A case study of the statutory care home review system in one Local Authority. Statutory reviews of older people's care home placements are a legacy of the Community Care reforms of the 1990s in the UK. Using a mixed method approach this small-scale qualitative study was designed to explore how the statutory care home review system operated from the perspectives of its multiple stakeholders, but paying particular attention to the role played by the older person. The study also set out to assess the relevance and usefulness of the concept of 'street-level bureaucracy' as developed by Upsky (1980) in understanding how discretion was used in operating the system. It is argued that, in a context in which the adult social care sector has been 'transformed' by processes of privatisation, marketization and 'modernisation', the exercise of discretion is no longer the sale preserve of 'street-level bureaucrats' (front-line practitioners), but rather, it is dispersed among the various statutory and non-statutory actors in the review system, including managers, care home providers relatives and older -people themselves. The study revealed a system which had undergone multiple reorganisations in response to a variety of national and local policy initiatives and, against this context, was struggling to cope with the implementation of ambiguous and, often, conflicting policy agendas. Overall, the system was compromised by the need to balance ensuring care standards with the need to meet performance targets, often leading managers, practitioners and care providers to have to tolerate sub-optimal standards of care. It is proposed that, generally, in order for review actors to manage the tensions inherent in the system, it was helpful if the older person either voluntarily adopted or was steered into a position of passive participation in care reviews, suggesting that reviews can be as much a source of disempowerment for older people as empowerment.

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Older people resident in care homes are amongst the most vulnerable and dependent in any society. This study aimed to explore perspectives on decision making in a care home in the United Kingdom (UK), considering the appropriateness of who made the decisions, how and under what authority. It used grounded theory methodology in a case study framework, in a single care home. Field work was conducted between December 2009 and January 2011 in an inner metropolitan area. Participants were twenty one residents, eight relatives, five registered nurses and six care workers. Data were collected using; interviews; informal conversations; observation and examination of documentation. Participants' perspectives were considered through a values based lens with emphasis on autonomy and dignity as the most dominant in policy, ethical discourse, professional and empirical literature. Findings were constructed from systemic analysis of the data. Two central phenomena were identified, resident as decision maker and others decide for resident. Decisions were categorised into three types, everyday, infrequent and advance decisions. Each group of participants viewed different decision types as most important. Staff appeared to have little knowledge of policy and law and notably, they appeared not to consider mental capacity in relation to decision making, nor did they demonstrate recognition of the ethical dilemmas they faced. All participants found it difficult to articulate values underpinning decision making. Despite staff accepting that residents were able to make decisions and had a right to do so, residents' preferences were not always respected. There was a tension between staff's desire to offer choice, the need to minimise risk and provide good care within the constraints of the organisation with a finite number of staff. If operationalised, the value of solidarity could help relieve the tension and potential dissonance experienced by actors in the care home under study and similar care home environments. Solidarity promised mutuality and reciprocity which would allow all actors to be recognised and valued, ultimately benefiting the residents' quality of life.

In the planning and delivery of services the voice and choice of consumers have appeared as the foremost key factors. For a large number of organisations the received feedback from customers about the quality of services, which are the criteria and indication of their level of satisfaction play a crucial role in the improvement of quality. Although across developed western communities, the importance of customers’ views has gained acceptance, few studies have been dedicated to the exploration of the voice of the residents in care homes. The review of the literature regarding residents’ satisfaction and quality in care homes revealed that the voices of residents in care homes are usually not heard or are absent. Moreover, the adoption of quality improvement tools in health care has lagged behind that in other industries and there is generally a failure to use an appropriate methodology in care homes, one based on residents’ voice, for improving quality. As a result, the main aim of this research is to investigate residents’ voice regarding improving their satisfaction in care homes. Further, the researcher seeks to obtain data by using an appropriate methodology to assist care home managers in enhancing the quality of the services they offer by assigning weights to quality indicators pertaining to improving quality and residents’ levels of satisfaction. For this purpose, this research employs both qualitative and quantitative approaches to develop a research process entailing: (1) a comprehensive literature review to recognise the phenomenon; (2) interviews with fifteen older people who lived in three different care homes in order to discover the most important residents’ needs and requirements in such homes; (3) a resident survey with one hundred and two residents in thirty five care homes. These were conducted to assess their preferences for the importance of demanded qualities; their satisfaction with provided services and the attributes of each demanded quality based on the Kano model, in order to identify the priority of improvement. Next, (4) there was the development of the House of Quality (HoQ) to optimize quality to assure residents’ satisfaction; and finally, (5) an evaluation study was conducted with thirteen service providers, in order to assess the accuracy and appropriateness of the methodology. This research has contributed towards a better understanding of the residents’ voice, and applying it for enhancing quality and residents’ satisfaction in care homes. For the first time residents’ requirements are prioritised and classified in this context through accurate methods. Moreover, an understanding of the attributes of care home residents’ needs in relation to a Kano model has been elicited. The novelty of this proposed methodology is in utilising the Quality Function Deployment (QFD) in care homes to translate the voice of residents’ regarding their requirements into service planning. The research methodology and results facilitate care home managers with a hierarchy for improvement planning at both service and executive management levels.

40% of residents living in care homes in the United Kingdom have significant depressive symptoms, compared with 9% living in the community. Care homes can appear to be depressing places, but whether the physical environment of homes directly affects depression in care home residents is unknown. The overall aim of the thesis was to establish whether the physical environment or specific features of the physical environment predict depressive symptoms in older people living in care homes. A mixed methods approach was used: 1. A systematic review was conducted to identify and evaluate instruments designed to measure the physical environment of healthcare settings and informed the choice of instrument used to measure the physical environment of care homes in an observational study. 2. Semi-structured interviews with 15 participants living in four care homes identified features of care home design that were considered important to investigate in the observational study and assisted with interpretation of the results. 3. An observational study explored the longitudinal relationship between the physical environment and depressive symptoms using data from an interventional trial among older people living in care homes. The physical environments of 50 care homes were assessed using The Sheffield Care Environment Assessment Matrix (SCEAM). Depressive symptoms were measured using the Geriatric Depression Scale (GDS-15) for 510 residents living in the care homes at baseline, six and twelve months. Multi-level modelling was used to analyse the data. Interviews revealed residents valued environments that increased opportunity for social interaction, maximised physical function, and allowed access to outdoor space. In the observational study the overall physical environment of care homes (overall SCEAM score) did not predict depressive symptoms. Care homes that scored highly on the SCEAM domain community weakly predicted lower depressive symptoms. Controlling for dependency (Barthel Index), social engagement (Index of Social Engagement) and home type (nursing/residential) ‘access to outdoor space’ predicted greater depressive symptoms. This finding initially appeared counterintuitive; however evidence from the interview study suggested access to outdoor space was restricted for residents in many different ways: locked doors, lack of paths, inadequate seating, steep steps, and needing permission or assistance of staff to go outside. Residents may have ‘free access to outdoor space’ but are prevented from using the outdoors for reasons that negatively affect their decisional autonomy and consequently their mood. The research provides evidence to support care home design that encourages social interaction and allows unrestricted access to outdoor spaces in order to positively influence mood in care home residents.