Preventing cold-related harm in older people: a qualitative exploration of domiciliary care

Illness and death caused by living in a cold home is a serious issue in England, and response has focused upon practical interventions which can neglect the moderating effect of individual contextual or behavioural influences. People over 65 are vulnerable to cold and more are remaining at home, with help from domiciliary care services, as their care needs increase. Responding to a gap in the literature, this is the first study to examine how the domiciliary care system contributes to the prevention of cold-related harm in older people, and the influencing factors. The study used qualitative interviews and thematic analysis, underpinned by an interpretive constructionist epistemology, to explore the views and experiences of service commissioners (n=5), provider organisations (n=7) and direct care staff (n=10) within Yorkshire, England. A paradox was found in which the opportunity to deliver interventions by the domiciliary care system was undermined by the system itself. Response to increasing demand and fewer resources meant less time to care and a focus upon task; reducing the care staffs’ ability to run a dual agenda of care and prevention. National policy guidance to galvanise the prevention of cold-related harm within social care was not translating into commissioning practice; providing no incentive to deliver interventions or equip care staff with the knowledge and skills to do so. Regardless of these factors, some care staff reported delivering interventions that aimed to reduce the risk of harm in their clients. Importantly these were reported to go beyond the efficacy of practical interventions alone. The care staffs’ actions appeared to be driven by individual behavioural influences and therefore individual staff response to risk was variable. As such, the study concludes that the outcomes of an older person at risk of cold-related harm, and in receipt of domiciliary care services, is currently a matter of chance. Strength lies in the exploration of the domiciliary care system at both system and individual level. Thus, providing insight and understanding of the influences upon the system, and individuals within it, and ultimately the effect upon the prevention of cold-related harm. Notwithstanding sample and geographical limitations, the recommendations address what needs to happen if the opportunities presented by the domiciliary care system to prevent cold-related harm in older people are to be harnessed; including: how preventing cold-related harm can be incorporated into commissioning practice, how provider organisations can be encouraged to consider cold when delivering care and how care staff can be equipped with the knowledge, skills and motivation to do so.