Does paperwork intended to improve the quality of care in older people’s care homes make them better places to live, or does it reduce the amount of time devoted to caring?
This research examines the practical impact of paperwork in care homes and makes suggestions for its improvement.
It is a misnomer to talk of a single ‘set’ of paperwork. The research identifies more than 100 separate items of paperwork that must be completed regularly in care homes, responding to a range of regulatory and commissioning requirements. But a shared view of what should be valued in care is lacking.
Poor co-operation and co-ordination between agencies responsible for regulation, monitoring and purchasing care results in information being duplicated, often several times with a slightly different emphasis each time. This effect is referred to in this study as a ‘composite burden’.
Staff see some of these information demands as bearing little relation to an assessment of the quality of care a home provides for its residents.
n the care homes visited, about half of the paperwork produced was used infrequently. Some staff felt that paperwork was inefficiently designed or implemented. Providers’ interpretations of the value of regulatory paperwork also varied widely.
Some managers in care homes report spending 20% of their time on paperwork rather than on leadership activities that could improve the quality of care for residents.
Some staff feel they were judged more on an ability to produce quality paperwork than an ability to deliver quality care. Paperwork has limited our ability to quantify and measure the quality of interactions between care staff and residents. Paper offers false assurances in this regard and yet it is these interactions that are of ultimate value to residents and their relatives.
Public confidence in the regulatory and inspection regimes that should protect us when we are at our most vulnerable is plummeting, and government initiatives to improve care quality and strengthen regulation are being announced at ever shorter intervals. The Joseph Rowntree Foundation (JRF) wants to understand how approaches to risk and regulation in care homes can be developed in ways that support good relationships and improve people’s quality of life.
This research explores the role of paperwork in residential care homes for older people. It is currently estimated that more than 376,000 older people live in around 10,300 care homes in the UK – a population that will increase significantly over the next 20 years as the number of people in the UK aged over 85 doubles. Two key beliefs were central to the research methodology. First, that the purpose of paperwork should be driven from the perspective of those it is intended to benefit –residents. Second, that care should be provided in a way that is ‘human’ – focusing on the creation and maintenance of meaningful relationships between care staff and residents.
What paperwork is for and who decides this
Care homes have a list of core ‘must-dos’ based on key legislation and embodied in 28 standards of quality and care. Yet different agencies also make requests of care homes and these requests have different emphases across the country. In addition to this moveable feast of ‘must-dos’, views about how guidance should be interpreted to meet funding or regulatory requirements also vary. Additionally, some requests made by inspectors and regulators are seen by care homes as bearing little relation to the quality of care provided.
It is a misnomer to talk of a single ‘set’ of paperwork. There is little co-operation or co-ordination between different regulators and commissioners and duplication arises when they ask for much the same information, but tailored to their individual needs. From their point of view, what is requested is reasonable. However, the impact of several commissioners asking for similar but slightly different information places an extraordinary burden on the home. This composite impact is often what homes are describing when they complain about a ‘paperwork burden’.
Many interviewees felt that this issue reflected deeper system-wide uncertainty about what should be valued in care and what high-quality care should look like. Without this understanding, it is unlikely that agreement will be reached on the things care homes need to do, not just to comply with regulatory and commissioning requirements but to raise the quality of care.
Use and application of paperwork
In the care homes studied, about half the paperwork was used infrequently. However, staff still felt they had to produce it, and that the primary purpose of much of the paperwork was to ensure legal compliance or prevent litigation. In some cases, staff felt that paperwork was designed inefficiently. In other cases, paperwork seemed to be inefficiently implemented, with room to eliminate or streamline wasteful internal procedures.
Some managers reported spending 20% of their time on paperwork rather than on leadership activities to help ensure high-quality care for residents. Some staff reported that they increasingly feel themselves judged primarily on their ability to produce quality paperwork rather than quality care. The use and application of paperwork was explored further in three areas – care planning and daily records; risk assessments; and staff supervision. The research found that while care plans are important documents, the resident’s voice can be lost when he or she is seen as a set of care needs. In risk assessments, the focus tends to be on avoiding risk rather than on managing risk and enabling residents, whose wishes and priorities can be a secondary consideration. Paperwork associated with staff supervision and performance is rigorously assessed by regulators, yet does not always result in effective staff development. These are just some of the areas in which paperwork does not necessarily help achieve intended outcomes.
Paperwork and its contribution to achieving what residents value
Paperwork is frequently of limited value in promoting good-quality care. This is especially true in terms of quantifying and measuring interactions between care staff and residents in a care home –interactions which determine care quality and the experience of care. In numerous conversations with residents and their relatives, the quality of these interactions emerged as the single most valued and most remembered aspect of care. However, it is difficult to capture this on paper and more needs to be done to increase the weight given to observed care quality in homes. Used in this way – to assess all of the aspects of a care home’s working culture and care ethos – paperwork could help contribute to better quality care relationships and to strengthening residents’ voice in the care process.
Conclusion and recommendations
The balance between prevention of poor care and promotion of good care is out of kilter. Care homes spend an inordinate amount of time attempting to cover themselves against potential blame or litigation for poor care. Paperwork has become an industry in its own right, fuelled by fear and insecurity. Instead of being an addition to care quality, paperwork can lead to ‘subtractions’ – literally taking away from the delivery or management of care. Five of the most significant subtractions are:
Leadership: Many interviewees felt that time spent by leaders on paperwork could be better spent on leadership activities, being a visible presence in the home and demonstrating how to build good relationships with residents and staff.
Value of care: Interviewees suggested that the value placed on paperwork was too high compared to the value placed on providing high-quality care.
Vocation: Staff are judged more on their ability to complete paperwork than on their ability to deliver good care, creating unnecessary differentials in ability and divisions of labour. This can distance staff from their job and reduce their sense of vocation.
Co-operation: Paperwork does not drive providers, commissioners, contractors and regulators to higher levels of co-ordination, nor does it help them establish a shared value system for care.
Professional autonomy: Regulation can lead to regularisation; reinforcing the mechanistic nature of some care practice, for example regular bed-rail assessments. Staff in care homes need to take action because they recognise that it is the right thing to do at the time. Routine should not undermine staff autonomy or be a substitute for professional judgement. In the short-term, a number of limited steps to improve regulatory paperwork could be taken:
Adoption of a single incident reporting form.
Alignment of national inspection criteria across agencies such as the Care Quality Commission, NHS and local commissioners.
Sharing and use of information across inspectors of care.
Geographical alignment (improving consistency of approaches to inspection taken by commissioners and regulators in specific local areas).
Organisation of paperwork for different audiences (organising a set of paperwork that can be owned and used by the resident and organising paperwork that is used more by staff on a day-today basis).
Longer-term systemic improvements will require more ambitious change:
Care home inspection should involve observed assessment of care, giving real weight to choice, participation, dignity and respect. These are observable in the day-to-day interactions between residents and staff and should be at the heart of any inspection and regulatory regime.
The primary role of risk management should be to enable residents to live their lives in a way that they value as opposed to defending the home from potential litigation or reputational loss. This requires additional training and a better understanding of risk and enablement among regulators and commissioners. Care homes, commissioners and regulators should generate more collective approaches to accountability to reduce defensiveness and improve shared learning and calculated risk-taking across the care home sector.
About the study
The research was conducted in two care homes in Birmingham and one in York. As well as examining the current use of paperwork, focus groups and interviews were conducted with residents, relatives, volunteers, frontline staff, managers, commissioners, providers and regulators. The authors would like to thank all those who kindly gave their time and expertise.