Summary of the impact

Research findings have informed the development of training and support for care home inspectors and toolkits for use by caring professionals, all of which are provided through the Care Quality Commission (CQC) website. Findings have also been disseminated nationally and internationally through a book aimed at practitioners and policy makers that has now been published in German and Polish and is selling strongly in Australia and the USA. The study has furthered professional and public awareness of the need for improved night-time care in care homes, in particular improved communication (from staff to residents) and training.

Underpinning research

Residential and nursing homes exist to provide a 24-hour service. However, most research projects have focused only on the daytime care and services. In addition, standards specific to the provision of night-time care are notably absent from both legislation and policy guidance. A review of the literature indicated a need to improve understanding of night-time care practices and for more explicit guidance on standards of care at night.

The research was funded by the Joseph Rowntree Foundation over a series of three grants (2006-2010, £90k total). The work was led by Wilkinson (PI, UoE 2001-date) (with Diana Kerr as research fellow UoE 1/08/2003 - 31/12/2008). Colm Cunningham (University of Stirling Dementia Centre) was also involved in the first few years of the research. The night-time work arose from a wider interest in improving care for older people, and the project has provided a wealth of material that has now been disseminated and elaborated over a two-year period.

The study was conducted in two stages. In the first stage semi-structured interviews were conducted with care home inspectors, residents, relatives and night-time care staff, and observations of night-time care practices in three care homes. The second stage involved action research in which recommendations from the first stage were implemented and evaluated through written records kept by, and interviews with, both managers and night staff.

It was found that care staff, inspectors and relatives expressed high levels of anxiety related to a lack of knowledge about what happens at night and resultant worries about `what if' situations. In practice, this anxiety — exacerbated by poor communication and low levels of staff training and recruitment — resulted in poor night-time care practices. Night staff were notably less well trained, supported and supervised than day staff, yet they were working with high levels of responsibility and accountability, often providing complex levels of care.

This action research has identified a number of key strategies that address areas of concern and which have since had an impact on both policy and practice:

• Regular management involvement: the provision of clear guidance and staff supervision.
• A strong emphasis on individual care: enabled through night-time keyworkers and individualised care plans.
• Reduced dependence on agency and bank staff: to minimise the workload of regular night staff and improve quality of care.
• Dementia-focused and night-time appropriate training for all night staff.
• Control of noise and light levels, and other environmental variables: such as reducing voice levels, using silent pagers for alarm systems, and dim lights in communal spaces.
• Clear communication is central to all the work: all staff should be able to communicate clearly and appropriately with residents. Morning handover meetings should be more structured and inclusive.

These findings have informed policy and the development of guidelines for practice used by inspectors and care home staff.

References to the research

Selected research grant support
Wilkinson, H, Dissemination of the night-time care project, December 2007 — October 2009; Joseph Rowntree Foundation, £24.8k.

Wilkinson, H, Development of UK Care Commission Working Group, April 2007 — January 2012, Joseph Rowntree Foundation, £4k.

Wilkinson, H, Exploring night-time care for residents of care homes, April 2006 — November 2007, Joseph Rowntree Foundation, £61k.

Details of the impact

The research findings uncovered an important area for practice development. The impact of the work has been, and continues to be, considerable at policy and practice levels, while also raising public awareness of the needs of older adults at night in care homes.

Policy
In 2009 the researchers were funded (by the Joseph Rowntree Foundation) to establish a working group with representatives from each of the UK care regulatory bodies. This group worked over four meetings to translate the research findings into recommendations and actions for practice. The most practical of these is a checklist which informs practice and raises awareness of night-time care. This checklist is targeted at care home inspectors and care home managers. The implementation of the checklist is most evident in its use by the Care Quality Commission (CQC) (England and Wales). The CQC have used the checklist to inform changes and additions to their regulation and inspection policy/guidance, for use by all care home inspectors (CQC Working Group 2009 — see below). The checklist is also freely available on their webpage of resources for care home managers to raise awareness among managers about inspectors' expectations in relation to night-time care quality [5.1].

The study was also presented at the Scottish Policy Innovation Forum in 2008 to an audience of people responsible for making and implementing policy.

The Scottish Care Inspectorate reviewed the work and the recommendations internally, then left the use of the checklist to the choice of individual inspectors rather than taking the more systematic approach recommended by the English CQC.

In 2009 findings from the study were submitted by the Joseph Rowntree Foundation to the Department of Health in response to their consultation informing the national dementia strategy in England.

Practice
Care home inspectors in England and Wales now use the checklist developed as part of this project. In 2011, the National Mental Health Development Unit incorporated specific guidance, arising from this research, on night time care for older people in care homes with delirium, dementia and depression [5.2].

The study produced materials made freely available to care practitioners, including a set of posters and a postcard, as well as a short piece of drama (`Night and Day' audio-play with Forum Interactive), with facilitation guidelines which are used in training for carers. In addition, a summary of the findings of the study and links to the training materials has been widely published on a range of websites which provide information and training to social care professionals in the public and voluntary sectors and informal carers both nationally and internationally. These include the Voluntary Health Scotland website, communitycare.co.uk, connect-in-care.net, and skillsforcare.org.uk, and the International Association of Homes and Services for the Ageing (IAHSA) global ageing network. The study has also informed guidance provided by some of the leading charities and social care information networks, such as the Social Care Institute for Excellence and the Housing Learning and Improvement Network which inform social care practices in the UK [5.3]. The findings of the study have also been disseminated to social care practitioners internationally, for example, through the Aged Care INsite journal [5.4] and Aged Care Channel in Australia.

Further dissemination and practical advice for practitioners is also now available in the book Providing good care at night for older people (Kerr and Wilkinson), which was launched in November 2010 at the UK Dementia Congress and has since been translated into German and Polish [5.5]. The Polish edition sold 200 copies in the first 6 months (April — Sept 2013) [5.6].

Public
In addition to the impact of the research in policy and practice, the findings have also raised public awareness of the importance of night-time care for older adults in care homes through press releases and coverage in the media. In 2008 the research was reported in The Guardian newspaper, Scotsman and Evening News (Edinburgh), and on the BBC News Channel and STV [5.7, 5.8].

Sources to corroborate the impact

PDFs of all web links are available at
www.wiki.ed.ac.uk/pages/editpage.action?pageId=175640387

5.1 Care Quality Commission Working Group (2009), Guidance for inspectors: night time care prompts care homes. Newcastle upon Tyne, Care Quality Commission.
http://webarchive.nationalarchives.gov.uk/20100303171149/http:/www.cqc.org.uk/guidanceforprofessionals/socialcare/careproviders/guidance.cfm?widCall1=customWidgets.content_view_1&cit_id=34772

5.2 National Mental Health Development Unit (2011) Let's respect: Toolkit for care homes. Social care institute for excellence 'Dementia Gateway'.
http://www.scie.org.uk/publications/dementia/environment/CaseNight.asp

5.3 Housing LIN (Learning and Improvement Network) (2009) Caring for People with Dementia at Night
http://www.housinglin.org.uk/Topics/browse/HousingandDementia/Practice/Practice/?&msg=0&parent=5152&child=5294

5.4 Aged Care INsite (2011), Night-time dementia care advice.
http://www.agedcareinsite.com.au/2011/12/night-time-dementia-care-advice/ (password protected). Also available at www.wiki.ed.ac.uk/pages/editpage.action?pageId=175640387

5.5 Kerr, D, Wilkinson, H (2011). Providing good care at night for older people: practical approaches for use in nursing and care homes. London: Jessica Kingsley Publishers (now also translated into German and Polish). Available from HEI.

5.6 For endorsement of Polish edition contact President at Fraszka Edukacyjna Publishers.

5.7 BBC News Channel (28 April 2008) 'Concern at night care for elderly.'
http://news.bbc.co.uk/1/hi/scotland/7371909.stm

5.8 Topping, A. (30 April 2008) 'Off diary: More light needed on night-time care'. The Guardian, London
http://www.guardian.co.uk/society/2008/apr/30/longtermcare?INTCMP=SRCH