Leading through crisis: care home managers' COVID-19 experiences examined through systems-led setbacks and social...

Care homes in England experienced disproportionate harm during the COVID-19 pandemic, yet existing policy analyses offer limited explanation of the structural and positional vulnerabilities faced by care home managers. This conceptual paper applies systems-led setbacks and social positioning theory to examine how pandemic policies shaped care home management across macro, meso and micro contexts.

Qualitative research evidence relating to care home management during the pandemic was examined using a multi-level thematic analysis. Evidence was organised across six policy domains: hospital discharge, communication with families, personal protective equipment, end-of-life care, testing and surveillance, and vaccine roll-out. Recurring patterns were interpreted through the combined theoretical framework.

Five overarching themes were identified: liminal positioning, accountability displacement, rights erosion, information asymmetries and temporal misalignments. Across all six domains, managers were required to implement complex and frequently contradictory directives while operating with limited authority, incomplete information and insufficient institutional support. System-level decisions therefore interacted with managers' marginal organisational position, amplifying risk for both staff and residents.

Systems-led setbacks and social positioning theory provide greater explanatory depth than conventional policy analysis by showing how structural inequities and positional vulnerabilities compounded pandemic harms. Future preparedness frameworks should explicitly recognise the authority, information needs and institutional position of care home leaders, and involve them directly in policy design and implementation to reduce avoidable harm to people living and working in care homes.