Background:In England, care homes are the primary providers of long-term care for older adults. The increasing recognition of the importance of social care underscores the importance of collaboration between the National Health Service and care homes. The lack of data sharing among stakeholders limits opportunities for co-ordinated care, service development and research. Objectives:Identify how to support research, service development and innovation in care homes. Combine existing evidence with care home-generated resident data to create a minimum data set that is relevant and usable for stakeholders, including residents, relatives, practitioners, researchers, regulators and commissioners. Design and methods:The study used a mixed-methods approach, structured into five work packages, supported by patient and public involvement and engagement with residents, carers and staff: Work package 1: Conducted two evidence reviews on outcome measures and factors enhancing research productivity in care homes. Work package 2: Created a trial archive for secondary data analysis. Work package 3: Conducted a scoping review, a realist review and a national survey to define minimum data set content and assess implementation challenges in English care homes. Work package 4: Linked residents' data from National Health Service and social care data sets with data from study care homes, deriving useful minimum data set variables and assessing data quality. Work package 5: Piloted the minimum data set at two points in care homes within three integrated care systems, conducted focus groups and interviews with care home and integrated care system staff. Three national consultations explored how stakeholders use resident information, measure quality of life and minimum data set usefulness. Additionally, subprojects examined data availability in domiciliary settings, staff reasoning when assessing resident well-being and completing research during rapid policy changes. Findings:The reviews revealed significant heterogeneity in outcome measurement and questioned the appropriateness of some methods and measures used for care home research. The Virtual International Care Home Trials Archive merged data from 6 United Kingdom randomised controlled trials with 5674 residents across 308 care homes. International minimum data set studies are a valuable resource for international comparative research. The wide range of measures used are mostly clinical with under-representation of measures important to care homes (e.g. quality of life). A national survey of care homes demonstrated the range of information, including clinical measures being routinely collected. The realist review identified motivation, front-line staff monitoring and embedded recording systems as important for minimum data set implementation. The pilot study recruited 996 residents from 45 care homes, with 727 residents' data included in the minimum data set. Residents' digital care records were linked to statutory health and social care data sets, creating a viable minimum data set prototype with metadata as resource. Conclusions:The study provided an evidence-based critique of care home research and a resource for secondary data analysis for future research. It developed a prototype minimum data set linking National Health Service, social care and care home data, demonstrating its importance as a basis for discussions between health and care staff. Limitations:The COVID-19 pandemic disrupted relationships and recruitment. Governance challenges prevented linking residents' data to general practitioner records. Future work:Future research should assess whether the care home minimum data set improves resident outcomes, service delivery, staff experience, cross-sector collaboration, resource use and digital technology implementation. Funding:This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR127234.

Introduction Health and care data are routinely collected about care home residents in England, yet there is no way to collate these data to inform benchmarking and improvement. The Developing research resources And minimum data set for Care Homes' Adoption and use study has developed a prototype minimum data set (MDS) for piloting. Methods and analysis A mixed-methods longitudinal pilot study will be conducted in 60 care homes (approximately 960 residents) in 3 regions of England, using resident data from cloud-based digital care home records at two-time points. These will be linked to resident and care home level data held within routine National Health Service and social care data sets. Two rounds of focus groups with care home staff (n=8-10 per region) and additional interviews with external stakeholders (n=3 per region) will explore implementation and the perceived utility of the MDS. Data will be assessed for completeness and timeliness of completion. Descriptive statistics, including percentage floor and ceiling effects, will establish data quality. For validated scales, construct validity will be assessed by hypothesis testing and exploratory factor analysis will establish structural validity. Internal consistency will be established using Cronbach's alpha. Longitudinal analysis of the pilot data will demonstrate the value of the MDS to each region. Qualitative data will be analysed inductively using thematic analysis to understand the complexities of implementing an MDS in care homes for older people. Ethics and dissemination The study has received ethical approval from the London Queen's Square Research Ethics Committee (22/LO/0250). Informed consent is required for participation. Findings will be disseminated to: academics working on data use and integration in social care, care sector organisations, policy makers and commissioners. Findings will be published in peer-reviewed journals. Partner NIHR Applied Research Collaborations, the National Care Forum and the British Geriatrics Society will disseminate policy briefs.

Objectives To assess the feasibility of capturing older care home residents’ quality of life (QoL) in digital social care records and the construct validity (hypothesis testing) and internal consistency (Cronbach’s alpha) of four QoL measures.Design Cross-sectional data collected in wave 1 of the DACHA (Developing resources And minimum dataset for Care Homes’ Adoption) study, a mixed-methods pilot of a prototype minimum dataset (MDS).Setting Care homes (with or without nursing) registered to provide care for older adults (>65 years) and/or those living with dementia. All homes used a digital record system from one of two suppliers.Participants Data were extracted from 748 residents. All permanent residents, aged 65 years or older, were eligible to participate, including those lacking capacity to consent. Temporary residents and residents in their last weeks of life were excluded.Outcome measures and analysis The English language versions of Adult Social Care Outcomes Toolkit (ASCOT)-Proxy-Resident, ICEpop CAPability measure for Older people (ICECAP-O), EQ-5D-5L proxy and the QUALIDEM were added to the digital record. As there have not been any previous studies of the structural validity of the English language version of the QUALIDEM, ordinal exploratory factor analysis (EFA) was applied for this measure only. Feasibility (% missing by software provider and measure), % floor/ceiling effects (>15% at lower/upper end of the scales), convergent or divergent construct validity (criterion of >75% of hypotheses accepted) and internal consistency (Cronbach’s alpha ≥0.7) were assessed for all four measures.Results The ordinal EFA of QUALIDEM did not replicate the findings of previous research. A six-factor (36 item) solution was proposed and used in all subsequent analyses. There were low rates of missing data (<5%) for all items, except ASCOT-Proxy-Resident Control (5.1%) and Dignity (6.2%) and QUALIDEM item 35 (5.1%). Ceiling effects were observed for the ASCOT-Proxy-Resident and two of the QUALIDEM subscales. None of the scales had floor effects. Cronbach’s alpha indicated adequate internal consistency (α ≥0.70) for the ASCOT-Proxy-Resident, ICECAP-O and EQ-5D-5L proxy. There were issues with two QUALIDEM subscales. Construct validity for all measures was adequate.Conclusions The findings support the use of EQ-5D-5L, ASCOT-Proxy-Resident and the ICECAP-O in care homes for older people. The choice of measure will depend on the construct(s) of interest. More research is needed to establish the psychometric properties of the QUALIDEM in an English care home setting.

INTRODUCTION:Information on care home residents in England is captured in numerous data sets (care home records, General Practitioner records, community nursing, etc.) but little of this information is currently analysed in a way that is useful for care providers, current or future residents and families or that realises the potential of data to enhance care provision. The DACHA study aimed to develop and test a minimum data set (MDS) which would bring together data that is useful to support and improve care and facilitate research. It is that utility that underscores the importance of meaningful public involvement (PI) with the range of groups of people affected. This paper analyses the involvement of family members of care home residents and care home staff through a PI Panel. OBJECTIVES:The objective for the PI activities was to consistently bring the knowledge and perspectives of family members and care home staff to influence the ongoing design and conduct of the DACHA study. METHODS:The bespoke methods of PI included a dedicated PI team and a PI Panel of public contributors. Meetings were recorded and minutes agreed, resulting actions were tracked and reflections on the PI recorded. A democratic, social relations approach was used to frame the analysis. RESULTS:A PI panel met 17 times. All meetings included both family members and care home staff. Analysis of the records and reflections developed the following themes about the operation of the PI: deepened understanding of the data environment in care homes; Influence on the pilot MDS; aiming for best research practices with care homes; personal/professional development for PI members; expectations of the project. Learning points for future research projects are developed. CONCLUSIONS:PI shaped the design and conduct of the DACHA study, grounding it in the needs and perspectives of people using and providing social care. Data research has a huge responsibility to accurately incorporate relevant public perspectives. There is an implicit assumption that records and data are objective and 'speak for themselves' however there can be unintended consequences from introduction of new data requirements in practice. PATIENT OR PUBLIC CONTRIBUTION:Public contributors to this manuscript include family members of older people living in care homes and staff of care homes. The wider study also involved as the public, older people living in care homes. Public contributors helped develop the project, contributed throughout the conduct of the study and some chose to be involved in preparing this manuscript.

Background In care home research, residents are rarely included in patient and public involvement and engagement (PPIE) despite their lived experiences of day-to-day care. This paper reports on a novel approach to PPIE, developed in response to Covid-19, and utilised in a large UK-based study focused on care homes. PPIE sessions were facilitated on behalf of the research team by Activity Providers (APs) already working within the care homes. This paper provides an account of how PPIE with care home residents can be achieved. Methods An exploratory design was used to see if it was possible to support “in-house” PPIE, with researchers working at a distance in partnership with care home staff. The National Activity Providers Association recruited five APs working in care homes. A series of optional discussion or activity sessions were developed by the research team in partnership with APs, tailored to reflect the research topics of interest and to make sessions accessible to residents with differing needs. Results APs facilitated four rounds of PPIE with up to 56 residents per topic, including individuals living with cognitive and communication impairments. Topics discussed included residents’ views on data use, measuring quality of life and the prioritisation of care-related data for study collection. Feedback from the residents was observed to have unexpected and positive changes to participating care homes’ practice. APs valued participation and working with researchers. They identified acquisition of new skills and insights into residents’ thoughts and preferences as direct benefits. Challenges included time pressures on APs and managing emotive feedback. APs were able to approach residents at times convenient to them and in ways that best suited their individual needs. PPIE with residents provided different perspectives, particularly with respect to the importance of different types of data, and constructive challenge about some of the research team’s assumptions. Conclusions PPIE with APs as research partners is a promising approach to working in an inclusive and participatory way with care home residents. The voices of older care home residents, including those living with cognitive or communicative impairments, are important for the successful and meaningful completion of research.

Background: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. Objective(s):To explore variations in the care home nursing and support workforce; how resident and relatives' 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' needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers. Design:Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 - two evidence syntheses (one realist); WP2 - cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 - analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 - secondary analysis of care home regulator reports; WP5 - social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model. Setting:English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings. Participants:Managers, residents, families and care home staff. Findings:Staffing's contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop 'familial' relationships between staff and residents, and staff-staff reciprocity, 'knowing' residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. 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. Limitations:Many of our findings stem from self-reported and routine data with known biases - 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. Conclusions: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 - rather than available - inputs and outcomes. Study registration:This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062. Funding: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 Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

Abstract Background Care homes are increasingly important settings for intervention research to enhance evidence-informed care. For such research to demonstrate effectiveness, it is essential that measures are appropriate for the population, setting and practice contexts. Objective To identify care home intervention studies and describe the resident outcome measures used. Design Scoping review. Methods We reviewed international care home research published from 2015 to August 2022. We searched MEDLINE, EMBASE, CINAHL and ASSIA. We included any intervention study conducted in a care home, reporting resident outcomes. We extracted resident outcome measures, organised these using the domains of an adapted framework and described their use. Results From 7,330 records screened, we included 396 datasets reported in 436 publications. These included 12,167 care homes and 836,842 residents, with an average of 80 residents per study. The studies evaluated 859 unique resident outcomes 2,030 times using 732 outcome measures. Outcomes were evaluated between 1 and 112 times, with 75.1% of outcomes evaluated only once. Outcome measures were used 1–120 times, with 68.4% of measures used only once. Only 14 measures were used ≥20 times. Functional status, mood & behaviour and medications were the commonest outcome domains assessed. More than half of outcomes were assessed using scales, with a fifth using existing records or administrative data. Conclusions There is significant heterogeneity in the choice and assessment of outcomes for intervention research in care homes. There is an urgent need to develop a consensus on useful and sensitive tools for care homes, working with residents, families and friends and staff.

Context: In many countries, there is a specification for information that should be collected by care homes. So-called ‘minimum data-sets’ (MDS) are often lengthy, and report on resident health and wellbeing, staff, and facilities. In the UK, the absence of any easily accessible data on the care home population was highlighted at the start of the COVID-19 pandemic. Care homes faced multiple requests for data from external agencies who had little knowledge of what care homes were already collecting. Objective: This study aimed to identify the range (and method) of data collected by care home organisations, in a country without a mandated MDS. Methods: Online survey of care homes (with/without nursing) in England. Care homes recruited via research and care home networks, social media. Questions covered data content, storage, and views on data sharing, analysed with descriptive statistics. Findings: 273 responses were received, representing over 5,000 care homes. Care homes reported extensive data on the health, care and support needs of individual residents, their preferences, and activities. Clinical measures and tools adopted from health were commonly used, but few collected information on quality-of-life. Care homes reported uses of these data that included monitoring care quality, medication use, staff training needs, budgeting, and marketing. Concerns over privacy and data protection regulations are potential barriers to data sharing. Implications: These findings challenge the notion that incentives or mandates are required to stimulate data collection in care homes. Care home organisations are collecting an extensive range of resident-level information for their own uses. Countries considering introducing social care records or an MDS could start by working with care home organisations to review existing data collection and evaluate the implications of collecting and sharing data. A critical approach to the appropriateness of health-related tools in this setting is overdue.

Background Care homes provide long term care for older people. Countries with standardised approaches to residents' assessment, care planning and review (known as minimum data sets (MDS)) use the aggregate data to guide resource allocation, monitor quality, and for research. Less is known about how an MDS affects how staff assess, provide and review residents' everyday care. The review aimed to develop a theory-driven understanding of how care home staff can effectively implement and use MDS to plan and deliver care for residents. Methods The realist review was organised according to RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines. There were three overlapping stages: 1) defining the scope of the review and theory development on the use of minimum data set 2) testing and refining candidate programme theories through iterative literature searches and stakeholders' consultations as well as discussion among the research team; and 3) data synthesis from stages 1 and 2. The following databases were used MEDLINE via OVID, Embase, CINAHL (Cumulative Index to Nursing and Allied Health Literature), ASSIA [Applied Social Sciences Citation Index and Abstracts]) and sources of grey literature. Results Fifty-one papers informed the development of three key interlinked theoretical propositions: motivation (mandates and incentives for Minimum Data Set completion); frontline staff monitoring (when Minimum Data Set completion is built into the working practices of the care home); and embedded recording systems (Minimum Data Set recording system is integral to collecting residents' data). By valuing the contributions of staff and building on existing ways of working, the uptake and use of an MDS could enable all staff to learn with and from each other about what is important for residents' care Conclusions Minimum Data Sets provides commissioners service providers and researchers with standardised information useful for commissioning planning and analysis. For it to be equally useful for care home staff it requires key activities that address the staff experiences of care, their work with others and the use of digital technology. Registration PROSPERO registration number CRD42020171323.

Care homes are central to the provision of care for older people and it is essential the leaders in this sector are supported to enhance the equality of care provided to these residents, often with multiple and complex needs and co-existing health conditions. The My Home Life Leadership Support program (MHLLS) is an innovative approach that enhances the culture of care in these settings. This study explored the findings of 298 participants who completed the program in England, Scotland, and Northern Ireland. Data were analyzed from two questionnaires which are routinely completed, by participants on the MHL LSP, the Assessment of Workplace Schedule (AWES) and the Perceptions of Workplace Change Schedule (PoWCS). The results were categorized by factors identified by the exploratory factor analysis. This study focuses only on the quantitative findings from pre- and post-questionnaires. The study also provides an updated factor analysis of the AWES and POWCS. The results provide robust evidence of the overall positive impact of the MHLLS program across the three participating countries. The key areas in which MHL participants report significant change within their care homes are recognition and regard for them and their staff, workload, quality of care, and working relationships. Overall, this study has demonstrated a significant positive change in managers' leadership skills and their perceptions of the impact of this on staff, relatives, and residents.

COVID-19 had a devastating impact on older people living in care homes. This study explored the clinical trajectory and management of COVID-19, as well as recovery of older people following infection during the early stages of the pandemic (May to August 2020). A two-phase exploratory qualitative study was used. Frontline staff with experience of caring for older people with COVID-19 were recruited to Phase 1, and senior care home operational and quality managers were recruited to Phase 2. During Phase 1 remote semi-structured interviews (n = 35) were carried out with staff working in care homes, hospital and community settings in England. During Phase 2, a remote consultation event was carried out with senior care home operational and quality managers (n = 11) to share Phase 1 findings and check resonance, relevance and gaps. Data were analysed using Framework Analysis. Older people with COVID-19 presented with wide ranging symptoms, and an unpredictable illness trajectory. The wide range of COVID-19 symptoms required timely testing and supportive interventions. Staff used different interventions to manage symptoms and reported uncertainties of how individuals would respond. In care home settings, health and social care staff needed to work together when administering interventions such as subcutaneous fluids or oxygen therapy. Alongside symptom management, supportive care focused on nutrition and hydration, social interaction, and maintaining physical activity to meet both physical and emotional needs. The effects of prolonged periods of social isolation and inactivity on the health and well-being of older people means rehabilitation is essential to enhance physical and emotional recovery, and to minimise impacts on cognition and function. The pandemic highlighted important areas for care of this population.

BACKGROUND:Care homes are complex settings to undertake intervention research. Barriers to research implementation processes can threaten studies' validity, reducing the value to residents, staff, researchers and funders. We aimed to (i) identify and categorise contextual factors that may mediate outcomes of complex intervention studies in care homes and (ii) provide recommendations to minimise the risk of expensive research implementation failures. METHODS:We conducted a systematic review using a framework synthesis approach viewed through a complex adaptive systems lens. We searched: MEDLINE, Embase, CINAHL, ASSIA databases and grey literature. We sought process evaluations of care home complex interventions published in English. Narrative data were indexed under 28 context domains. We performed an inductive thematic analysis across the context domains. RESULTS:We included 33 process evaluations conducted in high-income countries, published between 2005 and 2019. Framework synthesis identified barriers to implementation that were more common at the task and organisational level. Inductive thematic analysis identified (i) avoiding procedural drift and (ii) participatory action and learning as key priorities for research teams. Research team recommendations include advice for protocol design and care home engagement. Care home team recommendations focus on internal resources and team dynamics. Collaborative recommendations apply to care homes' individual context and the importance of maintaining positive working relationships. DISCUSSION:Researchers planning and undertaking research with care homes need a sensitive appreciation of the complex care home context. Study implementation is most effective where an intervention is co-produced, with agreed purpose and adequate resources to incorporate within existing routines and care practices.

Reforms to social care in response to the COVID-19 pandemic, in the UK and internationally, place data at the heart of proposed innovations and solutions. The principles are not well established of what constitutes core, or minimum, data to support care home residents. Often, what is included privileges data on resident health over day-to-day care priorities and quality of life. This Personal View argues for evidence-based principles on which to base the development of a UK minimum data set (MDS) for care homes. Co-produced work involving care home staff and older people working with stakeholders is required to define and agree the format, content, structure, and operationalisation of the MDS. Implementation decisions will determine the success of the MDS, affecting aspects including data quality, completeness, and usability. Care home staff who collect the data need to benefit from the MDS and see value in their contribution, and residents must derive benefit from data collection and synthesis.

Abstract Background Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood. Methods A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement. Results QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload. Conclusions These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.

The prevalence of people with dementia living in long-term care (LTC) is high and rising internationally, and the need to improve LTC for people with dementia is widely recognized. In some countries, LTC quality assurance programs use quantitative measures of LTC quality. To better understand how LTC quality assurance programs address dementia, programs were reviewed in four countries—Australia, England, Japan, and the United States. Quality measures from each program were identified (n = 38) and examined to determine how they address dementia. Most measures did not address dementia, but four risk-adjusted for dementia (antipsychotic use, fractures, falls, mobility), one was dementia-specific (dementia/delirium hospitalizations), and one excluded people with dementia (losing bowel/bladder control). Results show LTC quality measurement differs internationally, but few measures address dementia. Needed are new quality measures of direct import for people with dementia, for example through adoption of measures that are meaningful to people with dementia.

BackgroundLittle is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.ObjectivesTo develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.DesignA realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.SettingLong-term residential care facilitiesParticipantsLong-term care facility staff, residents, and relativesMethodsThe realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.Results66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents’ needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.ConclusionLeaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.

Abstract Little is known about how the workforce influences quality in long term care facilities for older people. Conceptually, quality is complex, often contested, and dynamic, has overlapping physical, social, psychological and emotional dimensions and can refer to both quality of life and quality of care. Assuming ‘more staff equates to better quality’ is intuitively appealing but research suggests that a more nuanced, non-linear, relationship exists. A programme of research in the UK is developing theoretical and empirical explanations of how staff promote quality for older people living in long-term care facilities. It shifts the debate from numbers of staff and their relationship to quality indicators toward recognising the ways in which staff more broadly influence quality. Our work will be useful for people and organisations making policy and delivering services on the best ways to deploy and support quality in long term care through the most valuable resource: its staff.

The Breakthrough Series Quality Improvement Collaborative (QIC) initiative is a well-developed and widely used approach, but most of what we know about it has come from healthcare settings. In this article, those leading QICs to improve care in care homes provide detailed accounts of six QICs and share their learning of applying the QIC approach in the care home sector. Overall, five care home-specific lessons were learnt: (i) plan for the resources needed to support collaborative teams with collecting, processing, and interpreting data; (ii) create encouraging and safe working environments to help collaborative team members feel valued; (iii) recruit collaborative teams, QIC leads, and facilitators who have established relationships with care homes; (iv) regularly check project ideas are aligned with team members' job roles, responsibilities, and priorities; and (v) work flexibly and accept that planned activities may need adapting as the project progresses. These insights are targeted at teams delivering QICs in care homes. These insights demonstrate the need to consider the care home context when applying improvement tools and techniques in this setting.

The Breakthrough Series Quality Improvement Collaborative (QIC) initiative is a welldeveloped and widely used approach, but most of what we know about it has come from healthcare settings. In this article, those leading QICs to improve care in care homes provide detailed accounts of six QICs and share their learning of applying the QIC approach in the care home sector. Overall, five care home-specific lessons were learnt: (i) plan for the resources needed to support collaborative teams with collecting, processing, and interpreting data; (ii) create encouraging and safe working environments to help collaborative team members feel valued; (iii) recruit collaborative teams, QIC leads, and facilitators who have established relationships with care homes; (iv) regularly check project ideas are aligned with team members’ job roles, responsibilities, and priorities; and (v) work Int. J. Environ. Res. Public Health 2020, 17, 7601; doi:10.3390/ijerph17207601 www.mdpi.com/journal/ijerph Int. J. Environ. Res. Public Health 2020, 17, 7601 2 of 21 flexibly and accept that planned activities may need adapting as the project progresses. These insights are targeted at teams delivering QICs in care homes. These insights demonstrate the need to consider the care home context when applying improvement tools and techniques in this setting.