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Creating a culture to maintain quality

When there’s no money around, how do we create the foundations for a culture that can maintain quality and the business? Tom Owen and Jess Watson share My Home Life’s experience of helping providers maintain quality and financial sustainability.

The challenges facing the sector continue to grow – there’s no question that things are tough right now. In an environment where many providers are on the edge of survival, there’s a drive to understand how to stay in the game financially without compromising on quality. At My Home Life (MHL is a UK-wide initiative promoting quality of life in care homes) we’ve been gathering knowledge from hundreds of managers and operators we’ve worked with. We don’t have all the answers but these insights show how a positive culture can be a foundation for maintaining the quality of care and improving business outcomes.

The danger of cutting back

On the whole, your customers are attracted by the ‘feeling’ of a home. Residents and families emphasise the importance of staff having time with the people in their care, and being drawn to the love and companionship that the home offers. A focus on quality is the key factor in performance.

Delivering this culture of care where there are deep connections between staff and residents isn’t always easy. Worryingly, even once established these cultures are fragile. When staff are aware of cuts like reducing staffing levels, or sensing the building not being properly maintained, this can significantly affect their motivation which, in turn, quickly impacts upon the quality of engagement with their work and the care that they deliver. Your home culture can suddenly become dominated by a sense of insecurity, anxiety and low motivation that will be felt by residents, families and the outside world – losing the positive feeling that attracts newcomers.

When things are tight, the business response is to look closely at what efficiencies can be made; typically staff, training, activities and maintenance. There may be good sense in scrutinising those aspects of the business away from the frontline delivery of care, if savings can be made. However, while this might lead to short-term gains on the balance sheet, don’t underestimate the damage that this can do to your business’ ability to deliver quality and attract new customers.

We’ve had many conversations with care homes about the opportunities and challenges they face in delivering quality, and what goes into creating positive outcomes. In this article we’ll focus on two parts of these conversations: developing managers and a positive organisational culture, and how together these can create a strong foundation for quality. If time and energy investments are made at this level, this provides the building blocks from which other aspects of quality (eg staff development; internal and external processes; wider community engagement) can develop. We will explore these other areas in later articles.

Manager development

It’s widely acknowledged that the care home manager’s role is pivotal for the success of a home. At its simplest, a manager who is resilient, skilled and confident is better able to value and develop their staff, engage positively with families and the community, and lead positive change in the home. However, the work of managers is hugely complex and multifaceted – in many ways, unrealistic. It’s difficult for managers to see themselves, and be seen as, a leader, conveying values and vision that support quality as well as modelling the behaviours that that they expect from their staff.

MHL has identified that regular professional support for managers can make a significant difference to the wellbeing of the manager and, as a consequence, the wellbeing of residents, relatives and staff. A small investment in their support can help retain their confidence, sharpen their skills and allow them to work more effectively in their complex roles with more resilience and energy.

This is also seen in international research. In the USA, as care homes became more engaged in culture change and adopted more of the associated practices, a number of benefits were found including an increase in person-centered care approaches and staff empowerment initiatives, staff retention, market competitiveness, occupancy rates and operational costs. Committed leadership was thought to be the driver of culture change.

Care home managers agree; when we asked one group how their monthly Leadership Support (through the MHL Transformation Package) helped them deliver business outcomes, their responses demonstrated the wide-reaching impact of supporting leaders:

  • Managers feel calmer, more able to cope with their complex role and so have more mental capacity to see the bigger picture of developing and growing the business.
  • Through better management and leadership, staff are taking ownership and developing creative solutions which support their engagement with the home and builds the reputation.
  • Improved staff wellbeing and engagement has led to better retention.
  • Managers have created a nurturing environment and positive atmosphere, noticed by relatives and external stakeholders and improving reputation.
  • The culture change in the home had led to a calmer, more engaged environment resulting in improved outcomes for older people with dementia who become less anxious.
  • Some described stronger connections with staff and relatives meaning they were more able to respond to customer needs, and pre-empt issues that might otherwise lead to complaints.
  • Due to increased skills in delegating, managers have more time to respond quickly to new business, delivering assessments and engaging with external initiatives.
  • Managers developed their professional confidence, meaning that how they articulate themselves to the outside world is better for business.
  • Some reported better communication with line managers resulting in the wider organisation having a greater understanding of what’s really going on.

The foundation for positive culture

Leadership at both company and home level is a critical enabler of positive culture. So we look at another vital building block – the relationship between manager and proprietor.

Where MHL has witnessed significant improvements in quality, there is a strong and positive working relationship between managers and the wider company. Managers regularly share with us how they perceive a lack of trust from their proprietors. They can feel that their time is spent responding to their proprietors’ demands, whether paperwork or simply pressure to deliver more income, rather than delivering their primary aim – quality of life for people within their care.

Of course, proprietors want to do their best to ensure that care homes are compliant and are not at risk of poor practice, but this must balance with not being overly controlling and enabling managers to take forward their own approaches. There’s great strength in providers using ‘servant leadership’ where, after a shared vision is agreed, the organisation does everything it can to support, enable and nurture the manager, allowing them and frontline staff to deliver great care (knowing that great care means good business). If problems occur, managers feel confident that the proprietor will quickly respond to what the manager states that they need to help them resolve the issue. Looking into how the organisation currently behaves and communicates is, therefore, crucial to achieve this confidence between manager and owner.

Here we see the value in investing energy in manager leadership alongside organisational culture. We’ve found that as owners notice improvements in the manager’s confidence, they are reassured that quality is being delivered. In turn, we see a healthier relationship emerging with greater respect for each other’s perspectives and priorities. The relationship becomes less adversarial, controlling and threatening, and more about two individuals working together to do the best for the business and, most importantly, for the quality of life of residents, relatives and staff.

In smaller providers, we often hear about a lack of clarity between the respective roles of the manager and the owner. Sometimes, owners are emotionally attached to the home, so it feels a real wrench to step back and allow the manager to lead. It’s also easy for the owner to feel so stressed by the high risk nature of the business and worried about the potential threats of things going wrong, that they want to come in and control the home. Managers may be developing their own plans and processes and then find their proprietor can come in with a completely different plan or process, disempowering the manager and creating confusion within the staff team.

There are actions that providers can take to help support managers:

  • Provide assistance (even if it’s just approving a morning off) for manager support, such as attending local managers’ forums.
  • If you are part of a group, encourage managers to meet up by themselves for peer support.
  • The owner or line-manager and the care home manager sit down together, clarify how they want to work together, understand what the home manager needs in order to deliver their best, and what they can realistically expect from one another.
  • Between owner and manager, develop clear plans for who leads on what and try to stick to them.

These conversations about openness and honesty aren’t always easy but it’s the foundation from which great things can happen.

Supporting managers and helping with their development can pay dividends in the current market. Balancing pressures on finances with a drive to deliver quality care can be achieved by establishing a positive culture.

Tom Owen is Director and Jess Watson is Social Action Lead at My Home Life England. Email: mhl@city.ac.uk Twitter: @MyHomeLifeUK

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