Researchers in the long-term conditions theme of our previous CLAHRC West Midlands carried out a two-year evaluation of a care home quality improvement programme in Walsall and Wolverhampton, supported by the West Midlands Academic Health Sciences Network (WMAHSN). This work is set to continue under ARC West Midlands as we evaluate the wider rollout and implementation of the programme, called SPACE, ‘Safer Provision and Caring Excellence’, in other areas and into the residential care setting. For us, care homes were unfamiliar and initially daunting research environments. Now that the SPACE evaluation has concluded and we are preparing for the next stage of our care home work, it is timely to consider what we learned from our first foray into the world of care home research.

First, care homes are used to being visited by ‘outsiders’. Unfortunately, many of these visits are associated with assessments and inspections of various kinds. Consequently, we encountered some hostility at the start of the project from managers and staff who believed our presence would place them under unwelcome scrutiny and judgement about the quality of their care. We worked hard to establish positive relationships, helped both by the overriding ethos of SPACE, which focused on co-creation of quality improvement (QI) interventions rather than imposing them upon the care homes in the programme, and by the programme facilitators, who – like us – were finding their feet in a new working environment.

Second, there is typically little culture of research participation or data collection in care homes. Our expectation that we would find an untapped treasure trove of process and outcome data ready to be mined for its riches was quickly scuppered by a reality check and the realisation that care homes are busy places where, quite rightly, the main business revolves around providing resident care. This is frequently done by overburdened staff in difficult circumstances, and research is not a priority. This reality check extended to our planned data collection from managers and staff, and we soon learned that flexibility was the order of the day. For example, it was imperative to accommodate the care home schedule. Mealtimes and early mornings are extremely busy and turning up on the doorstep with hundreds of survey packs to be handed out to staff was (understandably) not met with enthusiasm. Gradually, we came to understand the ebb and flow of the care home working day, and became more attuned to the times that it would be most appropriate for us to visit. Once we did this, our presence was welcomed and we felt less as if we were imposing.

Third, recruitment and data collection plans required pragmatism, both to allow an effective response to unanticipated changes, and to ensure that robust data could still be collected. One component of the evaluation was to interview managers and staff in multiple roles (clinical, domestic, maintenance, care assistants) in four care homes selected as in-depth case study sites. We meticulously planned how we would identify and recruit participants using a predefined sampling frame and giving potential interviewees time to read and digest our lengthy and exhaustive participant information sheets. Very quickly, we abandoned this approach, honed through years of research in primary and secondary care, and embraced opportunism, interviewing whomever we could temporarily tear away from their duties at short notice. This meant that we often spent as little as ten minutes with our interviewees, but found our data to be no less interesting or meaningful than that collected through more formal approaches.

Finally, each care home was different, and our approach to the evaluation was progressively tailored accordingly once we were familiar with what was effective (or not) in each of the 26 care homes that we worked with. By the time our evaluation drew to a close, we were genuinely saddened, having built up strong relationships with managers and staff in the majority of the care homes, and becoming familiar faces at SPACE meetings and events. Indeed, our primary issue then became one of ensuring we maintained our independence as evaluators when we had developed a strong desire to see the programme succeed and for everything to go well for the managers and staff we had come to know. After all, how often do researchers get to work in an environment with biscuits on tap, the chance to meet and stroke numerous therapy animals, and the tantalising possibility of being able to polish off a leftover slice of afternoon cake!

In the end, two years after our initial terror at the prospect of working in care homes, the SPACE evaluation had become the most rewarding piece of research that we carried out during CLAHRC WM and we are delighted to have the opportunity to continue our work as part of our incipient ARC WM programme. Hopefully, as researchers, we are now a little less naïve and the lessons we have learned to date will stand us in good stead.

Sarah Damery, Research Fellow Theme 1: Long-term Conditions 6