{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,8]],"date-time":"2026-10-08T20:06:54Z","timestamp":1791490014793,"version":"4.3.4"},"reference-count":220,"publisher":"National Institute for Health and Care Research","license":[{"start":{"date-parts":[[2024,4,1]],"date-time":"2024-04-01T00:00:00Z","timestamp":1711929600000},"content-version":"unspecified","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"DOI":"10.13039\/501100002001","name":"Health and Social Care Delivery Research (HSDR) Programme","doi-asserted-by":"publisher","award":["15\/144\/29"],"award-info":[{"award-number":["15\/144\/29"]}],"id":[{"id":"10.13039\/501100002001","id-type":"DOI","asserted-by":"publisher"}]}],"content-domain":{"domain":["journalslibrary.nihr.ac.uk"],"crossmark-restriction":false},"short-container-title":["Health Soc Care Deliv Res"],"abstract":"<jats:sec id=\"abs1-1\"><jats:title>Background<\/jats:title>\n<jats:p>Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-2\"><jats:title>Objective(s)<\/jats:title>\n<jats:p>To explore variations in the care home nursing and support workforce; how resident and relatives\u2019 needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents\u2019 needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-3\"><jats:title>Design<\/jats:title>\n<jats:p>Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 \u2013 two evidence syntheses (one realist); WP2 \u2013 cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 \u2013 analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 \u2013 secondary analysis of care home regulator reports; WP5 \u2013 social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-4\"><jats:title>Setting<\/jats:title>\n<jats:p>English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-5\"><jats:title>Participants<\/jats:title>\n<jats:p>Managers, residents, families and care home staff.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-6\"><jats:title>Findings<\/jats:title>\n<jats:p>Staffing\u2019s contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop \u2018familial\u2019 relationships between staff and residents, and staff\u2013staff reciprocity, \u2018knowing\u2019 residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act.<\/jats:p>\n<jats:p>Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-7\"><jats:title>Limitations<\/jats:title>\n<jats:p>Many of our findings stem from self-reported and routine data with known biases \u2013 such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-8\"><jats:title>Conclusions<\/jats:title>\n<jats:p>Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible \u2013 rather than available \u2013 inputs and outcomes.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-9\"><jats:title>Study registration<\/jats:title>\n<jats:p>This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062.<\/jats:p>\n<\/jats:sec>\n<jats:sec id=\"abs1-10\"><jats:title>Funding<\/jats:title>\n<jats:p>This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15\/144\/29) and is published in full in <jats:italic>Health and Social Care Delivery Research<\/jats:italic>; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.<\/jats:p>\n<\/jats:sec>","DOI":"10.3310\/gwtt8143","type":"journal-article","created":{"date-parts":[[2024,4,18]],"date-time":"2024-04-18T11:39:36Z","timestamp":1713440376000},"page":"1-139","update-policy":"https:\/\/doi.org\/10.3310\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":27,"title":["Relationship between staff and quality of care in care homes: StaRQ mixed methods study"],"prefix":"10.3310","author":[{"ORCID":"https:\/\/orcid.org\/0000-0002-6908-0032","authenticated-orcid":true,"given":"Karen","family":"Spilsbury","sequence":"first","affiliation":[{"name":"School of Healthcare, University of Leeds, Leeds, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-5444-194X","authenticated-orcid":true,"given":"Andy","family":"Charlwood","sequence":"additional","affiliation":[{"name":"Leeds University Business School, University of Leeds, Leeds, 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