Governing Healthcare Safety at the Margins: The Challenges of Good Governance in the Care Home ‘Hinterlands’

Safety is a priority concern for all health and social care systems. To date, research and policy has tended to focus on the governance of safety within primary and secondary care settings, with corresponding calls for the implementation of safety management systems more commonly found in other high-risk industries. There is growing recognition, however, that patient safety is equally, if not more, at risk in more marginal care settings where notions of ‘good governance’ seem especially problematic. In many developed nations, care homes have become a major site for patient (elderly) care, but where funders, regulatory and public scrutiny is often lacking. Care homes typically have low status within the wider care system, employing predominately low-skilled staff, and with limited regulatory oversight. Yet, they care for some of the most vulnerable people with complex care needs, and where emerging evidence suggests safety issues are significant. Drawing on qualitative research within the UK care home sector, the paper explores the challenges of good governance in care homes, mapping the regulatory environment for care homes, and exploring staff and manager perceptions of patients safety and its day-to-day management. Taking both a macro and micro perspective, the paper reflects on the limited reach for regulatory oversight of care homes, rendering care homes a type of hinterland for variable, and often poor practice.