“Crack on”: a qualitative study of care home managers experiences and responses to system-led setbacks during the crisis of the COVID-19 Pandemic in England 

Objectives: To explore care home managers’ experiences of systems working with various organisations, including statutory, third sector and private, during the second wave of the COVID-19 pandemic from April 2020 to January 2021 Design: An exploratory qualitative interview study using a systems theory approach focussing on the intersections of relationship interdependencies with other organisations. Setting: Conducted remotely with care home managers and key advisors who had worked since the start of the pandemic in/with care homes for older people across the East Midlands, UK. Participants 8 care home managers and 2 end-of-life advisors who participated during the second wave of the pandemic from November 2020. A total of 18 care home managers participated from April 2020 to January 2021 Results: Four organisational relationship interdependencies were identified: care practices, resources governance and wise working. Managers identified changes in their care practices as a shift towards the normalisation of care, with an emphasis on navigating pandemic restrictions to fit the context. Resources such as staffing, specialist reviews, pharmaceutical and equipment supplies were challenged, leading to a sense of precarity and tension. National polices and local guidance were fragmented, complex and disconnected from the reality of managing a care home. As a response a highly pragmatic reflexive style of management was identified which encompassed the use of mastery to navigate and in some cases circumvent official systems and mandates. Managers’ experience of persistent and multiple setbacks were viewed as negative and confirmed their views that care homes as a sector ere marginalised by policy makers and statutory bodies. Conclusions: Interactions with various organisations shaped the ways in which care home managers responded to and sought to maximise residents and staff well-being. Some relationships dissolved over time, such as when local business and schools returned to normal obligations. Other newly formed relationships became more robust including those with other care home managers, families, and hospices. Significantly, most managers viewed their relationship with local authority and national statutory bodies as detrimental to effective working, leading to a sense of increased mistrust and ambiguity. Key opportunities were lost to effectively engage the care home sector by statutory organisations who were perceived as relying excessively on mandate and regulation.