Background: Most people living in 24-hour care settings have dementia, and little is known about what makes long-term care a positive experience for them.

Method: This carer-led qualitative study examined working practices in 24-hour long-term care-settings, including hospitals, nursing and residential homes, with the aim of finding out and making recommendations about such settings. Using semi-structured interviews, managers, nurses and care assistants were asked about work practices, such as how they coped with difficult behavior, about shifts, staffing levels, staff retention and training. Relatives of residents with dementia were asked about their role and perceptions of the care provided, and residents were asked for their opinions of their care.

Results: Staff reported that residents presented with increasingly challenging behavior compared to the past, and that sometimes staffing levels and skills were inadequate. Of all the settings, hospitals had the most problems with staffing levels and retention, staff-relative relationships and staff support systems. Relatives saw their own role as positive. People with dementia of varying severity could usefully evaluate some of the services they received.

Discussion: Dementia-specific training and education of staff in all long-term care-settings, including induction, should address the management of problem behavior in dementia and thereby improve staff fulfilment and relatives' satisfaction. The long-stay hospital may not be appropriate as a “home for life” for those with dementia, and we recommend that long-stay care settings should be able to cater flexibly for a range of resident needs.