Table 1 Summary of main findings

Managers’ understanding of the intervention

To support implementation, Managers’ first needed to understand and see value in the intervention. Despite written and verbal explanations, managers’ understandings were very variable, affecting their ability to support its implementation.

Degree of manager support for the intervention

The degree of support for implementation from care home managers, and the value they placed on the intervention, played a crucial role in determining implementation success. Good managerial support included providing time and staffing cover for intervention leads, assisting less confident intervention leads, and supporting engagement with the intervention and resulting practice changes at a practical and financial level, across the care home.

Managers’ choice of intervention leads

Managers’ understanding of the skills required to implement a complex intervention, and the availability of staff with the requisite skills, affected managers’ abilities to select appropriately skilled intervention leads. As a result, some intervention leads did not have the required skills or were unprepared for the role and struggled to implement the intervention.

Management stability

Managerial stability had a key influence on implementation success, with many homes experiencing one or more management changes during the study. Such changes often signalled difficulties (e.g. in care, staffing or managerial expertise) within the home, and restricted the time new managers had to understand and support the intervention.

Intervention engagement and leadership by managers

Engagement with, and leadership of, the intervention varied greatly between managers. Some managers delegated all responsibility for implementation and engaged very little with the process. Others were very engaged, or took ownership by becoming intervention leads although this could be problematic; often possessing the skills, understanding and authority but not necessarily the time to undertake the lead role amid competing priorities.