Understanding care homes safety: culture and safety in non-mainstream care settings

Gartshore, Emily (2021) Understanding care homes safety: culture and safety in non-mainstream care settings. PhD thesis, University of Nottingham.

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The care home sector provides 24-hour residential care or nursing care to more than 450,000 vulnerable older people in the UK with complex needs and high levels of dependency. These services face many challenges in relation to funding, increasing demand, staff shortages and relying on an unregistered workforce with almost 40% possessing no qualifications. Care homes present a unique setting that provides care to individuals at significant risk of harm but has received little attention or research. Care homes provide a particularly rich context in which to study safety, as they are inherently complex organisations that have historically suffered many catastrophic failures and scandals and continue to struggle to achieve safety goals.

It was widely accepted that organisational culture was important for patient safety. Both the organisational culture and patient safety literature have been dominated by the positivist assumption that organisations are part of an external reality that can be both measured and manipulated. Many scholars now argue that positivist approaches do not reflect the complexity of contemporary organisations as they only capture the very surface of organisational cultures. The deeper levels of organisational culture and its impact upon safety have received little exploration in the patient safety literature and have not before been explored in the context of care homes.


The thesis aimed to empirically explore organisational culture and how this related to safety in care homes. The thesis focused on how residents, relatives and staff in this context made sense of their reality by investigating the basic underlying assumptions that underpin human perception and behaviour, specifically in relation to quality and safety. Through this exploration the thesis also captured how different groups contributed to and negotiated quality and safety.

Research Question

The thesis addressed the central research question:

• How do employees, residents and relatives give meaning to and value issues of safety in care homes?


The thesis aligned with the interpretive paradigm and adopted an ethnographic case study approach within the care home sector. Over 200 hours of observations and interviews with 50 participants took place across two care homes between January – December 2018. Inductive thematic analysis was used to analyse both interview and observational data.

Research Gaps and Intended Contribution

This study adds to the limited evidence base through its interpretive, ethnographic approach, accepted as a method suited to achieving a deeper level of cultural analysis. The approach taken has not previously been used to address safety in the care home sector, which presented a setting that was theoretically and empirically distinguished from mainstream care settings. Due to the under-researched nature of this care setting the study also enabled theoretical contribution to the patient safety literature. The findings from this study make a contribution to current debates around care home policy and practice, which was of particular relevance given the recent impact of the COVID-19 pandemic upon the care home sector.

The thesis makes a new contribution to the literature around patient safety by presenting a conceptual understanding of how culture relates to safety in care homes that comprises of Uncertainty, Identity and Role, Responsibility and Relationships. My study argues that within care homes there was a disconnect between the formal culture and approaches, and the informal culture within the care home. The study has highlighted that traditional patient safety orthodox approaches being used within care homes may be inappropriate due to the unpredictability and the assumptions that underpin how people give meaning to and value safety in care homes. Moreover, my study has shown that safety in care homes was achieved through attempts to get to know residents, focusing on their identity, building relationships and the importance of promoting resident autonomy and responsibility for their own safety.

Item Type: Thesis (University of Nottingham only) (PhD)
Supervisors: Timmons, Stephen
Waring, Justin
Crocker, Cheryl
Keywords: Corporate culture; Older people, Institutional care; Nursing home patients; Safety
Subjects: H Social sciences > HV Social pathology. Social and public welfare
Faculties/Schools: UK Campuses > Faculty of Social Sciences, Law and Education > Nottingham University Business School
Item ID: 66104
Depositing User: Gartshore, Emily
Date Deposited: 31 Dec 2021 04:40
Last Modified: 31 Dec 2021 04:40
URI: http://eprints.nottingham.ac.uk/id/eprint/66104

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