Why are some care homes so bad?

In early February this year The Telegraph published a rather terrifying article entitled A day in the life of England’s bad care homes1  From my point of view, as someone who was involved in inspecting care homes for two years, what was particularly shocking was the fact that none of the things described in the article seemed that unusual.   Examples included residents having to wait ages for a shower, having to wait to be got up in the morning, sitting alone with a cold cup of tea and stale toast out of their reach because there was no staff member around to fetch it for them, waiting to be taken to the toilet, sitting around doing nothing, the strong smell of urine everywhere, and so the list goes on.

This is not to say that all care homes are like this – they are not.  However, a significant minority are, and the question is: why?  It’s easy to draw up a list of potential culprits: bad management, bad pay and conditions leading to poor quality staff and high staff turnover,  acquiescent residents and relatives who do not want to rock the boat, poor (or non-existent) quality management.  Again, the list goes on.   Oh, and one thing I forgot to mention: a bad culture.  Actually, this is probably the one element that explains all the other problems, and yet is in danger of explaining nothing.  As I argued in a previous post, the word ‘culture’, used the context of dysfunctional organisations and services is often the cue for much hand wringing and angst, but nothing ever seems to change. 2  Yes, we know the culture has to change – but how?  And, anyway, what do we mean by ‘culture’ in the first place?

As I pointed out in my previous post, there are many definitions of organisational culture.  Just to give some examples: ‘..the unique configuration of norms, values, beliefs, ways of behaving…that characterize the manner in which groups and individuals combine to get things done’; ‘A set of understandings or meanings shared by a group of people’;  ‘..a pattern of beliefs and expectations shared by the organization’s members’; ‘Organizational culture is not just another piece of the puzzle, it is the puzzle..a culture is something an organization is.’3

Edgar Schein’s definition is perhaps the most sophisticated.  He defines culture as:

A pattern of shared basic assumptions that the group [social units of all sizes] learned as it solved its problems of external adaptation and internal integration, that has worked well enough to be considered valid and, therefore, to be taught to new members as the correct way to perceive, think and feel in relation to those problems.4

Schein’s approach to culture is interesting for a number of reasons.  To start with he is looking at how new members of an organisation are socialised into the culture; in other words, how they ‘learn’ the culture.  Furthermore, his definition allows for the fact that one organisation can have more than one culture because his focus is the group rather than the organisation as a whole.  In my previous post I talked about different worlds within the organisation but we could also talk about different cultures.

Another important element of Schein’s definition is his focus on shared basic assumptions, and in my view this is perhaps the most critical aspect of all when it comes to thinking about culture.  More than anything, culture is what is taken for granted, not up for discussion, not to be questioned.  This is why it is so difficult to change an organisation’s or a service’s culture, because it reaches to the heart of what the organisation is about.  Once someone has been in an organisation for a while they just ‘know’ how to behave, what to say (and what not to say), even how to think and feel.  Those who cannot adapt, who cannot accept the way things are, soon leave.  Unfortunately this simply reinforces the status quo and makes it even harder to change things.

How might such ideas be helpful in trying to understand why some care homes are so much worse than others?  I would start by looking at some of the shared basic assumptions that are held by all  or most of the key stakeholders in the service.  By ‘stakeholder’ I would include the provider, the management, staff, residents, relatives, visiting health professionals, and even the commissioners, if there are any.  The key question when it comes to a bad or sub-standard care home is why is this being allowed to continue?  Surely someone is going to say something, a relative or a staff member is going to complain, blow the whistle?  But all too often no-one does.

And the reason for this is not necessarily fear of reprisals or victimisation (though sometimes it is), but more often because everyone has come to accept that this is the way it is, this is how things are done around here.  One of the things about residential care homes is that they can be quite insular and closed communities, with their own routines, systems, processes and procedures.  New residents, staff, and even relatives soon learn to adapt to the way things are and stop asking awkward questions.  Like all organisational cultures,  care homes are delicately balanced eco-systems, and new arrivals soon learn how to maintain that balance.  In other words, no-one wants to rock the boat because everyone has something to lose.

Copyright Leslie Chapman and Therapeia Ltd 2015
  1. http://www.telegraph.co.uk/news/health/news/11387606/A-day-in-the-life-of-Englands-bad-care-homes.html []
  2. http://www.therapeia.org.uk/wp/consultancy/2015/03/07/approaches-to-organisational-culture/ []
  3. Taken from Brown, A., 1998. Organisational Culture, Harlow: Pearson Education Ltd. []
  4. Schein, E. (1992) Organizational Culture and Leadership. San Francisco, Josssey-Bass. p.12 []