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Cesagen · Research

Organisational Culture in the NHS: A feasability study to measure the impact on older people

Win Tadd, Sinead O'Mahoney

Start date


Funded by

Department of Health and Comic Relief


The quality of care and potential for the abuse and neglect of older people in institutional settings in the NHS has come under scrutiny following several recent high profile cases. Measuring quality in care is essential to driving improvements in clinical practice and preventing abuse and neglect. Organisational culture is central to promoting and delivering good quality care.It is equally important and challenging to measure excellence in care including quality of communication, respect for patient autonomy and choices as it is to document risks and potential harms to patients. An overprotective environment can itself be harmful in promoting custodial rather than rehabilitative care. This study seeks to measure quality in care and the potential for abuse and neglect of older people in hospital using mixed methods, quantitative and qualitative, including in depth interviews with patients, relatives, staff, periods of ward observation and organisational analysis, including interrogation of clinical governance risk registers.


  1. Determine the feasibility of identifying excellent care, abuse and neglect of older people in a variety of NHS settings including acute hospital, mental health, intermediate and continuing care settings.
  2. Develop a tool of organisational fitness, for measuring quality of care by combining data from different sources, to link organisational factors to individual patient experience.
  3. Establish the feasibility of taking a whole systems approach to measuring organisational excellence and the probability of abuse/neglect of older people at the level of the institution, versus measuring abuse/neglect at the level of the individual.


The research involves:

  • Case studies of four NHS institutions in the UK, one teaching hospital, one district general hospital, one mental health trust and one community hospital.
  • All existing data sources (clinical incidents, pressure sore registers, c-difficile, complaints etc.) that could be used to identify risk factors, abuse or neglect will be identified and interrogated.
  • Guided by the clinical governance data towards areas of potential excellence in care and areas of high risk/ vulnerability, an indepth study will be undertaken of 4 wards in the teaching hospital (2 acute, 2 elderly care/ rehabilitation), 4 wards in the District general Hospital, 2 elderly care wards in the mental health trust and 2 elderly care/ rehabilitation wards in the community hospital. Clinical governance risk registers will be validated against a sample of case notes from each ward to ascertain whether it is possible to determine thresholds of risk from these datasources.
  • In depth qualitative interviews with a small number of patients, carers and staff will be undertaken on each of the wards exploring awareness of abuse and neglect of older people and willingness to report. The relationship between individual experience of quality in care and organisational factors will be explored in the interviews with patients and staff.
  • Brief periods of observation will be undertaken on each of the wards to validate the staff and patient interviews. Staff actions, style of communication, responsiveness to patients and patient engagement will be observed.
  • An index of organisational fitness will be compiled for each institution from the various clinical risk registers, the observational and qualitative data.

Further information

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