A Better Home Life - A code of good practice for residential and nursing home care - Centre for Policy on Ageing.
The quality of life which residents experience will depend to
a great extent on the calibre of the staff caring for them. A
trained and experienced staff team, which is well managed and
adequately paid, is likely to provide high quality care in a responsive
and understanding atmosphere. People living in residential and
nursing homes are often vulnerable, both physically and emotionally.
Staff will be required to carry out personal and potentially embarrassing
intimate services for residents and will need special qualities
to do this sensitively and tactfully. Such qualities will include
personal warmth, patience and responsiveness to and respect for
the individual. They should be able to provide competent and tactful
care whilst supporting residents in maintaining and extending
skills and self-care abilities.
If residents are to receive a satisfactory standard of care, it
is important that the staff see themselves as part of a team which
is consistent in its shared aims, with members fulfilling complementary
roles. A balance of staff will therefore need to be appointed
to match the residents' needs.
There are four main groups of staff in the home to consider in
developing the staff team:
In addition, the role to be played by peripatetic staff such as
occupational therapists and chiropodists and by volunteers will
need to be considered carefully.
Current law requires that homes be run with an adequate number
of staff who have the right balance of skills and experience to
meet the needs of residents. Before registration, therefore, a
prospective owner must draw up a staffing schedule to show how
the staff team meets the residents' requirements. The schedule
is subject to inspection and approval by the inspection and registration
authority and the onus is on the applicant for registration to
provide sufficient evidence that the right level of staffing with
appropriate competence and training will be provided. Different
sized homes and levels of residents' dependency will require different
staffing complements. Nursing homes must have a registered medical
practitioner or first level registered nurse as the person in
charge as well as employing other qualified nursing staff for
nursing duties. The registration authority ultimately determines
the staffing levels and skill mix appropriate to the needs and
dependency of residents in each nursing home and sets it out in
a staffing notice before registration.
It is not acceptable for a home to be left in the control of a
person with insufficient training and experience. The staffing
establishment and rota system therefore need to be arranged so
that there are enough senior staff and they are suitably deployed
to give the cover required to meet the home's stated aims.
7.3.1 Recruitment
The recruitment of good staff is critical to the running of every
home and should be undertaken carefully. Staff at all levels will
need to demonstrate the right degree of knowledge, skills, experience
and attitudes relevant to their jobs. Managerial and supervisory
staff will need to have qualifications as appropriate.
The following stages are involved:
The same criteria should be applied in deciding whether to appoint
relatives of homeowners' families to work in the home.
Equal opportunities
It is sometimes difficult to balance equal opportunities procedures
with the needs and rights of residents. The recruitment procedures
and the composition of the staff team should as far as possible
match the mix of cultural and language backgrounds of residents.
Resident involvement
Consideration should be given to possible ways of involving residents
in the selection of staff. For example, where a new member of
staff will be working with a small group of residents, the final
choice could be made by the resident group after management has
screened for suitability. Where residents are involved they may
need help to take part in a selection process.
Advice on good practice in employment procedures can be sought
from registration and inspection authorities, employment agencies,
and independent bodies such as the Advisory, Conciliation and
Arbitration Service (ACAS).
7.3.2 Job descriptions
Job descriptions should describe the roles and tasks which staff
have to undertake. They should outline the management structure
and lines of accountability and the support and supervision available.
They should also set out the overall purpose of the job, linking
the importance of the tasks described to the aims of the home
as a whole.
7.3.3 Terms and conditions of employment
Recent employment law has made it mandatory for certain terms
and conditions of employment to be clearly stated in writing and
given to each employee as part of the contract of employment.
It is good practice to cover:
It needs to be recognised that a high turnover of staff in a home
is often an indicator of low quality. Where terms and conditions
of employment are poor with low pay, low status, inadequate training
opportunities and lack of career development staff are unlikely
to remain on a long-term basis. This in turn will have an impact
on the quality of care provided within the home.
7.3.4 Staff handbook
A detailed handbook should be readily available for each member
of staff, setting out terms and conditions of employment as above
and also covering procedures to be observed during working hours.
It may be an integral part of, or an appendix to, the contract
of employment. It should include:
7.3.5 Induction
New members of staff should be given a job induction during which
they are introduced to residents and other members of staff and
the nature of their job described. The aims and objectives of
the home and its routines and procedures (especially fire and
safety) should be set out for them, along with the standards of
care which all members of staff are expected to achieve.
7.3.6 Probationary period
It is good employment practice for all staff to undergo a formal
probationary period to ensure that they are suitable for the job
and the home. They should be properly supported during this time
with a review undertaken at the end of the period. Care should
be taken to ensure that new staff are not placed on duty together
and unsupported. It is good practice to place a new member of
staff alongside a more experienced person who can act as mentor.
7.4.1 Hours of duty
Duty rotas should be based on a working week of 36 to 40 hours.
Staff should not be expected to work additional hours regularly
or to work more than seven days continuously without taking a
break. Rotas should therefore pay attention to both shift patterns
and time off duty. Care should be taken to ensure that enough
time and attention is given to handover procedures between shifts
so that staff coming on duty are fully informed about any developments
or changes in residents' circumstances.
7.4.2 Dress
Clothing worn by staff should be suitable for the tasks that they
have to carry out. There are arguments for and against uniforms.
They tend to give an institutional feel to an establishment but
if a majority of residents express a preference for staff to wear
them then it may be appropriate. It is most important, however,
that uniforms do not create a misleading impression that staff
are nurses (if they are not) or that staff are qualified (if they
are not). Staff from ethnic minorities should be able to wear
their own style of dress.
Other options include a corporate colour, style or item of clothing.
Name badges can be helpful, particularly where there is a large
staff team or if residents find it difficult to remember names.
They are also helpful for visitors. They may be more suitable
if they are sewn names on cloth badges (rather than hard badges
or brooches where there is a risk of scratching residents) and
large enough to be read by residents with poor sight. Jewellery
such as brooches, chains and rings should either be covered or
not worn if it might scratch or harm residents.
Attention should always be given to matters of infection control,
either from resident to resident, resident to staff or staff to
resident, and so practical protective clothing should be available
for staff when needed.
7.4.3 Support for staff
Managers should ensure that managerial structures, communications
systems and staff supervision are sufficient to enable staff to
undertake their duties effectively.
Staff induction, manuals of guidance, inhouse training, staff
meetings and individual supervision should be considered carefully
and laid out in detail. The extent to which staff need these forms
of support will depend on the complexity and stress involved in
their work. It is important to remember that in the event of a
crisis or an enquiry, homeowners may have to demonstrate that
the support structures which they had in place were sufficient.
Good working relationships will be enhanced if all levels of staff
are included in discussions about the running of the home.
Staff meetings
Staff meetings should take place regularly and involve all staff.
They should normally be held in paid time and be arranged if necessary
on a rotating basis, so that all staff, including night staff,
can participate over a period of time.
Staff supervision
There should be one-to-one supervision sessions for all staff on
a regular basis although they may be required more frequently
for nursing and care staff than other staff categories. The sessions
should enable managers to ensure that staff are performing satisfactorily
and provide opportunities for constructive criticism and understanding
support. Personal and career development should be discussed.
In larger homes, delegated supervision may need to be arranged.
Stress
Working in the care environment can be stressful. Staff have to
learn to cope with death, serious illness and the difficult behaviour
of some residents. For a home to be able to deal with such things
as high levels of incontinence and aggressive and violent behaviour,
managers should have policies and procedures in place which ensure
enough support and training opportunities for staff and adequate
staffing levels.
Homeowners need to demonstrate that they have considered the residents'
needs in relation to all types of staff in drawing up their staffing
establishments. They will therefore need to set out the numbers
of staff, their designations and duties, their gradings or salaries
attached to posts, and the types of qualifications, experience
and training which will be expected for each post. It is important
to indicate the balance between part-time and full-time posts since
part-time work allows for more flexible deployment while full-time
posts tend to improve consistency and continuity of care. In larger
homes there may be scope for some posts to be specialist but in
smaller homes staff may carry a wider variety of responsibilities,
including managerial work, resident care, cooking and so on. In
all cases, however, the duties required of staff should be made
clear at the time of appointment and any changes of duty or role
should be recorded in writing.
7.5.1 Residential care homes: managerial and care staff
Minimum cover
In drawing up their management and care staffing establishments,
owners should consider two main factors. The first is the provision
of minimum cover. There must be a 'responsible person' designated
on duty at all times during the twenty-four hour day. This means
that there is someone present who can make decisions in an emergency,
who is familiar with the home's procedures and practices and has
the necessary skills and training to manage the service provided.
In larger homes or those where the work is more demanding, either
physically or in terms of residents' behaviour, minimum staffing
levels will be higher, and generally two staff will be needed
at any one time where residents have to be lifted.
As a rule of thumb, with allowance made for time off, holidays
and some illness, a home needs to employ 3.5 staff to provide
one person on day duty. Where at least two staff are needed on
duty at all times, the minimum cover would therefore demand 3.5
x 2 = 7.00 staff. These figures are given in full-time equivalents,
but could be filled by part-time staff where appropriate, or a
mixture of full and part-timers.
These approximate minimum staffing figures are based upon a full-time
working week of 36 to 40 hours. Where owners, managers or other
senior staff are resident and are prepared to be available on
call for longer periods, minimum staffing calculations may take
this into account. Adequate cover will need to be assured, however,
when some resident staff are absent; remaining resident staff
should not have excessive demands placed upon them. Owners' or
managers' dependent relatives living on the premises may also
be taken into account when cover is assessed. Where married couples
are the owners or are employed, care should be taken to ensure
that they have reasonable time off together each week and for
holidays, and that they are not under pressure to forego this
right for lack of staffing.
The minimum cover set out here is designed to cope with the general
running of the home but there are peaks and troughs in the residents'
demand for staff support and help. Peaks include getting up, mealtimes,
activities and going to bed; troughs include times when residents
are out of the building and rest periods. It is important, therefore,
not only to provide minimum cover but also to deploy staff to
offer additional support at peak periods. The employment of part-time
staff can enable such deployment to be flexible without causing
problems such as split shifts for full-timers.
Total staff required
The second main factor in the calculation of day care staffing
is the degree of need presented by the residents and the consequent
amount of staff time required. Needs will vary, particularly between
homes which are registered as residential care homes and those
which are registered as nursing homes, but even amongst residential
homes themselves needs will vary. Total requirements can be arrived
at by estimating the number of care hours required according to
residents' needs per week and then totalled per resident per annum,
and then totalled for the home as a whole. Thus the number of
staff needed can be worked out once allowance is made for holidays,
illness and other absences. This approach gives the total staffing
required for all managerial and care staff on day duties, inclusive
of the minimum cover outlined above. Even where an establishment
is geared towards encouraging self-care and participation in household
tasks, there can generally be no staffing reduction as staff will
still be needed to help in these activities although residents
who become increasingly independent will sometimes need less support.
Allowance has also to be made for leave, sickness, training, staff
meetings and other activities. Where senior staff are involved
in client selection, recruitment of staff, fundraising and additional
extraneous duties, further allowance will need to be made. In
general, a full-time employee can provide about 1,500 hours of
care time per annum.
There are a number of different models available which cover this
issue. One such model is contained in a handbook produced by the
Wagner Development Group. It gives guidance on calculating staffing
establishments and is helpful to owners and managers in establishing
a staff team (see Appendix 2).
Night staffing
Night staffing requirements will depend upon the mobility and
lucidity of residents on the one hand, and the type of handling
problems anticipated on the other. Where residents require lifting,
for example, two members of staff are needed, regardless of the
size of the home. In order to calculate the staffing required,
an establishment of 2.5 full-time equivalents is sufficient to
provide one person on duty although this does not take into account
periods of cover for sickness, annual leave or training. Where
waking staff on duty are not sufficiently experienced and trained,
it will be necessary for senior staff to sleep 'on call' on the
premises.
Nursing homes: managerial and nursing staff
The person in charge of a nursing home must be a registered medical
practitioner or a first level registered nurse. The registration
authority specifies by notice the qualifications of staff and
minimum staffing levels required in a nursing home, and when drawing
up the notice it will need to be satisfied as to the arrangements
for the management and control of the services to be provided.
This will include the arrangements for the delegation of responsibilities
and supervision of staff. At least one first level nurse should
be on duty throughout the day. The registration authority may
decide that a second level registered nurse may be in charge during
the night, but that nurse must be fully appraised of the general
nursing needs of all residents. A first level nurse should be
nominated to tee 'on call' where a second level nurse is in charge
at night. The current registration of all qualified nursing staff
should be checked with the United Kingdom Central Council for
Nursing, Midwifery and Health-visiting (UKCC).
Nursing levels
It is not possible to specify standard staffing ratios because
of the variation in needs and circumstances of residents in different
nursing homes. The NAHAT handbook (see Appendix 2)
outlines
the variety of factors which need to be taken into account in
determining staff mix and staff levels. These include:
On the basis of these factors and others as described in the NAHAT
handbook, the registration authority will determine the number
and type of qualified nursing staff to be employed and the ratio
of trained to untrained staff. The same range of factors as in
7.5.1 above will need to be taken into account in determining
levels of non-nursing staff.
7.5.3 Ancillary staff
Ancillary staffing includes staff not primarily engaged to undertake
managerial, nursing or social care roles, but the value of their
contact with residents or their therapeutic role should not be
underestimated. In large establishments the management of ancillary
staff is likely to require experience and a different set of skills.
While no specific guidelines are offered for the numbers of such
staff, owners should consider the tasks listed below.
Cooking
In some homes, care staff may do the cooking to help create a
homely atmosphere, or, in larger establishments, it may be done
by full-time cooks. The approach should be determined by the overall
aim of the home, and appropriate training made available to ensure
that residents obtain a varied, balanced diet that also reflects
their individual wishes.
Laundry work and needlework
In large homes, or where incontinence presents major problems,
consideration may be given to the appointment of staff to deal
solely with laundry. Needlework may be undertaken by residents
or care staff, but there may be homes where a needleworker should
be appointed to care for residents' clothes. It is important in
both laundering and needlework that residents' clothing is well
looked after, since carelessness may not only damage the clothes
but seriously upset residents and their families who see it as
a sign of institutional treatment.
Domestic work
Communal areas will normally be cleaned by paid staff, even in
homes where residents are encouraged to clean their private rooms.
Old buildings are sometimes more difficult to clean and will require
extra time and attention.
Gardening and maintenance
This work may be carried out by owners, care staff, residents
or outside contractors. In some circumstances, however, staff
may be appointed to carry out maintenance work, since good maintenance
is important for the comfort of residents, especially when they
are dependent on the efficient functioning of heating systems,
hot water supplies, other household systems and aids with which
the home is equipped.
Clerical Work and administration
It is important that both the care and managerial aspects of the
home are properly backed by clerical and administrative staff,
to ensure that residents' records, correspondence, appointments,
financial records and general administration are kept up to date,
without using senior managerial time inappropriately.
7.1 Introduction
The staff team
7.3 Staff recruitment and selection
7.4 Working conditions
7.5 Staffing establishments