Personalisation in care homes for older people

Over 350,000 older people in England live in care homes, generally for the final months or few years of their lives. It is important for their dignity and wellbeing, and that of their families, that they should receive high-quality personalised care and not just ‘warehousing’. Our “Evaluation of Direct Payments in Residential Care Trailblazers" report found that providing personalised care for older people in care homes presents a range of challenges and that there are a number of issues that require further investigation to inform policy and practice.

This study investigated how personalisation is understood and put into practice in care homes and explored the context and challenges of providing personalised care in residential settings.

The study addressed three research questions: 

• How is ‘personalisation’ conceptualised in residential care? 

• Which approaches are being adopted to promote personalisation in care homes for older people? 

• What are the barriers and facilitators to achieving a higher degree of personalisation in care homes for older people? 

The study reviewed the UK and international research literature to identify approaches to personalisation, assess their effects and understand any barriers and facilitators. We also reviewed relevant policy documents and approaches to promoting personalisation developed by selected public sector, private and voluntary organisations. Interviews were carried out with a selection of managers of care homes for older people to find out how they understood the aims of personalisation and how this translated into personalised care in the care homes they managed. Finally, 50 Care Quality Commission inspection reports on care homes rated as ‘inadequate’ or ‘requiring improvement’ undertaken in 2018 were analysed to look at how ‘personalised’ care was being practised.

Review of policy and practice documents 

Personalisation refers to ‘the process by which services are tailored to the needs and preferences of citizens. The overall vision is that the state should empower citizens to shape their own lives and services they receive’ (Cabinet Office 2007). In adult social care in England, the idea of personalising services has led to different approaches in domiciliary and residential care. In domiciliary care, the term ‘personalisation’ indicates an intention to enable service users to have more choice of and control over services they receive, with direct payments being the primary mechanism. This interpretation of personalisation portrays the individual as ‘customer’ of care services. 

In residential care, the focus has been on delivering ‘person-centred care’ as an approach to improve the quality of care in care homes. The concept was developed to address shortcomings in the provision of care for people with dementia, but it is now used more widely. Its main route to improvement is to emphasise the importance of the relationship between residents and carers, and the role of carers to enable residents to live their lives as fully as they can. Care recipients are not cast as ‘customers’ but as human beings in need of support. We have reviewed the literature focusing on studies examining the effects of approaches to promote personalisation on care home staff and residents. The majority of studies we identified examined the effects of person-centred care training for staff on staff and resident outcomes, identifying the role of well-trained professional carers as central for personalisation. 

Interviews with care home managers 

We also interviewed care home managers (n=24). All managers emphasised the importance of staff building relationships of trust with residents and their families.The care relationship was seen as central in two ways: to enable staff to better know and understand the individuals in their care, particularly those with declining cognitive capacity; and to empower residents to express their individual needs, choices and preferences for care and support with confidence. Managers stressed the importance of attracting well-trained care staff with the appropriate attitude, aptitude and motivation to provide good personalised care. Appropriate staffing was often highlighted as a key ingredient to personalisation; however, managers voiced many concerns about staff recruitment, development and retention, which could limit care homes’ ability to provide personalised care. 

Most managers wanted their residents to be treated as if they were ‘family’ and used this metaphor to describe their ambition for creating an environment in which residents and staff enjoyed close, personal relationships. Managers noted a variety of strategies to enhance homeliness and family-like relationships including using opportunities for celebrations and providing residents to participate in domestic tasks if they so wished. Only a few managers spoke of their home as similar to a ‘hotel’ emphasising customer choice and comfort in their approach to personalising care. 

Analysis of care home inspection reports 

We also reviewed inspection reports by the Care Quality Commission (CQC), focusing on care homes rated as "requires improvement" and "inadequate". Despite the negative ratings of these homes, reports suggested that staff promoted personal relationships in many ways and benefited residents' welfare by encouraging continued interaction with family, friends, and local communities. Most common barriers to delivering personalised care mentioned in reports were poor communication between staff, lack of commitment to personalised care from management, challenges to maintaining adequate staffing levels, and a lack of staff skills and understanding of person-centred care.