Persistent Challenges to Quality Nursing in Care Homes (Royal College of Nursing)


This Royal College of Nursing (RCN) report identifies ten key challenges to the provision of high quality care in care homes. These are:

1. Funding and Admissions

Lack of funding affects the types of residents that care homes accept:

  • People are admitted with more severe and complex care needs, but with inadequate funding to meet their needs as both social care and Continuing Health Care (CHC) eligibility criteria are become stricter.
  • Inappropriate residents (i.e. those whose needs a care home may be inadequately equipped) are accepted to fill vacant places.
  • Care homes show an increasing preference for self-funding residents due to the low fees paid by local authorities and cuts to CHC budgets. Some care homes balance low fees from local authorities by taking only residents who can make top-up payments privately; with obvious implications for equality of access to care.

2. Staffing Levels

Shortage of care assistants and registered nurses is reported commonly; yet the lack of guidance on staffing levels in care homes makes it hard to quantify the extent of this problem. The care delivered may fall below nurses’ expectations, and this impairs the ability of homes to meet the needs of residents with high dependency and complex needs.

3. Appropriate Skill Mix

Lack of guidance around appropriate ratios for registered nurses and health care assistants makes it hard to quantify the extent of this problem.

4. Recruitment and Retention

There is growing concern about high turnover and difficulties in recruiting staff with the right skill mix.

“Due to the constant staff turnover further staff are employed that have no experience and most importantly no ongoing training in basics such as adequate manual handling [or] dementia awareness…”

Errors may be overlooked by management so that staff do not leave. The use of agency and bank staff could impact on safety, care quality and continuity of care.

Carers’ low pay, often at the minimum wage, £6.08 for workers aged 21 and over and £4.98 for workers aged between 18-20 may be the main cause of recruitment and retention problems regarding carers in homes.

5. Low Morale and Extreme Pressure

Inadequate funding, staffing levels and low pay take their toll (see above).

6. Lack of Training

The report mentions:

“a lack of funding to provide training, particularly to provide anything above and beyond statutory training and more advanced or specialist training (i.e. catheterisation, ECG, IV therapy or dementia care)”.

7. Lack of Equipment

8. Inspections and Bureaucracy

Some nurses allege that there may be unintended consequences arising from CQC inspections. Discharge planning may create a large amount of bureaucracy, which can be duplicative, time-consuming and takes care staff away from frontline care.

9. Care Home Culture and Concerns About General Management

Organisations and / or general management may be suspected of being driven by the profit-motive rather than providing high-quality care. Poor general management is a common frustration, with a perceived failure to engage the experience of frontline care staff. Management may not support nurses or take them seriously when they report concerns regarding care of residents.

10. Difficulties Working With Professionals From Other Sectors

There may be inadequate out of hours support for residents needing medical attention. A cultural divide may exist, resulting in care home nursing staff not being respected or valued as highly (compared with nursing staff in the NHS).

Full Text Link


Royal College of Nursing (2012). Persistent challenges to providing quality care: an RCN report on the views and experiences of frontline nursing staff in care homes in England. London: Royal College of Nursing, March 2012.

About Dementia and Elderly Care News

Dementia and Elderly Care News. Wolverhampton Medical Institute: WMI. (jh)
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