Srna Mandic, Masa Filipovic Hrast: Evaluation in care homes and empowerment oof residents: A case study from Slovenia
Evaluation in care homes and empowerment of residents: A case study from Slovenia
Srna Mandi~
University of Ljubljana, srna.mandic@fdv.uni-lj.si
Masa Filipovi~ Hrast
University of Ljubljana, masa.filipovic@fdv.uni-lj.si
Abstract
This paper discusses evaluation in care homes, with a focus on participative evaluation, which specifically aims to empower people through participation, the development of valid local knowledge and further changes in the organisational culture in care homes. After an overview of various methods generally used to assess the quality of services in care homes, we use the model of participative evaluation as a yardstick against which to examine the quality of the evaluation practices among Slovenian care homes. Firstly, a survey among managers revealed various types of evaluation used and the fact that nearly all homes use it. Secondly, in DSO Fužine (chosen as a case study), a qualitative study was performed by placing the "evaluation practice" into the local frame of awareness and by means of a focus group of residents, aiming to identify residents' perceptions of the power of their voice regarding the daily life in home, regarding various power instances and the role of evaluation practice. The overall perception of residents was they have a fair control over life in the home, a form of "direct democracy"; while these findings cannot be generalised to all homes, they certainly represent a surprising extra quality in comparison to the present "outside world" of the currently troubled Slovenian society.
KEYWORDS: care homes, empowerment, evaluation, participation, direct democracy
Introduction
Participative evaluation in a care home1 (i.e. the topic of this paper) is a decidedly particular issue, possibly seeming relevant for only a handful of deep specialists. However, if observed as an intersection of broader fields, the topic may engage many wider issues
1 In the article. we will use the term "care home". Other possible terms also include residential home and home for older people. It should be noted that the term care home does not imply intensive care or nursing home, but is used in its wider meaning and describes general institutional care for the elderly.
ANTHROPOLOGICAL NOTEBOOKS 20 (1): 69-85. ISSN 1408-032X
© Slovene Anthropological Society 2014
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and questions. It is about a public policy and the control that users of its services may have by utilising various mechanisms; it is about the quality of life of older people and what they themselves, the staff in homes, and wider policy can do about it. Furthermore, above all, it is about being active subjects, taking part in construction of their lives, as opposed to being powerless objects of care as in pre-modern asylums for the aged.
There is a growing body of literature on old age care as well as public policies, social service programmes and their evaluation: both frameworks are relevant for our analysis. In recent discussions of these issues, an increasing variety of approaches and disciplines is used, offering new ways of observation and understanding. In addition to the "traditional" social policy disciplines, such as social work, public policy analysis or sociology, anthropology has also entered this domain and policy and has come to be recognised as a new field of anthropology (Shore & Wright 1997). There is a wide range of anthropological studies in specific policy fields, including medicine (see Whyte et al. 2003) or old age care (see Henderson & Vesperi 1995). Anthropologists' empirical and ethnographic methods can widen the understanding of policy processes by uncovering the constellations of actors, activities, and influences that shape policy decisions, their implementation, and their results (Wedel et al. 2005; Batterbury & Fernando 2006). As anthropology 'has always had the keen sense of the dependence of what is seen upon where it is seen from and what it is seen with' (Geertz 2000: 4), anthropological analysis has been applied to a number of policy issues. One of them is the language used in policy; discourse analysis helps to understand this language and deconstruct it by examining how it is used for the labelling of groups, for the framing of issues. etc. (Sutton 1999). For this article, the more relevant anthropological knowledge is based on field work (Gupta and Fergruson 1997) and in dealing with culture (cultures). Particularly relevant is the background of interpretive anthropology, attempting to explain social phenomena by placing them in local frames of awareness and focusing on the local knowledge'(Geertz 2000). This knowledge has been further developed in notions of organisational culture (Seel 2000), and evaluation culture (Toulemonde 2000), relevant for our analysis.
In this paper, we deal with the evaluation of care homes and particularly focus on participative evaluation. In contrast to traditional evaluation, which serves to assess quality of a project or a programme, participatory evaluation also specifically aims to empower people. In particular, people are empowered through participation, construction of their own knowledge, which is then used to change power relations and promote social action and change (Brunner & Guzman 1998). In participative evaluation, the local context of the programme and of its stakeholders is used as the starting point for 'the development of valid local knowledge, based on shared understanding and the joint construction of meaning' (Cousins & Whitmore 2007: 92). In this article, we take the model of participative evaluation and use it as a standard against which to examine the quality of the evaluation practices among Slovenian care homes; for that purpose, we place the "evaluation practice" in the local frame of awareness (i.e. among residents in a selected home: Dom starejših občanov Fužine), and wish to establish to what extent evaluation used is perceived as serving to empower them. However, we also aim to consider the wider cultural and historic context in Slovenia, where popular perceptions of care homes
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Srna Mandic, Masa Filipovic Hrast: Evaluation in care homes and empowerment oof residents: A case study from Slovenia
are changing from a pre-modern to a more modern ones, from being perceived as only serving people's last days by giving them minimum facilities (i.e. hiralnica), to the one where support is tailored to the needs of residents, who have more active control over their quality of life. In addition, we also wish to observe the policy and organisational levels of care for older people and aim to provide an overview of evaluation practices used across Slovenian care homes.
The structure of the paper is as follows. First, we start with an overview of approaches to assessment of quality in care homes. We show the diversity of methods used, reaching from studies to standardised procedures of evaluation and national quality management frameworks. The increasing significance of evaluation practices in old age care is highlighted and documented. Next, we present the paradigm of participatory evaluation and summarise its conceptual background and its potential for empowerment. Then, we turn to Slovenia; after an overview of the various practices of quality management and evaluation in care homes, we present original survey data of homes, systematically presenting the coverage of various types of evaluation used. Following is the qualitative data, gathered via a focus group of residents in a selected home, focusing on their perceptions of evaluation practices in the home and their outcomes in terms of empowerment of residents. The selected home is not meant to represent an "average case", but a top quality home; the research question is to see how high quality is reached for the top quality homes in terms of empowerment of residents.
Assessing the quality in care homes: an overview of practices and approaches
There has been a growing concern about the quality of care homes in recent decades, and the issue has been raised in numerous ways, involving different disciplines, techniques and actors. Starting with early case studies, using both quantitative and qualitative data, assessment has been continuously growing and developing; one significant branch is the complex and standardised procedures of evaluation and quality management of services, the other branch being integrated quality frameworks at national and even international levels. These basic approaches, to a considerable extent coexisting and interacting, are briefly presented in this section.
Variety of single studies
Various aspects of care homes, their services and resident satisfaction have frequently been examined by researchers in recent decades. Such research continues to provide a valuable source of information; however, there is an enormous variation in its focus and in both quantitative and qualitative approaches. This variety is present from earliest studies; some of the most indicative cases can be summarised as follows.
In the early phase of the quality assessment, the quality of services was measured through direct observation methods. An example of this is a study by Townsend (1962), who performed observation of 173 care homes with his research team in a national research project on institutions of long-term care. He has graded these homes according
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to their quality and found higher quality in smaller non-profit care homes. Along with visits and observations of institutions, they have also carried out interviews with social workers and other staff members, which was a somewhat exceptional approach for that time. Numerous other American studies, summarised by Linn et al. (1977), have also measured quality of care homes "from the outside", with the use of evaluations of external evaluators (such as social workers) and objective indicators, linked to staff and nursing process (such as the number of physician hours, nursing coverage and licensed nursing hours) or other physical characteristics of the homes (e.g. size).
The majority of the studies used a cross-sectional approach, i.e. observing care homes in a selected point in time. A classic study of Linn et al. (1977), however, adopted a longitudinal approach. Furthermore, they studied patient outcome as a measure of quality of care. In this study, 1000 men were observed after their transfer from a general hospital to 40 nursing homes, immediately after transfer and in the period of six months. The goal of the study was to observe whether characteristics of the care home (predominantly structural variables) have any influence on differential outcome of patients (defined as: improved, remained the same, deteriorated or dead) and location of the patient (discharged from home, still in home, readmitted to hospital, dead). With the multivariate analysis of covariance and controlling for age, health diagnosis and expected outcome, the nursing home variables associated with being alive were more professional hours per patients and higher factors scores related to meal services. They found, similarly to other studies in the field at the time, that structural variables rarely correlated with other means of evaluating the quality of care (Lin et al. 1977: 342).
In later development, various studies were increasingly used for assessing the quality of homes, their services and the changes introduced; particularly significant were the evaluation studies and evaluation procedures that became paramount in social services.
Evaluation methods and quality frameworks
The interest for quality assessment, including its measurement, has been growing in recent decades; there is also a growing motivation for assessment among homes, driven by the changing modes of governance in the social sector (competitive tendering, etc.) as well as by changing expectations of residents and their families with regard to quality of care. In addition to single or national studies, two specific branches of quality assessment have gained recognition: specific evaluation procedures and general quality frameworks.
Evaluation has come to be recognised as an indispensable element of public policies and programmes of social services (Parsons 1995; Guba & Lincoln 1987; Hogwood & Gunn 1984; Martin in Kettner 1996); its function is to provide feed-back information about the quality reached. The information is thereafter used by various stakeholders for making decisions on how to further run the program and the services. Various types of evaluation have been developed, diverging with regard to the position of the evaluator and other stakeholders, as well as the methods used. Regarding the role of programme users, two distinctive approaches exist: the traditional evaluation and the participative one; this is specifically discussed in a later section.
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In his overview of evaluation practices across the EU, Toulemonde (2000) argues that evaluation was nationally developed under diverse external and internal influences and in different times and at different paces; however, he finds marked differences 'in the way that evaluation fits into the administrative culture of each country. While in some parts of Europe it is still a bureaucratic exercise, in others it is already part of democratic functioning' (Toulmonde 2000: 351). In particular, evaluation is found to have diverse meanings, ranging from "administrative exercise", "management tool" or "democratic duty", reflecting various states of maturity and professionalism.
In care homes for older people, a variety of evaluation practices exists, including standardised procedures. Moos et al. (1996) presented a holistic approach to evaluating residential facilities: the Multiphasic Environmental Assessment Procedure. They describe assessment procedures such as identifying resident and staff characteristics, critiquing the physical and architectural features of a facility, determining residents' and staff members' appraisals of the social climate, and evaluating the judgments of external observers. Another recent initiative on measurement of quality in care homes is the project entitled Quality Management by Result-oriented Indicators - Towards Benchmarking in Residential Care for Older People, aimed at collecting and validating result-oriented quality indicators on the organisational level of care homes, based on an exchange of experiences in selected Member States. Apart from the quality of (nursing) care, particular focus was given to the "quality of life" domain. Economic performance, leadership issues and the social context complemented the domains used to define, measure and assess the quality of results in care homes. In all the fields, different perspectives of stakeholders are considered, such as staff, management, funder, general public, family of resident. In the two of the listed fields, i.e. quality of care and quality of life, the perspectives of residents are included. (Hoffman et al. 2010).
For the Slovenian context, particularly relevant is yet another approach, the E-Qalin quality management system, which was a result of a European Commission-funded Leonardo da Vinci project (2004-2007) with partners from Austria, Germany, Italy, Luxembourg and Slovenia. It paid particular attention to the assessment of relevant stakeholders' involvement in planning, implementing, monitoring and improving processes and structures (Hoffman et al. 2010). The E-Qualin2 system is used as a system to evaluate quality in: residential care for older people, community care and services for people with disabilities (thus far only in German), as well as social work (thus far only in Slovene). The model developed for residential care asks for the WHAT, WHO and HOW in the care home and guides its users from the general quality management issues towards their daily practice in care settings. It is used to analyse structures and processes according to the classic PDCA-cycle (plan, do, check, act). Furthermore, it emphasises the involvement of all stakeholders, but in particular that of residents.
Besides evaluation, the wider quality frameworks of services for older people are also becoming increasingly relevant. Along with the growing concern for old age care in the majority of EU countries, some quality standards and frameworks for the
2 Their web-site is accessible at: http://www.e-qalin.net/index.php?id=2&L=1
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long-term care services are defined at national level, or at subnational levels. As Polacek et al. (2011) found in their overview of social services of general interest in case of long-term care (LTC), in the majority of EU countries there is a strong focus on skills and competence of the LTC workforce, and in many there is also a focus on accessibility of services. In many countries, users also seemed to have a role in the implementation of a quality framework and quality approaches; however, in some, this role was less distinct (e.g. Poland, Austria and Denmark).
Developing quality standards in long-term care has also gained increasing attention at the level of European Union, with increasing desire for EU standards in assuring the quality of social services:
The main focus of quality initiatives is often placed on the quality of structures and processes. This is due in the first instance to the professionaliza-tion of long-term care, with a particularly strong focus on the qualification requirements of staff in the past and with an emphasis on raising the quality of care processes. The second point is that the change to a user-oriented, user participation perspective required for stronger outcome orientation is taking time to evolve in Europe, particularly where quality of life aspects are involved (Hoffman et al. 2010: 18).
Participative evaluation, organisational culture and empowerment
The features that define participatory evaluation, in contrast to the traditional evaluation, are summarised by Cousins and Lorna (1995) as follows. Traditional evaluation is characterised by the dominant role of hired, external evaluators, while in participative evaluation a "bottom-up" approach is used, guided partially or fully by the program participants, staff and members of the board and community. In the traditional approach, the engaged stakeholders range from programme sponsors and managers to program beneficiaries and interest groups. In contrast, in participatory evaluation, the focus is on primary users. In the traditional approach, stakeholders' participation is consultative, and they are consulted only at two points of the evaluation process: early with regard the focus of the evaluation, and later, in interpretation of data. However, in participative evaluation, participants are active during all research phases, they are involved in developing instruments, collecting data, analysing them, as well as in reporting and dissemination of results. Participative evaluation has some advantages and disadvantages in comparison to the traditional evaluation, summarised by Zukoski and Luluquisen (2002): it is less expensive than hiring an external evaluator, but requires more time; it gives participants more control and may strengthen their relationships, but there is a need for serious coordination and evaluation training for participants, who have to be motivated and committed.
The distinctive feature of participative evaluation with its on-going activities is in its impact on organisation. According to Cousins and Lorna (1995), participative evaluation may serve as an organisational learning system through which shared
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understanding of organisational operations is developed; by facilitating the program participants to learn about the program and improve it through evaluation, the capacity of the organisation to learn is enhanced. Thus, the evaluation process can lead to an organisational change beyond the specific aims of evaluation and even lead to a change in the organisational culture. This is built on a dynamic notion of culture in the sense that it is being constantly produced and reproduced by its members; as stated by Douglas, it is about '... the admonitions, excuses, and moral judgements by which the people mutually coerce one another into conformity' (1985: xxiii). Building on such a dynamic understanding of culture, Seel (2000: 2) defines organisation culture as 'the emergent result of the continuing negotiations about values, meanings and proprieties between the members of that organisation and with its environment.' Moreover, organisational culture is operationalised as:
... the result of all the daily conversations and negotiations between the members of an organisation. They are continually agreeing (sometimes explicitly, usually tacitly) about the 'proper' way to do things and how to make meanings about the events of the world around them. If you want to change a culture you have to change all these conversations - or at least the majority of them (Seel 2000: 2).
This is the point of Seel's anthropological criticism of the traditional, top-down management of organisational change, which considers only large-scale change, such as organisational structure, and disregards the significance of conversation. Also relevant for this discussion is Seel's distinction between two types of organisational culture: the blaming culture and the forgiveness culture. Each type provides a specific filter through which meanings and values common to that culture are ascribed to critical comments about the program. Thus, in organisations with a blaming culture, critical comments are commonly understood as accusations and threats; in contrast, in the context of a forgiveness culture, such comments are understood as observations and encouragement for improvement.
These features of organisational culture, summarised according to Seel, are specifically significant also for discussion of participative evaluation. Firstly, the importance of conversations is recognised; the process of participative evaluation (in its own turn) encourages them by facilitating the programme users to meet and discuss relevant issues. Secondly, participative evaluation itself is driven by the aim of seeking improvements, this being the frame for observations and information gathered and discussed. From this perspective, participatory evaluation can be seen as the introduction of an improvement-oriented framework of meaning; it is encouraging conversations towards seeking improvement, thus counteracting the "blaming culture".
However, considering more general aims and functions of participative evaluation, two principal streams are distinguished: the practical participative evaluation, serving the pragmatic aims of improving organisational decision-making and problem solving; and the transformative participative evaluation, primarily serving the empowerment of those members who are less powerful (Cousins & Whitmore 2007). The transformative stream
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of participative evaluation can thus be seen as a 'developmental process, where through involvement of less powerful stakeholders in investigation, reflection, negotiation, decision-making, and knowledge creations, individual participants and power dynamics in the sociocultural milieu are changed' (Cousins & Whitmore 2007: 91). As defined by Brunner and Guzman (1989), it is an 'educational process through which social groups produce action-oriented knowledge about their reality, clarify and articulate their norms and values, and reach consensus about further action' (Brunner & Guzman 1989: 11). Therefore, the transformative participative evaluation helps create conditions in which participants can empower themselves.
Evaluation practice in Slovenian care homes
Building on afore presented concepts, we wish to observe the practices of evaluation used in Slovenian care homes. Besides the general overview of the extent, to which evaluation of any kind is being used, we also wish to identify the types of evaluation used; for this survey and qualitative methods are used. In addition, a particular care home was chosen as a case study where qualitative data is gathered to observe evaluation procedure more in depth, seeking to understand how in that particular local context evaluation practice functions in comparison to the ideal type of participatory evaluation; thus, in line with the principles of the case study design (see Yin 2009), the phenomenon of participatory evaluation is observed within a real-life context of the chosen home; specifically, the case study is exploratory and not intended for statistical generalisation.
However, first a brief overview of the policy context of residential care and its quality is presented.
Care homes, their quality and old age care policy in Slovenia - a general overview
Institutional care for elderly is well developed in Slovenia, especially when compared to other forms of care for the elderly (such as day care centres or help at home (Mali 2010; Hlebec 2012; Mandic 2012). The development has been to a large degree quantitative (increasing number of homes), as well as in part qualitative development. The Strategy of Care for the Elderly till 2010 - Solidarity, living together and quality ageing of the population (2006),1 and The national report on strategies for social protection and social inclusion (2008-2010) set objectives in terms of access to care for the elderly. The main concern was increasing accessibility of care, in terms of coverage. According to the report of SSZ (Association of residential care homes Slovenia), there were 96 residential care homes in the Association2 in 2011. At that, 60 were public and 36 were private with concessions. In total they provided 17009 places for elderly (SSZ 2011). These capacities suffice for the 5% coverage of the elderly population (65 years or more), which was one of the goals set in these documents.
General provisions for quality of care homes in Slovenia are described in Rules on norms and standards of social services (Ur.l. RS, st. 45/2010, also Ur.l. RS, st. 28/2011, 104/2011). Here the basic standards for institutional living are defined, along
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with normative for human resources and organisation of homes (into smaller organisational units, such as living groups, housing groups or household groups). Additionally, there is some reference to the issues of quality of institutional care in Strategy of Care for the Elderly till 2010, where modern social concepts of the smaller groups of residents are promoted, and human relations within the institutions are stressed (MDDSZ 2006: 23).
Slovenia has also been a part of several European projects and is increasingly aware of the need for improving the quality of care in care homes. An example is a WeDo project (Project: For well-being and dignity of elderly). Another example is the already described E-Qualin project. Furthermore, the individual homes also carry out different quality evaluations. Also relevant, though not as common, is ISO standard of quality (ISO 9001:2008 which sets out the requirements of a quality management system (ISO 2013). However, there has been no systematic overview of the coverage of homes by evaluation practices and their types, neither about their outcomes in terms of resident empowerment, the issue of our study.
Methods of quality assessment and their scope - survey data
To obtain a systematic overview of quality assessment in care homes in Slovenia, we carried out a short internet survey among 133 directors of care homes3 in Slovenia as part of the project 'Community Care of the Elderly' (TP, 2011-2014); we received answers from 84 of them. A little more than half of the homes were public (59%), while others were private with subsidies or work permits. We have them several questions on quality evaluations in their homes, the results of which we will present here.
The clear finding was that quality assessment is widely used by care homes; evaluation is practiced as a rule, and cases without quality assessment are an exception. Specifically, only two cases, one public and one private, revealed having no such practice. The rest used various approaches.
E-Qualin is practiced by one in four care homes, more frequently among public homes than among private care homes; the most frequent reasons given for not using it were that this model was time-consuming and also requires too many human resources. The ISO 90001 certificate has been obtained by approximately one in twelve care homes, also more frequently among public care homes. However, the large majority (approximately eight in ten homes) stated that they use other methods of quality assessments. Most claimed to mainly be using their own questionnaires (measuring satisfaction among residents) on a yearly basis. Some care homes prepare the questionnaires themselves, some use outsourcing (private companies that do evaluations); some focus on broader issues of satisfaction and quality, some focus only on separate issues (food, care, free time, etc.); surveys are done with residents, staff and/or residents' family members.
3 We have included care homes as well as their separate units. When comparing the sample to the homes that are included in Skupnost socialnih zavodov Slovenije SSZS (data from 2011), we can see that the sample is similar to the composition of care homes included in SSZS in terms of size of homes and in terms of shares of public and private homes.
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Among other forms of evaluations, we can also find: book of criticisms and compliments, statistical reporting of health status of residents (number of falls, transfers to hospitals, use of antibiotics, etc.), use of student workers, regular meetings with residents, control and meeting with staff, gathering of individual comments, constant communication with residents, etc. The estimation of their quality of evaluation is mainly that it is at an acceptable level or better (61% of respondents); however, a significant share is critical of these evaluations.
What about the participation of residents? The majority of respondents (75%) said that they have a council in their care homes, which includes residents as representatives; almost half of the respondents (46%) have residents organised in smaller groups. The large majority of respondents were of the opinion that residents have enough influence on quality of services (89%).
Table 1: Overview of quality evaluation in care homes in Slovenia, n and %
	Public care	Private care	Total
	home	home	
	n=48	n=35	n=83
E-Qualin model practiced (certified			
or in the process of certification)	18 (39%)	3 (9%)	21 (27%)
Adopted ISO standard	5 (11%)	1 (3%)	6 (8%)
Other adopted methods of quality			
evaluation	32 (73%)	29 (91%)	61 (80%)
Does not have any method of			
quality evaluation	1 (2%)	1 (3%)	2 (2%)
Quality evaluation is estimated to			
be on an acceptable level	26 (58%)	22 (67%)	48 (61%)
Residents are represented in the			
Council of the home	44 (98%)	12 (39%)	56 (74%)
Residents are organised in smaller			
groups	20 (44%)	16 (50%)	36 (47%)
Source: Community care of elderly 2012 survey, own calculations
The Fužine care home: a qualitative study
For a more in-depth study, a care home in Ljubljana was chosen, due to the fact that it is one of the homes that have undertaken E-Qualin model, and is a public care home (a more common type in Slovenia). It is also one of the most popular homes and thus is generally believed to be among the top quality care comes in Slovenia. As an exploratory case study, it is not intended for statistical generalisations, but, according to Yin (2009) for qualitative exploration of the how and why of a phenomenon (i.e. of good quality of care and of participatory evaluation). The aim of the qualitative study was to identify how
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residents perceive their position in the home regarding decisions about daily life in home and the level of empowerment achieved. For this purpose, a focus group was carried out, investigating more detailed questions, of which we present only four: first, the general perception of residents' influence in the home; second, indications about the prevailing organisational culture in the home; third, the impact of the evaluation practices in the home; and fourth, the present and past perceptions of attitudes toward care home.
The focus group was conducted in March 2013 in Dom starejših občanov Fužine There were seven people in the focus group; the manager in DSO Fužine was asked to choose from among more active part of residents; there were two men and five women, their ages ranging between 65 and 91 years, the majority being 80 and above; however, one member of the group was only 48 years old but with a severe physical handicap. The education level ranged from secondary to higher education; four residents had been residing in the care home for at least seven years, one resident for three-and-a -half years and two residents for two months.
A. Do the residents have any say in what is going on in the care home? Have you achieved any changes?
The question was open and intended for residents to bring up the most relevant areas and instances. Besides food, the areas most frequently mentioned were daily activities and trips where the residents' initiative was highlighted:
Mostly we make changes about the meals. If there are things we dislike this can change if there are more such people (J). We ourselves propose where to go for trips, such as to go to Dob for cherries; we have been to the Stična monastery, and the Volčji potok arboretum; and mountain hut on Gradišče... We go to gather grapes, make wine and sell it. We make dolls. (K).
Nothing is impossible in our home. We have regular meetings in household units, and there is resident council with seven members, and they work closely with the staff in planning the activities, in dealing with problems, new initiatives, suggestions. If we want something new, a change, it is not impossible, and we really work with the staff. In principle, the resident council would meet once a month, but at the moment we have slowed down a bit. but we talk about everything and make the list what we plan for the next month... we have so many activities and events, so I wonder whether any tourist club is better. Actually, we make proposals in household units for various activities. Well, a special quality of our home is that the centre for older people in the Fužine community is located here, so we get together. Sometimes it is difficult, it gets crowded ... There is no such thing that we could not do. If a resident asks for something, it is forwarded and it is heard ... (I).
Instances or making changes and proposals by residents were mentioned on four levels: the basic household unit, the Council of Residents, The Home Council, and wider public engagement.
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We can say everything in household units... the council of residents is something different. We elect it. (M).
We have elections like in the parliament ... on the council of residents we deal with most critical stuff that is forwarded from household units, where minutes are also kept. everyone says his or her opinion, proposals and comments, no names. Like here today. We have the best form of direct democracy in the home. Everyone can have a say.. The council of residents sometimes support the management by sending letters to the ministry and so ... Once a year we have a joint meeting with the Council of the local community Moste. (I).
B.	How is the staff receptive for your suggestions and critical remarks? Are they generally open to criticism or perhaps resent it?
The basic perception, shared by the whole group, was that the staff is receptive and also open for critical comments:
They are perceptive. If we want something, a couple of us gather together, something like three of us, and we can get it (K). On an occasion, I asked whether a person was offended and she said no and was to me even nicer than before (M).
Furthermore, the critical comments were perceived as accepted; no case of bad feelings because of suggestions and critical comments were mentioned in the group. No evidence for any domination of "the blaming culture" in the home was found. Instead, human quality of staff was highlighted.
We have wonderful staff here. they work miracles. they work under difficult conditions and are really something. there are no conflicts here. All those who leave us after completing their internship say that they got the best training here. The staff has this positive principle (I).
C.	E-Qualin is used for evaluation of this care home. Can you recognise that activity and find any use in it?
The discussion revealed that evaluation practice is recognised by residents and that they take part in it; however, compared to other mechanisms, it was not seen as having any extra significance.
Yes, some independent students come; we answer these surveys, so the quality of services is scored. I think our score is relatively very high compared to other homes. Also, when these polls are in preparation we can participate (I). There is a special meeting for that. we discuss it. And we get all sorts of surveys, all the time, from student papers to doctoral theses (M).
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D. What were the images of the care homes in the past? What were your attitudes toward care homes?
The respondent recognised that the image of the care homes in the past was decidedly negative. The participants of the focus groups remembered the old care homes as hiralnice4 orpoorhouses (ubožnice), which as they said were intended for elderly, mainly those living alone:
You know, I saw the hiralnico in Domžale. That was very hard life. Then, when my father went there... (K)... They called care homes poorhouses (ubožnice). I know where such a house was. But in the past there were not so many people as today (G). They called it hiralnica. They said, the person that goes to Bokalce, is written off (L).
However, respondents felt that these images were in the distant past and that their present care home is quite the opposite of this image:
Here a person is in the front, and here we are home. We have come here to live and not to die. We will all die once, but in some care homes you have special sections where older frail people are put separately. They make special departments only for frail, physically disabled. In our home, there is solidarity, there is no department where all residents would be all frail, or all disabled. Here we are one big family. I fit in. We publish a newspaper, we are good-natured people, we help each other in need (C).
Nevertheless some negative feelings regarding care homes are still present but are more hidden:
When I decided to go, I did not dare to tell the neighbours and say goodbye, that I am going. I was ashamed. We have a lovely house and everything was all right. I was 80 years old. There was no need. I had everything at home. I was not ill and I was ashamed. Everybody was asking me what is the matter with me. if I had lost my mind (G).
Conclusions
This paper examines evaluation in care homes and specifically focuses on participative evaluation and the issue of empowerment of residents. After an overview of variety of methods generally used to assess the quality of services in care homes, the model of participatory evaluation is specifically discussed; with its distinctive aim (i.e. the empowerment of residents) this model is used in our study as an ideal model, against which to appraise the evaluation practices used in Slovenian care homes. Participative evaluation, with its on-going activities and wide participation, is seen as an element of an organisational learning system and as leading to changes; moreover, it is seen as an element of an organisational culture receptive of participation and open discussion of
4 Old people homes that were perceived for only those who went there and wasted away, i.e. languished.
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quality issues, in contrast to the blaming culture in which critical comments are commonly understood as accusations and are not welcome. In our analysis, we observe the process of evaluation in care homes as potentially serving as a mechanism of control over the quality of service and of the active role of residents if participating.
An overview of the practices of quality assessment that are used in Slovenian care homes, based on the survey of managers, has revealed that evaluation is widely used and only exceptionally not practiced. While the E-Qualin model is used by approximately one in four homes, the most common are other methods of quality assessment, widely varying from in-house questionnaires to outsourced surveys. Among managers, the prevailing opinion was that the quality of evaluation performed is at least on an acceptable level. In addition, the survey revealed a fairly good level of participation of residents and their representation in decision-making procedures at the levels of the councils of homes; however, their representation is unusually high in public homes, but rather low in private ones, which calls for more concern by future studies and policy.
Finally, our qualitative case study of a selected care home served to observe how the issues of the service quality and empowerment issues are dealt with within a "local frame of knowledge" and as filtered through the actual organisational culture of the home. Thus, the phenomena of quality of service and of empowerment were explored within a real-life context, intending to answer how and why the quality level was reached, and not to provide a representative case to serve for generalisations of Slovenian homes. In operational terms, the aim of the study of DSO Fužine was to examine residents' perceptions about how their voices are heard and respected in the care home and how they feel their control over daily life and their sense of empowerment in home. A focus group of seven active residents in the care home was organised, and four focused questions prompted discussions to detect the range of attitudes.
Firstly, an open question about whether residents have much say about the care home revealed the areas, instances and overall sense of empowerment in the home. Besides food, the areas most often mentioned were daily activities and trips, for which residents' initiative was repeatedly highlighted. With regard to instances in which residents can initiate changes and improvements, all four levels were mentioned: reaching from the basic household unit, over the Council of Residents to the top level of the Home Council and stretching outwards to wider public framework. However, the lowest two intra-organisational levels were found to be more open and, in words of a resident, representing "the best form of direct democracy". The overall perception of residents was that they have a fair control over life in the home; some residents even praised the staff for being very receptive.
When examining indications of the organisational culture in the care home and the issue was raised about the openness of the staff to residents' critical comments, the focus group expressed the notion that criticism was generally accepted by the staff. No indication of a blaming culture resenting critical comments, was expressed; quite the contrary: the "positive principle" among the staff was mentioned.
When discussing the role of the E-Qualin evaluation procedure, residents recognised it as significant for service quality assessment, for its discussion and for
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ranking of care homes with regard to their quality. The awareness that their home is ranked very high seemed to further add to residents' satisfaction and sense of control over their life. However, the contribution of E-Qualin to the residents' sense of empowerment seems to have been only minor in comparison to other mechanism of participation in decision making in home.
The life in the care home as it was presented in the focus groups seems to be far from the old-fashioned portrayal of the care homes. It was emphasised that the care home feels like home, like one big family. Nevertheless, some negative feelings regarding care homes are still present but are more hidden. When recounting their decisions for entering the care home, feelings of shame were connected with this decision.5
In conclusion, the wider implications of our findings should be considered. The results, indicating a high level of empowerment of residents, cannot possibly be generalised. To the contrary, the care home selected does not represent an average case, but a top quality home. That is why no conclusions can be drawn for the average and even less for the lowest end cases; this remains the challenge for future studies. Our results reveal top quality homes and how high this quality is with regards to terms of empowerment of residents. However, our findings can serve as guidelines for other care homes, showing not only how significant is resident participation for their well-being and for the quality of services, but also demonstrating that it is possible.
In addition, our findings could also be relevant for wider Slovenian society. Specifically, the detection of such a high sense of empowerment within an institution was surprising and challenging, not only because of the general criticism against institutional care, but also in relation to the outside world. That is to say, the social situation in Slovenia is presently characterised not only by a generally very weak evaluation culture, but also by the public political discourse dominated by the blaming culture, not to mention the current social uprising movement calling for direct democracy. In comparison to this situation, what was found in our case study certainly represents a surprising extra quality.
5 This is linked to the views held in local surroundings/neighbourhoods, which can influence also the attitudes toward ageing and how people cope with old age and their living circumstances (see also Jelenc Krašovec & Kump 2009; Kneževič Hočevar 2012; Filipovič et al. 2012).
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Povzetek
Prispevek obravnava evalvacijo v domovih za starejše, s poudarkom na participativni evalvaciji, katere specifični cilj je krepiti moč/opolnomočiti ljudi s sodelovanjem, z razvijanjem skupnega lokalnega znanja ter s spreminjanjem organizacijske kulture v domu. Po kratkem pregledu raznovrstnih metod ocenjevanja kakovosti storitev v domovih za starejše analiziramo evalvacijske prakse v slovenskih domovih za starejše in kakovost ter praks primerjamo s participativno evalvacijo kot idealno-tipskim modelom. Najprej, z rezultati naše ankete direktorjev domov ugotovimo, da evalvacijo uporabljajo skoraj vsi domovi in to zelo različne metode. Nadalje smo izvedli fokusno skupino med prebivalci Doma starejših občanov Fužine izbranega kot študije primera in tako umestili evalvacijske prakse v lokalni okvir znanja. Na podlagi fokusne skupino smo ugotavljali kakšna je percepcija prebivalcev doma glede njihovega vpliva v vsakdanjem življenju doma, nasproti različnim vodilnim strukturam ter vlogo evalvacije pri tem. Splošna ugotovitev članov fokusne skupine je bila, da imajo precejšen vpliv na življenje v domu in obliko neposredne demokracije. Teh izsledkov sicer ne moremo posplošiti na vse domove, zagotovo pa predstavljajo presenetljivo visoko kakovost v primerjavi z "zunanjim svetom" sodobne krizne slovenske družbe.
KLJUČNE BESEDE: domovi za starejše, krepitev moči, evalvacija, participacija, neposredna demokracija
CORRESPONDENCE: SRNA MANDIČ, Faculty of Social Sciences, University of Ljubljana, Kardeljeva pl. 5., 1000 Ljubljana. E-mail: srna.mandic@fdv.uni-lj.si.
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