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.

Volunteer mentoring (befriending and peer support) is provided across a wide range of services for people with varying health conditions. Despite such services for carers of people with dementia increasing in number, there is little evidence for the benefits they may offer. Using a pragmatic approach, this thesis investigated the impact of volunteer mentoring on carers. It also explored the processes by which volunteer mentoring works and the experiences of volunteers delivering the interventions, many of whom are former carers. A systematic review and survey of volunteer mentoring services highlighted conflicting findings surrounding the impact of the services, the perceived importance of experiential similarity of volunteers and matching carers and volunteers. However, reported outcomes from the systematic review and survey were more consistent, namely reducing emotional distress, loneliness and social isolation of carers. To explore these issues in greater depth, a sequential explanatory mixed methods design was adopted. Data were collected from carers using validated rating scales (HADS, MSPSS and the UCLA Loneliness Scale) and semi-structured interviews. Data collection from volunteers was by semi-structured interviews only. No statistically significant changes were found after the six month study period for anxiety, depression or loneliness for carers. However, significant differences in perceived social support scores were found (p = 0.042). Post-hoc analysis showed this to be between baseline and three months follow-up (p = 0.015). Of the three subscales of the MSPSS, only support from a ‘significant other’ was shown to be statistically significant between baseline and three months (p = 0.013). Qualitative findings showed volunteer mentoring to be an important source of emotional and social support for carers, which was facilitated by the volunteers’ experiential similarity. Similarly to carers, volunteers reported the importance of experiential similarity in developing bonds with carers. They discussed the importance of developing mutually beneficial relationships which leads to a two-way flow of support. Volunteers also reported satisfaction and enjoyment from their roles. Data integration showed volunteer mentoring can be a source of social support for carers. The statistically significant difference in perceived social support from a ‘significant other’ between baseline, three months follow up, was confirmed by carers taking part in the qualitative phase. They perceived that volunteer mentoring can help them be networked into other services and help them to cope better with their caring role. It is argued that volunteer mentoring is an important source of support for some carers and that the development of these types of services should be considered alongside other forms of social support. This was one of the first studies of its kind to investigate both the process of volunteer mentoring and its impact specifically on carers of people with dementia. It is concluded that without experiential similarity, carers and volunteers may not develop the level of trust necessary to form mutually beneficial relationships.

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