Research and analysis

Research exploring the experience of social care practitioners in relation to extreme temperatures

Published 22 January 2024

Applies to England

This research explores the experience of social care practitioners, employed by Care Quality Commission (CQC) registered providers to provide domiciliary care and care in care homes, in relation to extreme temperatures.

Executive summary

Background

The study Heatwave Mortality in Summer 2020 in England: An Observational Study showed that high ambient temperatures pose a significant risk to health. The same study revealed that during heatwaves, significant excess mortality occurs in care homes and in people’s own homes. Other vulnerable groups, such as older adults and people with chronic health conditions, are also at increased risk of morbidity and mortality during heatwaves (1).

During the summer of 2022, England experienced record high temperatures that exceeded 40°C for the first time on record. The 2022 report Heat mortality monitoring report: 2022 estimated that there were 2,985 (2,258 to 3,712) all-cause excess deaths associated with 5 heat episodes during the summer of 2022, the highest number in any given year.

This research was commissioned to help understand the attitudes and actions of social care practitioners and to understand the contexts in which they were operating during the summer of 2022. The research also explored the infrastructure social care practitioners were working within and the processes that were in place during this time to help them manage the effects of heat.

At the time the research was conducted, national guidance from the UK Health Security Agency (UKHSA) on managing the effects of extreme heat was provided through the 2022 Heatwave Plan (HWP), which has since been replaced by an Adverse Weather and Health Plan (AWHP) for England.

Methodology

UKHSA commissioned Discovery Research, an independent research agency, to conduct the study. A qualitative approach was used to explore the research objectives.

Discovery Research interviewed 29 social care practitioners and conducted 4 interviews with priority stakeholder representatives in the social care sector – a detailed sample breakdown is available. The interviews lasted for one hour and were conducted remotely using Microsoft Teams.

In recognition of the varying temperatures experienced in different parts of England during these extreme high temperatures, participants were drawn from a broad geographic sample across England that covered urban and rural settings around London, Birmingham, Leeds, Plymouth, Greater Manchester and Liverpool. Further criteria was applied to ensure a range of roles were represented in the research.

The research explored these main themes:

• broad attitudes towards extreme high temperatures and how social care practitioners experienced the summer of 2022
• specific action plans or processes they had in place for the extreme high temperatures in the summer of 2022, and the lead time they had for these plans
• their recall of the Heat-Health Alert (HHA) emails and how useful they found them
• their reaction to UKHSA’s 2022 HWP for England
• what information was used to inform social care practitioners around the extreme high temperatures, and how effectively this information was disseminated down the care system chain to frontline workers
• how the heat impacted social care practitioners themselves; their work and wellbeing, and the knock-on effects for those they were caring for
• identifying main differences between type of care provider and setting

Summary of main research findings

Awareness and perception of risk

Awareness and perceptions of risk varied considerably among participants.

For most social care practitioners interviewed, the extreme high temperatures last summer were deprioritised below other issues such as staff shortages or managing COVID-19.

Awareness of the full extent of risks that extreme high temperatures posed to those they were caring for was mixed. However, the risk of dehydration was the foremost concern for nearly all participants.

There was a stronger awareness of who was at most risk – those with cognitive decline (for example dementia), learning disabilities, neurodiversity (for example autism) and those with mental health conditions (for example depression, bipolar affective disorder) were felt to be particularly vulnerable to the health effects of extreme high temperatures.

Those unable to thermoregulate, be that due to old age or certain medical conditions, were also felt to be particularly vulnerable to extreme high temperatures.

Domiciliary care appeared to be the setting where clients were most vulnerable to extreme high temperatures. Social care practitioners were only present intermittently making it harder for them to manage heat risks in their clients’ homes and monitor their clients’ behaviours.

Many domiciliary social care practitioners found clients often adopted unhelpful behaviours, for example, keeping heating on or wearing heavy jumpers during periods of extreme high temperatures. Often this was out of habit and because they were not experiencing feeling hot.

The majority of social care practitioners interviewed reported experiencing adverse effects of extreme high temperatures on themselves as well, which impacted the quality of care they were able to provide.

Staff shortages meant social care practitioners were often on tight schedules, travelling around in hot, non-air-conditioned cars and working in environments that were not well-designed for extreme high temperatures.

Volume and format of information available

For owners and managers of care settings, and other stakeholder groups who cascade information to their members, there was an overwhelming amount of information available on what to do in extreme high temperatures and they found it hard to identify a single, trustworthy source.

The information they received was often not succinct enough, or not in a format that was easy to share with other people in their organisations, especially frontline workers.

Only a minority of frontline workers received information about what to do during extreme high temperatures and this information was typically just being forwarded on, such as UKHSA’s HWP for England and the HHA email in summer 2022.

Much of the information was not being passed through in an accessible way and frontline workers often turned to search engines to plug any gaps and access a more digestible means of knowing what to do during extreme high temperatures.

A minority of social care practitioners were aware of UKHSA’s 2022 HWP for England. Once seen, all types of social care practitioners found it useful, especially the detailed plan that care settings could implement depending on the HHA level and the advice on what behaviours to look out for and what these behaviours might be a sign of.

The HWP also did a good job of eliciting an accurate sense of risk by referencing the excess fatalities in care settings attributed to extreme high temperatures.

Despite its perceived utility, the HWP for England was too lengthy even for most managers to digest, and not in a format that could easily be passed on to frontline workers.

More social care practitioners were aware of the HHA emails and clearly valued them as they provide a credible source confirming there really would be extreme high temperatures.

The layout of the HHA emails, however, was also perceived as inaccessible and the appearance was not engaging for participants.

Planning ahead

Apart from a few exceptions, most social care practitioners interviewed took a reactive approach when responding to extreme high temperatures, for themselves and their clients, with little planning in advance. This primarily involved:

• keeping cool and hydrated
• changing the diet and frequency of meals
• ensuring clients were well protected from the sun
• ensuring there was more measuring of water intake, food intake and ambient temperatures

Often it was after 1 or 2 days of the extreme high temperatures hitting that a plan was put into place. On occasion, one of the actions was to hire additional staff if the extreme high temperatures were found to be preventing existing staff from working.

Official action plans did not feel commonplace to the frontline carers interviewed because staff tended not to know about them, even if their managers were making them; often these plans were not getting through to frontline workers.

Actions taken

Despite all this, actions were being taken, but often focused on reinforcement of practice from previous summers, just executed in a more intense, and regimented manner.

Keeping clients cool was the primary strategy. This involved:

• using fans, if air conditioning (A/C) not available
• using water sprays
• supplying ice lollies
• closing curtains, windows
• providing cool flannels and cloths
• giving clients multiple showers a day, for example, one in the morning and another one in the evening
• encouraging clients to wear light, loose-fitting clothing

Keeping clients hydrated involved:

• ensuring clients drank enough
• providing alternatives to keep clients hydrated but also providing sustenance, for example, fruit lollies

Changing clients’ diets and frequency of meals involved:

• providing lighter food, more salads, fruit lollies
• offering more frequent snacks

To make sure clients were well protected, greater emphasis was placed on:

• providing shaded, cooler areas in outside space
• not going out during the hottest parts of day
• buying extra sun cream
• providing sun hats
• turning immobile clients more regularly to prevent skin deterioration

Practitioners were measuring:

• how much each resident was drinking
• the temperature of the rooms, if available

Counter-productive behaviours also took place. A minority of social care practitioners reported that they would take clients out for the day to enjoy the hot weather, even on some of the days of extreme high temperatures.

There were a few behaviours that differed from previous summers:

• changing the residents’ activities (for example swapping outdoor walks for indoor bingo, or scheduling outdoor activities to be earlier in the day)
• ensuring fewer people in one room for activities and meal times
• preventing family from visiting, to keep the number of people in the facility down
• hiring additional staff to cope

Background to the research

The heatwaves in 2020 caused 2,556 deaths, the highest heat-related mortality since the introduction of Public Health England’s HWP for England in 2004 (now UKHSA), and the majority of reported deaths (n= 2,224) occurred in the group of those aged 65 years and over.

During summer 2022, England experienced record high temperatures that exceeded 40°C for the first time on record. UKHSA and the Met Office issued the first Level 4 HHA and the Met Office issued the first red National Severe Weather Warning Service (NSWWS). Extreme high temperatures happened between:

• 16 and 19 June when temperatures reached 32.7°C
• 10 and 25 July when temperatures reached 40.3°C
• 8 and 17 August when temperatures reached 34.9°C

This research was commissioned to help understand the attitudes and actions of social care practitioners and to understand the contexts in which they were operating at this time. The research also explored the infrastructure social care practitioners were working within and the processes that were in place during this time to help them manage the effects of heat.

Specifically, the research looked to:

• explore broad attitudes towards extreme high temperatures and how social care practitioners experienced the summer of 2022
• understand what specific action plans or processes they had in place for the extreme high temperatures in the summer of 2022, and the lead time they had for these plans if and when they were put in place
• explore recall of the HHA emails and how useful they found them
• briefly explore their reaction to UKHSA’s HWP for England
• explore what other information was used to inform social care practitioners around extreme high temperatures, and how effectively this information was disseminated down the care system chain to frontline workers
• focus on the social care practitioners’ perspective; how the heat impacted their work and wellbeing and the knock-on effects for those they were caring for
• identify main differences between type of care provider and setting

Sample of research participants

A qualitative approach was used to explore the research objectives. The sample spread was aimed at reflecting a wide range of professionals, rather than being statistically representative of the sector.

The full sample breakdown for each criteria was as follows.

Level of responsibility of the social care practitioner

There were:

• 9 managers or owners
• 20 frontline staff, 5 of whom were agency staff (frontline staff comprises those working in client facing roles, and includes both domiciliary carers and carers in care homes)

Size of setting

This research included:

• 22 residential care homes
  • 1 small, with 10 or fewer beds
  • 13 medium, with 11 to 50 beds
  • 8 large, with 50 to 100 beds
• 7 carers providing domiciliary care

How the setting was funded

The sample included:

• 14 working for a private company
• 10 working for publicly funded or NHS
• 5 other, including charities

Type of clients the setting cared for

There were:

• 10 CQC registered for working with people with learning disability or disabilities
• 28 CQC registered for working with older adults, many of whom with dementia, but also Parkinson’s disease and end of life care

Stakeholders representatives

Stakeholder interviews took place with:

• a CEO of the Care Workers Charity
• a Chair of The National Care Forum
• a CEO of Crossroad Care – a Network partner of Carers Trust
• one group interview with Executive Officer of Cornwall partners in Care and 3 care partners

Recruitment of research participants

Participants were primarily selected by a network of recruiters across the country. The recruiters use databases of potential participants that they have built up over time and these databases are refreshed regularly. Databases are built up initially through a variety of means, including cold-calling and referrals from people who have previously participated. On this occasion, this recruitment approach was supplemented by UKHSA who were able to promote the research via contacts in the adult social care sector, passing on the contact details of those who were interested in participating to Discovery Research.

Potential participants were initially identified and were sent an email invite asking if they would like to take part. Following a positive response to this email, the recruiter would then contact the person to take them through a recruitment screener to ensure they fitted one of the profiles highlighted in the detailed sample breakdown. At the end of the screener, they were asked to give consent to their participation in the research.

Fieldwork

Participants initially completed an email pre-task before taking part in the interview. This pre-task contained a brief, open-ended survey asking them about their experience of the extreme high temperatures in 2022.

These questions took the form of open-ended questions and asked the following:

1. How were the people you were caring for during the extreme high temperatures? How were they feeling physically and mentally?

2. Were you more concerned for the health of the people you were caring for at this time than you would normally be? In what way?

3. What, if anything, did you do to help the people you were caring for?

4. Did you, or the organisation you work for do anything to prepare in the run-up to the extreme high temperatures?

5. Was there any particular action plan your organisation put in place, or process that you followed in response to the extreme high temperatures? If so, what did this consist of?

6. If you did not feel more concern for the people you were caring for, why was this?

In-depth interviews lasting one hour were conducted remotely using Microsoft Teams. Interviews were conducted using a topic guide to structure the discussion across some main themes. Participants were encouraged to give open-ended responses to the questions in the guide.

Analysis of interviews

A combination of inductive and deductive coding was applied to the interviews using the framework approach (2). Codes and themes identified through this process were tested through regular team discussions throughout the fieldwork period. Coding was initially applied by a single researcher and these codes were then confirmed and supplemented by the other researchers on the project.

Caveats and limitations

This research was carried out 7 months after the end of the summer of 2022, so despite completing a pre-task before the interview to help trigger their memories, participants were reflecting back over quite a long period. Consequently, some recollections, especially of how difficult the days of extreme high temperatures may have been, were not always easy for participants to verbalise.

The research also took place while the COVID-19 pandemic was still a very serious concern for social care settings, and for some social care practitioners this meant that the effects of the extreme high temperatures were overshadowed by what was perceived to be a much more significant risk.

In addition, fieldwork for this report occurred during a period in which the HWP 2022 was operational, at a time when the AWHP was in development. The alerting system and underpinning guidance now in place under the AWHP differ in important ways from provisions under the HWP, so findings reported here do not necessarily apply to the AWHP. Implications arising from this report will nevertheless be considered for future updates of the AWHP.

When considering these findings, it is important to bear in mind what a qualitative approach provides. It explores the range of attitudes and opinions of participants in detail. Unlike quantitative research, it provides an insight into the contexts and the drivers underlying participants’ views. Findings are descriptive and illustrative, and not statistically representative.

Main findings

Attitudes towards extreme high temperatures and how social care practitioners experienced the summer of 2022

For many, the extreme high temperatures in the summer of 2022 was deprioritised below other issues.

From a cultural perspective, many interviewees simply did not associate England with having extreme high temperatures, and certainly not to the extent where this could pose a risk to health. While most felt the country is not well adapted to dealing with hot weather, they did not believe this will become a continuous trend and did not spontaneously identify warmer summers as a consequence of climate change. Social care practitioners reported that this had deterred them from proactively preparing for summers and meant that many were not investing in future measures that could ameliorate the impacts of extreme high temperatures on those they were caring for.

Importantly, there were other matters perceived by interviewees to be more pressing in the summer of 2022. Staff shortages, the continuing impacts of COVID-19, supply shortages, price inflation and the broader and ongoing restructure of the care sector all led to preparations for extreme high temperatures being pushed down the list of priorities. These factors contributed to perceptions of the risk of heat being minimised – as they were overshadowed by other concerns. Participants also noted that the impacts of the extreme heat were felt by the population more generally, and some didn’t spontaneously mention the specific risks related to their clients.

Carers from residential care homes said:

The care home is no different to a shop or an office; everyone is struggling in the heat.

We were a bit more vigilant, but at no point did we think the patients were more at risk.

I didn’t think that clients were particularly at risk; I thought we were well covered, at least we had enough fans.

Recall of last summer’s extreme high temperatures greatly varied, from noticeably different, to similar to previous years.

Attitudes were framed by their recall of their working environment, their travel to work, their home lives, their belief in what’s being reported on the news and their own sense of comfort and wellbeing.

Those who felt that the 2022 heatwave was noticeably different reported it being ‘unbearably hot’, having a challenging working environment, having a commute that was uncomfortable in the heat, experiencing unprecedented temperatures and experiencing personal, peer, and client discomfort. They were also most likely to mention the media fanfare that they felt elevated the sense of fear. Often, these views were expressed by those working in environments that were not well adapted to extreme high temperatures, for example, in buildings that were old and poorly insulated and certainly buildings that did not have A/C.

Carers from residential care homes said:

We had to work in horrendous heat; it was relentless and frustrating. It was hard to work and even harder to settle the clients.

I felt stressed, tired, worried and sick – mostly because of the residents but also all the extra work I had to do to make sure they were safe.

Residents were distressed, ringing the buzzer all night. It was so hot but we couldn’t open windows for security reasons. It was challenging, relentless.

Those who felt the summer of 2022 was not much different to other summers reported it being ‘hot, but no big deal’, and compared it to recent years, such as the summer of 2019. In contrast, they talked quite positively about the summer and valued the good weather for themselves and the people they are caring for. Their view was that despite it being very hot at times, these periods were short lived, so felt manageable. Often, these people were working in environments that were better set up to deal with hot weather either because the building had better insulation or it had A/C. Quite often, the private residences with better funding tended to have these favourable environments.

Social care practitioners themselves were often negatively impacted by the heat, which affected the quality of care they were able to give, particularly those providing domiciliary care.

For many, the hot weather in the summer of 2022 resulted in an increased workload, either because their clients required greater attention and monitoring than normal or because of staff shortages – school closures or train disruption caused by the heat was often the reason staff couldn’t make it to work. This had knock-on effects, with staff not able to take breaks and becoming physically exhausted. Some social care practitioners reported feeling fatigued or sick, especially those delivering domiciliary care and those working in residences that had poor insulation and no air-conditioning. Some of the stakeholder groups interviewed also shared anecdotes about social care practitioners passing out in their cars.

It was also an emotionally challenging time for social care practitioners. Clients were feeling distressed, frustrated and agitated and this resulted in social care practitioners feeling overwhelmed themselves. Consequently, some staff simply stopped coming in to work and others took time off after the extreme high temperatures to recover. Furthermore, many staff also experienced disruptions at home or to travel that affected their ability to work, exacerbating a staff shortage issue in the sector.

A manager from a residential care home said:

We were probably most impacted by nurseries closing and heat affecting rail lines. We’ve got air conditioning in all our facilities, so the travel issues were more important for us.

A knock-on effect of staff shortages was that more agency staff had to be brought in, leading to a perception that standards of care were affected. The quality of handovers was mixed, meaning that agency staff often did not know the background of the clients or understand their usual behaviours, so were less able to spot the dangerous effects that extreme high temperatures might be having on them. The agency staff were also less aware of any specific plans in place to manage the extreme high temperatures. An example of a good handover typically involved information being passed on about the condition of the client and how they were reacting to the extreme high temperature.

Primarily, social care practitioners working in domiciliary settings were most negatively impacted by the extreme high temperatures, mostly because the homes they were operating in were less likely to have any mitigations against the heat, such as A/C. In addition, working across multiple locations meant they needed to constantly adapt to different environments and situations. But this was not limited to just those delivering domiciliary care, some working in residential homes with poor ventilation and no A/C also experienced significant personal discomfort.

Implications

There is a need to make social care practitioners more aware of the risks that extreme high temperatures can have on health, to ensure social care practitioners prioritise it more and put proactive plans in place.

There is a need to frame extreme high temperatures in the context of ongoing climate change – that is to say, the climate of the UK is changing, and extreme weather events are likely to become increasingly frequent, to avoid them feeling like one-off events.

The physical and mental health of frontline social care practitioners during extreme high temperatures needs to be addressed: they are the ones delivering the care and when they suffer, the care they provide also suffers.

There is a subsequent knock-on effect of staff either not coming into work during these times, or taking time off afterwards, exacerbating the workforce retention problem in the sector. More support might be needed in this area to mitigate this.

Detailed look at social care practitioners’ awareness of the risks that extreme high temperatures pose

Awareness of specific risks and symptoms varied considerably.

Most social care practitioners were aware that extreme high temperatures could theoretically pose a risk to their clients, but they were not fully aware of how at risk they may be or of the most serious implications of these risks.

Keeping clients hydrated was identified as a top priority for nearly all social care practitioners. They knew that dehydration was more likely in the heat and that they therefore needed to keep clients’ fluids up. They were typically more aware of any changes in behaviour around being dehydrated, like being particularly lethargic or having very dry lips, and were alert to clients struggling more than usual.

However, practitioners were often unaware of specific risk factors and signs. In regard to dehydration specifically, although they were aware they had to look out for signs of confusion, disorientation, excess sweating, differences in speech and lethargy, this was not always laddering up to what this might be a sign of, that is to say, dehydration. A compounding issue here was that some clients, such as those with dementia or cognitive decline, experience these kinds of symptoms as part of their condition regardless of whether they are dehydrated. Therefore, practitioners needed to be conscious of what behaviour was typical for a specific client, in order to know if anything had changed. This was particularly an issue where settings had to bring in agency staff, as these staff did not know the clients or have experience of how their symptoms would usually manifest.

On the other hand, there was some awareness of specific heat-related illnesses, for example, heatstroke and heat rashes. Preventative measures were taken, for example, keeping clients out of the sun, using sun cream, making sure they wore hats and ensuring appropriate clothing was worn. Nevertheless, awareness of specific symptoms to look out for was not consistent across the sample.

Awareness of the implications of risks was fairly low.

Unless the social care practitioner had experienced a fatality firsthand, there was little knowledge that the consequences could be this severe. When they learned about the dangers of extreme high temperatures, many were shocked and reconsidered the level of attention they would pay to extreme high temperatures in the future. There was low awareness of the potential of fatalities due to extreme high temperatures in managers and owners as well as frontline workers.

A carer from a residential care home said:

I know heat can cause confusion, restlessness and dizziness but I can’t remember where I heard that.

There was a stronger awareness of who was at most risk across all social care practitioners – those with a learning disability or disabilities, neurodiversity (for example autism), cognitive decline (for example dementia) as well as people with mental health conditions (for example depression, bipolar) and those with poor thermoregulation.

Social care practitioners identified clients with Alzheimer’s disease and other types of dementia as groups with increased heat-related risk. In particular, they found it difficult to ensure the suggested behaviours were being followed, especially ensuring that clients were keeping themselves hydrated. Those with other cognitive disabilities, or with neurodiversity (for example autism), were also mentioned by social care practitioners as a group for whom it was hard to ensure suggested behaviours were being followed.

Moreover, there was strong concern for the very elderly, aged over 90 years, who had poor thermoregulation and were displaying behaviours that made the situation worse, for example, keeping heating on or wearing heavy jumpers.

There was also a clear focus on clients with certain medical conditions, especially those with heart and respiratory issues. Those on certain medications were a further focus for social care practitioners as being more vulnerable to extreme high temperatures. For example, there was a clear understanding that taking certain steroids could cause the skin to burn easily in the sun and have a diuretic effect, which in turn could increase the danger of dehydration.

Carers from residential care homes said:

There is a bigger risk for those with learning difficulties as they don’t always understand why they can’t do what they’re doing and they can’t always communicate how they’re feeling.

Some residents I work with have dementia and can’t always say if they are too hot or dehydrated, I’ve got to keep an eye on people and it’s often a process of elimination to work out what was wrong. There’s a clear mental strain on the people I care for and they get more angry as well.

A domiciliary carer said:

I look after 2 people and they can’t always regulate their temperature – one is always hot and one is always cold. Another man I was caring for was struggling with his breathing because of the heat and humidity.

Implications

Exposure to UKHSA’s 2022 HWP for England and the initial information about fatalities, shocked social care practitioners and helped them to understand the risks. It is important to get information on risk to them, and they are very open to receiving it.

While awareness of risk groups is generally good, there is a clear opportunity and need to educate social care practitioners on signs of specific illnesses.

Exploring information sources that social care practitioners used during the extreme high temperatures in the summer of 2022

The advice and guidance available from UKHSA was useful, but social care practitioners were not always aware of it, especially frontline workers.

Managers were most aware of UKHSA’s HWP for England and its supporting documents and found it immensely useful, using it extensively to educate and inform their processes. One manager of a residential home had used the different HHA levels, and the information contained under each level, as the basis to create their own action plan, supplementing what was already in the plan with some points particular to their own setting. Other managers, even if not using it as a basis to create their own action plans, found it a very useful checklist of what they could do.

Significantly, the HWP for England highlighted the potential severity of extreme high temperatures by talking about fatalities in the initial paragraph. As mentioned previously, this was something that concerned owners, managers and frontline workers alike. They felt it was important to highlight this fact even more in further communications. Practitioners identified another opportunity to make them more aware of the risk by talking about how extreme high temperatures will be happening more regularly. Knowing these situations are likely to happen more regularly might persuade some social care practitioners to plan ahead more.

However, awareness of and access to the guidance was low across most other types of social care practitioners and some were shocked to learn of its existence as they felt it is something everyone should be exposed to.

Important information around mental health and specific conditions needs highlighting more clearly in UKHSA’s HWP for England.

The impact that extreme high temperatures can have on mental health is something all social care practitioners reported, but it did not feature prominently in the HWP for England at the time (the AWHP, however, directly addresses the effects of high temperatures on a range of mental health outcomes). Social care practitioners wanted to understand how to boost the morale of their clients when they are often trapped inside for days, but they also wanted advice to improve their own mental health during what can be a difficult time for them personally.

They were also looking for more granular guidance for some specific conditions, for example, people experiencing Alzheimer’s, respiratory conditions, and those with hearing impairments.

Furthermore, they needed more information around what the risk factors were and what to look out for in their clients during extreme high temperatures, and what they might be a sign of.

Finally, they would like some tailored advice depending on the type of care setting, so different advice for residential care and for domiciliary care.

A carer from a residential care home said:

Dementia and Alzheimer’s clients are by far the trickiest. I’d like advice on how best to care for them.

A manager from a residential care home said:

I want to understand ‘the chain’. So if something happens in terms of the weather, what is the knock-on effect of this and then how this affects different types of patients and in what ways.

The Heat-Health Alert email raises awareness that there is an issue, but it is not clearly actionable.

The HHA email successfully put the extreme high temperatures on social care practitioners’ radars and was seen as a credible source confirming that extreme high temperatures were definitely going to happen. It also had a high level of awareness, most managers having received it and a few frontline social care practitioners having it forwarded to them from management.

However, while successful at alerting people, it was less successful at telling people what to do, and this is what they were most interested in. Social care practitioners were looking for some clear and succinct instructions contained in the body of the email, not in a link, of what actions were required to keep their clients safe.

It was also not clear what the alert level meant. In particular, without seeing the full scale it was hard to know if, for example, an amber level was a high risk or a medium risk. Participants also reported about the ‘real feel’ of the temperature and thought that this could be explained in more detail.

Nearly all participants also found the layout hard to digest. It contained a lot of text with little bulleting or visuals to break it up. Time-poor social care practitioners said they were unlikely to engage in the detail based on the current design.

Carers from residential care homes said:

It’s useful but there’s too much information and it’s quite unspecific. All the important stuff is hidden and in reality, I don’t think I’d read it, let alone know what to do with it.

It’s good they’re alerting us but it’s a lot of info and they don’t actually tell us what to do. I want to know how to look out for dehydration or overheating, that’s the most important thing. This is more like a weather update.

A sector stakeholder said:

Without having a full scale, I don’t know what those levels mean. I’m not an expert on temperatures.

Rebranding of the Heat-Health Alerts to UKHSA has some risks, but also brings an opportunity.

There was mixed knowledge of UKHSA at best, especially compared to the Met Office, so some social care practitioners thought they may pay less attention to an email coming from UKHSA, at least initially.

That said, some participants also reported that having the Met Office as the dominant brand was not always beneficial. Managers and owners in particular receive frequent alerts from The Met Office and this can reduce their credibility, especially if the weather they were being alerted about does not come about.

Managers were overwhelmed by information and frontline staff didn’t have enough.

There were multiple sources where managers were getting information from; the news, charities, local authorities. These sources are often supplemented by accessing search engines to find out how best to prepare. Most often these were generic searches around how to keep people cool in hot weather, but social care practitioners were also trying to get much more specific information.

Information that they were looking for included:

• how to manage people with particular conditions in hot weather
• how different care settings can manage hot weather
• how client’s mental health at these times can best be addressed
• specific behaviours to look out for that might be the sign of clients suffering from the heat

One manager also used a search engine to find policies other social care settings had put together for hot weather. And the NHS was often the website that came up in these searches and the site they were most likely to consult.

All these sources meant a lot of information for them to process, especially difficult when it came in formats that were not easy to digest, such as lengthy documents like UKHSA’s HWP for England. However, they didn’t have time to read all this information or put it into a format that would be easily digestible for their teams.

A manager from a residential care home said:

I get information from the news, head office, the Met Office, Age UK… I often feel bombarded but feel I need to read as much as I can as I want to be well prepared.

Ideally, they wanted a single, trustworthy source of information, to save them time and effort, but no one had come across this, and most sources of information they turned to were perceived to have some drawbacks:

• the news was good for general awareness, but many thought it over-sensationalised the weather situation
• word of mouth and social media was good for receiving information quickly and passing it on, but again social care practitioners felt this could be dramatised for social currency
• the Met Office was a more trusted source and participants broadly took some notice of the HHA, but false alarms were frequent
• communication from local authorities was again seen as trustworthy and credible, but was often hard to digest
• and information from social care stakeholder groups was often information being passed on from other sources, so was seldom easy to digest

The most common issue with these resources was that they were hard to pass on to frontline workers, or at least hard to pass on in a way that will make frontline workers likely to read them.

This meant that frontline workers often had relatively low awareness of the guidance that is available, although this was typically less pronounced in residential care homes where they tended to be more aware of guidance coming from management. This often meant that frontline social care practitioners were simply applying common sense to the situation and hoping that was good enough.

Implications

The UKHSA’s HWP for England was a useful and vital tool, but awareness of it was low. There is an opportunity to promote national hot weather guidance materials to all staff, in all settings, not just managers.

While guidance and advice was strong in the UKHSA’s HWP for England, it could be difficult to digest. There is potential to visualise or ‘chunk’ information into easy formats for time-poor professionals, adopting mnemonics, bullet points, and infographics wherever possible.

There are clear knowledge gaps that future guidance could focus more on:

• more succinct information on the basics of how to keep clients cool
• how to manage people with particular conditions in hot weather
• how different care settings can manage hot weather
• how client’s mental health at these times can best be addressed
• advice around specific behaviours to look out for that might be the sign of clients suffering from the heat
• directing them towards policies that other social care settings had put together in response to the hot weather may also help

Alert levels are useful, but there is a need to explain the different levels more, what they mean, and crucially, the subsequent action that needs to take place.

The HHA email could also be more instructional. As well as alerting social care practitioners of the extreme high temperatures, there is the opportunity to provide instructions and advice in the body of the email, as well as clearer navigation to UKHSA’s AWHP for England and supporting guidance materials.

Ideally, practitioners would prefer the highlights in the main body of the email as attachments may easily be missed.

What social care settings did during the extreme high temperatures in the summer of 2022 and what, if anything, they did to prepare

Social care practitioners, including managers and owners, typically took a reactive approach to the extreme high temperatures.

Only a few took a really proactive approach. Typically they were private social care settings. The most forward-thinking were planning for potential extreme high temperatures months prior to the summer, but no earlier than the beginning of spring. Plans included checking and updating policies and their facility, getting feedback on the plans from residents and their families and doing stock takes, especially on fans that are known to be in high demand once hot weather hits. Typically, this was more likely to happen in private residential homes, which were better funded and had more demands from next of kin to be prepared for such events.

Domiciliary carers said:

Our manager upped our visits across the day and brought on extra staff. It meant we could keep a closer eye on the clients.

We had a team meeting where our manager told us the steps to be taken: they got some additional agency staff onboard so that they could keep a closer eye on people, by providing more visits. Generally we gave people more fluids – we were aiming for 2L per day. This is monitored anyway but it was more intense over the heatwave. We provided fans for people to have in their homes and checked that people were suitably dressed in light clothing and remained indoors when possible.

Managers from residential care homes said:

Our action plan is linked directly to the different Heat Health Alert levels – as each level is reached, our action plan kicks in accordingly. This plan was then refined to make it relevant for our business.

It would actually be great if UKHSA could provide a blank template using the HWP plan for England as the base for people to add or amend.

Managers reported that they were typically putting plans into place 1 to 2 weeks prior to the extreme high temperatures hitting, typically this was triggered by mass media reporting. This more reactive approach involved the purchase of additional stock, for example, fans, ice lollies, sun cream, drinks and so on. This was typically when they started having staff meetings or brainstorms on how to deal with the heat and when communications and plans started to get sent out.

But the majority were doing very little until the extreme high temperatures actually started. Typically they were just doing their best to keep residents calm, cool, and hydrated. Often it was after 1 or 2 days of the extreme high temperatures hitting that a plan was put into place. On occasion, one of the actions was to hire additional staff if the extreme high temperatures were found to be preventing existing staff from working.

Managers from residential care homes said:

A week before we started changing residents’ activities so they were inside more, then we introduced 2 sittings for dinner to keep number in rooms down.

It’s just really hard to know what to do until you’re actually experiencing it.

A carer from a residential care home said:

We were on the back foot this time around and had to catch up. We hadn’t made plans for other years and imagined we’d just do it when we got an alert.

Often the plans they wanted to put in place were limited by the facility set up, financial limitations or by barriers the patients themselves put up.

For residential care homes, the lack of A/C and the funds to install it was often the biggest frustration that social care practitioners reported. Staff shortages during the times of extreme high temperatures also made implementing strategies more difficult and this was exacerbated by the fact that patients needed greater care and attention meaning that staff were occupied for longer periods with each patient. Some residential homes were also restricted in terms of keeping doors or windows open as they were concerned about patients absconding.

It was clearly harder to implement plans in the domiciliary environment. Often patients themselves would push back on suggestions to help them manage the heat better such as wanting to keep heating on, wanting to wear thick jumpers. domiciliary social care practitioners also had much less time with each patient before they had to move on to their next visit, making it harder to enforce any plans.

A carer from a residential care home said:

We had a cool room, but if we moved someone there, everyone would want to follow, undermining its impact. It became difficult to use it.

Frontline workers were often unaware of any official organisational heatwave plans, and simply followed their own knowledge and instincts.

Among frontline workers, there was very little awareness of official heatwave plans from the organisations they were working for. Many felt they had very little support from management and often had to take matters into their own hands, for example buying ice lollies for their clients or bringing in their own fans. This situation was exacerbated for agency workers who often got brought in last minute with little time to inform them of any plans that were in place.

It appears that the domiciliary care environment is where official plans or processes were least likely to be implemented. The lines of communication between managers and these workers were much more complicated and any plans that were in place were harder to implement in the domiciliary environment due to the variability of the homes. There was the odd exception where managers organised transport for replacement staff to get them to the various homes, but this was the exception rather than the rule.

Often the strategies put in place reflected those from previous summers but they were just implemented more regularly and more consistently.

Keeping clients cool was the primary strategy, this involved:

• using fans, if A/C is unavailable
• using water sprays
• supplying ice lollies
• closing curtains, windows
• providing cool flannels and cloths
• giving clients multiple showers a day rather than one in the morning and one in the evening

Keeping clients hydrated:

• ensuring clients are drinking enough
• providing alternatives to keep clients hydrated but also providing sustenance, for example, fruit lollies

Changing the diet and frequency of meals:

• providing lighter food, more salads, fruit lollies
• offering more frequents snacks

Ensuring clients were well protected:

• providing shaded, cooler areas in outside space
• not going out in hottest parts of day
• buying extra sun cream
• providing sun hats
• preventing clients from going out in hottest part of the day

Measuring:

• recording how much each resident is drinking
• keeping a tab on temperature of the rooms – if available

A focus on more immobile clients:

• turning immobile clients more regularly to prevent skin deterioration

Counteractive behaviours could also take place. For example, some social care practitioners reported about how they would take clients out for the day to enjoy the hot weather, even on some of the days of extreme high temperatures.

There were, however, some different behaviours compared to other summers, including:

• changing the residents’ activities
• ensuring fewer people in one room for activities and dinner
• preventing family from visiting, to keep the number of people in the facility down
• hiring additional staff to cope
• providing transport for domiciliary social care practitioners

Implications

Social care practitioners tend to take a reactive, rather than a proactive approach to planning. Education is required on climate change, the reality that extreme weather will become more commonplace in England, and the subsequent impact on vulnerable groups.

Workplace barriers can impact effectiveness of action. Social care practitioners need greater help understanding how to maximise the effectiveness of the information they have got and help to address barriers to implementing recommended actions – often they ask for grants, for example to install A/C.

Official ‘plans’ within the organisation are often not being circulated and communicated effectively enough, even if managers are making them. Frontline staff need to be made aware of the ‘bigger picture’ and their role within it. Every facility needs to be made aware of the importance of planning.

Action is happening, but the reason behind the problem, namely the extreme high temperatures, is not always understood, especially by the frontline workers. Educating on the ‘why’ may empower social care practitioners to take the right action.

Exploring the dissemination of the information to managers and then on to frontline workers

The chain of information was vulnerable to being broken between managers and frontline staff.

While managers received a good amount of information around how to make plans and what to do in extreme high temperatures during the summer of 2022, they sometimes found it hard to know what to pass on and seldom had time to process often lengthy documents to frontline staff.

While frontline staff may have received some instructions, these were often not in a digestible format. Additionally, they were often not informed of the bigger picture: ‘why’ they needed to do these things.

That said, there was clearly an attempt to disseminate this information, with some strategies working better than others.

Staff meetings were used extensively and elevated the issue for the wider teams, but these normally relied on the attendees remembering the information they had been given and much was forgotten. There was little evidence of handouts being given to remind frontline workers of the main points from the meeting.

Notice boards were used quite a lot where there was a communal area, and often contained more easily digestible posters or infographics, but these were easily missed and easily forgotten.

Email was used quite extensively and provided the opportunity for frontline workers to reread and digest, but many frontline social care practitioners are not desk-based so found most information provided in this format hard to digest if reading through their phone’s email applications.

Leaflets and booklets were much more portable and easily digested but there was little evidence of these being used. When they were available they weren’t always picked up.

The most effective means of communication that was reported was when a meeting was held emphasising main messages around how to manage extreme high temperatures and these same main messages were summarised and reiterated in various formats, for example, posters and portable cards.

It is clear that frontline workers need information that is accessible, shareable and succinct, and ideally in a format that is easy to read on a mobile phone.

Mobile phones are the lifeline for frontline social care practitioners, especially for domiciliary social care practitioners who are always out and about, and it is where they were most likely to access information on extreme high temperatures and how they share that information. WhatsApp groups are most commonly used for sharing information.

A sector stakeholder said:

In-home carers get all their information on their phone. If they can’t read it on their phone, they’re not going to read it. This isn’t very accessible for them.

Implications

There are multiple strategies for dissemination, all with positives and drawbacks, therefore a multifaceted yet succinct approach would give social care practitioners the best chance of reading and digesting available information.

Reiteration is vital; information from meetings should be summarised and reiterated in various formats, for example, posters, portable cards and more.

Content should not only focus on what to do, but also why they are doing what they are being asked to do.

Mobile phones are important for frontline social care practitioners. It is essential to make sure the GOV.UK format renders well to mobile and to provide information that is easily shareable to phones.

Laminated cards or small leaflets would allow a summary of main points and are easily digestible for very busy workers. They can also fit in pockets for easy reference.

Frontline social care practitioners are looking for clear bulleted advice on the signs to look out for and what to do in those situations. Specific guidance around how to avoid dehydration and how to manage the most vulnerable clients, for example, those with Alzheimer’s, would also be appreciated.

Main differences between type of care provider and setting

Job role and working environment had a big impact on how social care practitioners managed extreme high temperatures.

Frontline social care practitioners working domiciliary care felt least able to manage the situation. They had much less control over the environments they were working in and often found it hard to cool their clients and themselves down. Frontline workers also had limited time with the clients, which impacted their ability to safely monitor their wellbeing. This led to them becoming anxious about how they were getting on when they were not there. Frequently, frontline workers found that they needed to react to urgent situations when entering a domiciliary environment. For example, clients may have had their heating on or be dressed inappropriately. As previously mentioned in the report, these issues were exacerbated by the fact clients in their own homes were resistant to being told what to do.

A domiciliary carer said:

Some clients were wearing thick jumpers with the heating on. I had to figure out how to change their thermostat.

Furthermore, it was often hard to get information around how to manage the heat to frontline workers in a digestible way.

In some cases, management recognised the added challenges of the domiciliary environment and provided additional support to social care practitioners. This included providing additional agency staff to enable opportunities for more frequent visits.  

While many domiciliary carers utilise their own vehicles for travelling between homes, some reported that their usual mode of transport was public transport. This led to a further challenge as public transport links were sometimes impacted by the hot weather. One carer reported that their management had assisted with providing transport in this situation.

Agency workers were another group who found the extreme high temperatures particularly challenging, especially in the domiciliary environment. They were often brought in when teams were stretched, meaning there was little time to bring them to provide adequate handovers. Quite frequently, they were also the group with the biggest knowledge gaps around how to manage extreme high temperatures. If stationed in a residential home, agency staff were at less of a disadvantage as they were in a relatively controlled environment but they still often had to adjust quickly to these new environments, clients, co-workers, and protocols.

Frontline social care practitioners working permanently in residential homes had better tools available to them to manage the extreme high temperatures for their clients and themselves and were more able to regularly monitor their clients, be that fluid intake, temperatures (if needed), or changes in behaviour. It was also easier for them to monitor and make adjustments to the temperature of the rooms, opening or closing windows and doors, blinds and curtains, providing fans if needed and turning A/C off and on as required. They also had regular access to fluids and foods and could provide water or juice when necessary. Monitoring food intake was also easier for those working in residential homes. Furthermore, they were immediately on hand to help if clients had any issues and had the support of the residential home and superiors.

That said, they were also very busy and found it hard to find time to digest information about what to do in extreme high temperatures. The facilities also vary greatly between residential homes, for example, some had A/C and some did not, and this greatly impacted the level of care they were able to give.

They also had challenges with clients who had additional needs, be that clients with co-morbidities, those with Alzheimer’s, autism, or those with learning disabilities.

A carer from a residential care home said:

Some clients with autism are non-verbal, so it’s hard for them to communicate how they’re feeling and they might get very agitated and angry, which can be difficult to manage.

Managers and owners were certainly more on top of the situation, and were the most knowledgeable about what to do in extreme high temperatures. However, this also varied a lot depending on the manager’s or owners’ personal attitude towards the heat, and in particular their awareness and perception of risks posed. Moreover, their ability to deal effectively with the temperatures depended on how well their facility was set up for extreme high temperatures.

In the sample for this piece of research, we also noted some differences between privately funded care homes and care homes where clients were funded by the local authority or by a charity. Private residential care homes typically had more affluent clients and were better funded, meaning they were often better equipped to deal with extreme high temperatures, many having A/C installed. As a result, next of kin had higher expectations of how they might deal with extreme high temperatures. There were examples of managers liaising with clients or their next of kin, to ensure that they were adequately prepared.  

Care homes that were funded by the local authority or charity funded homes had more budget restraints compared to other settings, which made it harder to manage extreme high temperatures. In particular, most did not have A/C installed and the construction of the buildings in general was not conducive to managing extreme high temperatures, for example, old Victorian houses. They also seemed to be suffering from more staff shortages, all of which meant for a complex care challenge. On the plus side, obvious budget restraints and the clear strain on staff meant that families and loved ones often showed greater understanding.

A carer from a residential care home said:

I love my job but it’s hard going and we’re often understaffed. It could do with a revamp but there’s no budget there.

Implications

Agency social care practitioners and domiciliary social care practitioners need the greatest help. Information on how to manage the domiciliary environment needs to be more effectively cascaded to them and managers and owners need to be made more aware of the challenges they face.

Local authorities, NHS and charity homes are also in most need to help and support. They might have lower expectations given next of kin understand budget constraints, but they often have greater needs and budget constraints. Staff shortages and complex care challenges are often their reality.

Not all care facilities are created equal. Lack of A/C has a big impact on their ability to cope during extreme high temperatures. Access to grants to install A/C will clearly help, but also some facilities are clearly in greater need of simply being exposed to UKHSA’s HWP for England.

Conclusions

Previous literature including Heatwave Mortality in Summer 2020 in England: An Observational Study, provided quantitative evidence of the significant risk to health associated with high ambient temperatures. The same study also identified the increased levels of excess mortality in care homes and in people’s own homes, among vulnerable groups, such as older adults and people with chronic health conditions (1). In contrast, this qualitative study provides context through an exploration of the attitudes and actions of social care practitioners. The research also provides an understanding of the infrastructure social care practitioners were working with and the processes that were in place during this time to help them manage the effects of heat.

Across the qualitative sample included in this study, there is clear evidence of a general lack of understanding about the risks to health of extreme high temperatures both for the people they are caring for, as well as to occupational health for themselves. While some actions were being taken to mitigate the impact of the hot weather during periods of extreme heat, concern was more likely to be linked to comfort rather than risk to life or health. Furthermore, concern was typically not raised until the temperatures were already reaching peaks, and so these actions tended to be reactive rather than preparatory.

Domiciliary social care practitioners demonstrated the greatest challenges, both in terms of their ability to ensure that those they are caring for were safe and adequately protected against the heat, and in terms of looking after their own health and wellbeing. This was due to their limited control over the environment they are working in – they have limited time with clients and are unable to monitor whether clients are implementing the suggested actions. Added to this, they are often having to rush around between clients in non-air-conditioned cars, leaving them vulnerable to the effects of the heat, and affecting the quality of care they can give.

Social care practitioners identified the following priorities for future communications:

• more succinct information on the basics of how to keep clients cool
• clarity around specific behaviours to look out for that might be a sign a client is suffering
• how to better look after the mental health of their clients during these times
• specific guidance for certain conditions, that is to say, what signs to look out for and what to do if there are problems
• specific guidance depending on the type of care setting they might be working in

Practitioners also highlighted the importance of the format of communications, to ensure it is effectively cascaded to the people who need it the most: the frontline workers. Having multiple formats was felt to be the best approach to bring the greatest chance of success and provide the opportunity for the same messages to be seen on multiple occasions, therefore embedding them more deeply into the minds of social care practitioners. Recommendations included physical formats that can easily be handed out and shared with clients, as well as digital formats that could be accessed at any time. A top priority for digital formats was to ensure that these render well to mobile phones as workers typically relied heavily on their mobile devices.

This research was carried out at a time when UKHSA’s HWP for England was in place. While the HWP contained much of the information social care practitioners need, participants made clear that it needed to be in formats that were easier to digest. These concerns have been addressed to some extent through changes introduced under the newly introduced AWHP, in particular the development of action cards underpinning the plan with tailored recommendations for different settings including social care. These are now supported by summary checklists that can be printed out for use in community settings.

Although the HHA email was effective at eliciting an accurate sense of risk for social care practitioners, it could be even more effective after some reformatting of content and clearer explanation of what the different levels mean. Participants highlighted the need for more practical information on the danger signs to look out for and what actions can be taken within the body of the HHA email.

Managers could also benefit from advice on how to cascade information more effectively. For example, providing a meeting plan outline for when they brief their staff, and a subsequent plan of how to ensure this information is embedded.

The findings of the research also point towards a number of implications for future practice, and policy – particularly in terms of communication.

It is recommended that raising the awareness of risk would be instrumental in ensuring that social care practitioners are planning more in advance and that important actions are being successfully cascaded to frontline workers.

Based on the findings of the research, the main priorities to raise the awareness of risk include:

• communicating more explicitly about the number of excess deaths that extreme high temperatures cause in social care settings (for instance, this may be included in the body of the HHA emails)
• explaining more clearly that these extreme high temperatures will become more frequent due to climate change

Until perceptions of risk become more established, and due to the pressures in the social care sector around staffing and funding, social care settings may be unlikely to move away from acting in a reactive way to the extreme high temperatures. So, while the provision of pre-incident information that could be referred to when the incident occurs would be useful, and guidance on longer-term planning is also really important, they are most likely to engage with communication around what actions they can take just before the extreme high temperatures start or while it is happening.

Furthermore, this study suggests that occupational wellbeing of frontline social care practitioners needs to be considered more when providing advice and guidance. Ultimately, they are providing the care, and if they are suffering, both mentally and physically, then the care they are giving to the most vulnerable will not be optimal. Guidance for managers and owners on how to ensure their staff are not suffering in extreme high temperatures will be important.

Contact

This study was commissioned by UKHSA and was conducted by independent research agency Discovery Research. If you have any questions, you can contact the Behavioural Science and Insights Unit (BSIU) at bsiu@ukhsa.gov.uk

References

1. Arsad, F. S., Hod, R., Ahmad, N., and Baharom, M. (2022). Heatwave Impact on Mortality and Morbidity and Associated Vulnerable Factors: A Systematic Review Protocol. International Journal of Public Health Research, 12(1).

2. Gale, N. K., Heath, G., Cameron, E., Rashid, S., and Redwood, S. (2013). Using the framework method for the analysis of qualitative data in multi-disciplinary health research. BMC medical research methodology, 13(1), 1-8.