care providers.