Background: Elder abuse in care homes is probably common but inherently difficult to detect. We developed the first questionnaire to ask care home workers to report abuse anonymously.

Method: We held qualitative focus groups with 36 care workers from four London care homes, asking about abuse they had witnessed or perpetrated.

Results: The participants reported that situations with potentially abusive consequences were a common occurrence, but deliberate abuse was rare. Residents waited too long for personal care, or were denied care they needed to ensure they had enough to eat, were moved safely, or were not emotionally neglected. Some care workers acted in potentially abusive ways because they did not know of a better strategy or understand the resident's illness; care workers made threats to coerce residents to accept care, or restrained them; a resident at high risk of falls was required to walk as care workers thought otherwise he would forget the skill. Most care workers said that they would be willing to report abuse anonymously. Care workers were sent the newly developed Care Home Conflict Scale to comment on but not to complete and to report whether it was acceptable and relevant to them. Several completed it and reported abusive behavior.

Conclusion: Lack of resources, especially care worker time and knowledge about managing challenging behavior and dementia were judged to underlie much of the abuse described. We describe the first instrument designed to measure abuse by care home workers anonymously; field-testing is the logical next step.