Sustainable Creative Practice with Older People: A Collaborative Approach between Arts and Care Sectors

: Interprofessional working is common practice within the health and care sector and particularly within care homes to support the diverse needs of their residents. However, this is less common between the arts and care sectors despite the established impact of the arts on older people’s health, wellbeing, and quality of life. Arts activities that do take place in care homes tend to be time-bound, with artists utilising short-term funding to deliver a defined project often with limited engagement from care home staff due to their competing priorities. This article reflects on qualitative findings from the Artists’ Residencies in Care Homes (ARCH) programme led by Magic Me, which paired four leading arts organisations with four care homes in Essex who worked together over four years to deliver creative arts for the residents. Building trusted relationships and collaborative working between the artists and care home staff was essential for the success of the residencies and for generating and embedding sustainable creative practice in the homes. This article argues that for creative practice to become sustainably embedded in care homes, arts organisations and the arts and culture sector need to embrace interprofessional collaborative practice in health and social care.


Introduction
Research continues to demonstrate the positive impact of arts and creativity for older residents living in care home settings.In 2017, the 'Creative Health' report [1] set out comprehensive evidence demonstrating the beneficial impact of the arts, with key messages that the arts can keep us well, aid our recovery, and support longer lives better lived; meet major challenges facing health and social care: ageing, long-term conditions, loneliness, and mental health; and save money in health and social care services.More recently, in 2023, the 'Creative Health Review' [2] acknowledged the role of creative health in primary, secondary, and tertiary prevention as well as offering a holistic and person-centred approach across the life course, specifying: "In care homes, creative engagement improves health and wellbeing of residents and can reduce the need for medication.It can also improve the health and wellbeing of the workforce" (p.21).This is also recognised-if briefly-in the 'Framework for Enhanced Health in Care Homes' [3], which advocates for daily opportunities for meaningful activities such as music, arts, and gardening, and drawing on community assets to enhance the lives of residents and promote mental wellbeing.
There are many arts programmes being delivered in care homes and growing recognition of their value (e.g., [4][5][6][7][8]).For example, engaging in participatory arts and creative activities has been shown to play a role in addressing loneliness and social isolation for older people and promoting social relationships within care home settings [9][10][11], thus improving quality of life.Furthermore, Bosco, Schneider, and Broome [12] analysed the social and economic value of the 'Imagine Arts' programme, delivering high quality arts interventions across 17 residential care homes in England.They found a social return on investment of GBP 1.20 for every GBP 1 of expenditure, with benefits for residents echoing those found in the literature-community inclusion, mental and physical health, improved cognition, and decreased social isolation.Benefits for care home staff and Activities Coordinators (whose role is to organise stimulating leisure and social activities for residents) included improved skills in caring for older people and increased confidence in using arts interventions.Care home providers and managers reported a greater variety of activities they could offer to residents and the enhanced reputation of the home.While artists reported increased knowledge of dementia and confidence in supporting older people, they also experienced a decreased sense of control in delivering activities.The authors emphasised that for such programmes to be effective, "care home personnel and artists need to work together closely in a spirit of knowledge exchange" (p.23).
Collaborative working can be defined as: "Business relationships formed by committed organisations to maximise joint performance for achievement of mutual objectives and creation of additional value" [13].Interprofessional collaboration is nothing new for care homes, who work on a day-to-day basis with practitioners across health and social care services such as nurses and doctors.This is supported by initiatives such as the Quality Improvement Collaborative (QIC) approach that guides multi-professional teams through interventions designed to improve care in residential care homes [14].The need for effective collaboration intensified during the pandemic as reflected in the Care Quality Commission (CQC) 'Better Care Through Collaboration' report [15], which stated that the creative and innovative solutions in response to the pandemic required partnership work and highlighted the benefits of collaboration within care services.However, discourse around interprofessional collaboration within care homes has largely been limited within the traditional boundaries of health and social care [16], thus overlooking the potential contribution of the arts sector.
Collaboration across the arts and care sectors requires novel and creative approaches and practices that can account for "sometimes diverging interests and concerns" and "bridge unsettled interdisciplinary relationships" [17] (p.2).Nonetheless, research with nurses suggests that artists are valued within interprofessional care teams as they enhance the provision of holistic person-centred care by including meaningful cognitive and social engagement and contribute to "a culture in which creativity and interdisciplinary collaboration are more highly valued and activated" [18] (p. 1).Fortier and Coulter [19] conducted qualitative participatory action research to develop a conceptual framework of factors that affect cross-sectoral collaboration for arts, health, and wellbeing activities.They concluded that strengthening collaborative capacity (particularly within arts organisations), addressing structural constraints relating to power and resources, and aligning with public health agendas are essential for success.From the care sector perspective, a recent consultation asked care home residents and their families, Care Home Managers, staff, and Activities Coordinators across 67 care homes what was required for care homes to provide a daily offer of creative activities [20].It found that the greatest constraints were time, a lack of specialist knowledge, staffing structure and how teams work together, and ideas and resources.Meanwhile, care providers suggested they needed to work on developing community and arts partnerships, a culture shift in terms of belief in the necessity of regular creative engagement, more specialist training in arts and activities for people with complex needs, and more resources in terms of creative ideas.
To support the integration of creative health into the wider health and social care landscape, the 'Creative Health Quality Framework' [21] published in 2023 outlines eight principles to drive quality and good practice, including collaborative and sustainable working.This article focuses on collaboration and its importance for sustainability, which is recognised as a key principle for sustainable organisations and central to solving complex problems of sustainability [22][23][24][25].Our previous research on participatory arts in care homes identified the working relationship between participatory arts facilitators and care home Activities Coordinators-particularly in terms of the collaborative process-as crucial to the successful delivery of participatory arts activities for older people in care homes [26].This research involved extensive data collection with artists, care home staff, residents, and families, including researcher observations of the participatory arts in action; however, the findings around collaborative working emerged from the data and were not the focus of the research from the outset.In contrast, this current research focused specifically on how artists and care home staff can work together to deliver and embed creative arts during the Artists' Residencies in Care Homes (ARCH) programme.
ARCH was led by arts charity Magic Me who facilitated the pairing of four arts organisations with four care homes in Essex to deliver innovative participatory arts experiences for residents and staff over four years, 2019-2023.The ethos behind Magic Me and the ARCH programme was to provide meaningful, high-quality participatory arts activities that are otherwise inaccessible to residents, with the aim of improving overall quality of life and promoting social justice.They also aspired to raise expectations of what the arts can be and do in care homes and increase the understanding, skills, and confidence of the arts organisations to encourage continued work in the care sector.The four homes involved were managed by the same family-run company that aspired to deliver individual, person-centred care with empathy, kindness, and compassion.They all offered residential, residential dementia, respite, and end-of-life care and ranged in size from a 40-bedroom home to a 92-bedroom home.While they all delivered various meaningful activities for residents, Care Home Managers and Lifestyle Coordinators (also referred to as Activities Coordinators) put themselves forward for the ARCH programme and embraced it as a new opportunity for a longer-term partnership to deliver immersive, participatory arts rather than more passive performance or entertainment.The arts organisations were recruited by Magic Me as Arts Council England National Portfolio Organisations (NPOs) that had experience using different forms of participatory arts with a range of different groups, though not necessarily in the care home context.Their creative practice centred around dance, theatre, and touch that intended to deepen human connection, ignite creativity and play, tell stories without words, engage with science, and promote care, curiosity, and compassion.Magic Me and the care home management company worked closely together, visiting each care home and matching them with the arts organisations based on what they had expressed about their staff and residents and the personality of the home as well as practicalities in terms of size and geography.
Each arts organisation was autonomous in working with their partner care home to explore a range of different art forms and develop a unique project for the residency.This included encouraging ideas, interests, and input from care home staff and residents, which were incorporated into the developing projects, and adapting their creative practice based on care home staff knowledge and expertise of what would work-particularly for their residents with dementia and other physical or cognitive conditions-and spending time interacting with staff and residents.An example of how this happened in practice can be seen in films from 'behind the scenes' of one residency: (https://www.geckostill.co.uk/behind-the-scenes).Further details of the ARCH programme can be found on the Magic Me website (https://magicme.co.uk/project/artists-residencies-in-care-homesessex/) and in the final report (https://magicme.co.uk/wp-content/uploads/2023/09/Dareto-Imagine-ARU-Magic-Me-%E2%80%93-ARCH-Project-Report-FINAL.pdf).
The research conducted alongside ARCH aimed to enhance knowledge and understanding of the collaboration between artists and care home staff in delivering creative arts experiences for older people and explore the challenges and enablers of introducing arts activities in care homes to identify best practice.A key ambition of the ARCH programme was to integrate arts and creativity into the lives of residents and the culture of care homes to promote the sustainability of impacts.Here, we explore how collaboration between arts and care partners is essential for the sustainability of creative practice and subsequent positive impacts of arts and creative activities in care homes.

Materials and Methods
The research took a qualitative approach across three phases of the ARCH programme: research and development (R&D), artists' residencies, and legacy and embedding.Ethical approval was granted by the Education & Social Care School Research Ethics Panel at Anglia Ruskin University.

Phase One: Research and Development
An introduction day brought together 19 people, in person, from Magic Me, the arts organisations, the care home management company, and the research team.A dementia specialist and trainer co-led the day, offering an introduction to working creatively within care homes.The 'sticky notes' method [27] was used to invite responses to questions throughout the day including how everyone was feeling about the prospect of delivering ARCH, what was seen as exciting, what were the anticipated challenges, and what skills would be needed.A focus group discussion reflected on the day and what support was needed going forwards (16 participants).
Care homes hosted an introductory day for their partner arts organisation, where care home staff and artists got to know each other through introductions, a tour of the home, and a taster of the arts organisations' creative practice.The Care Home Managers and Lifestyle Coordinators played a pivotal role in welcoming those involved in ARCH to the homes.Researchers undertook unstructured observations to understand the preparation process and how artists and care home staff began getting to know each other.A focus group discussion was held to reflect on the visit and the hopes and concerns for the residencies (total of four focus groups).Telephone interviews were subsequently conducted with Care Home Managers to explore a strategic perspective on ARCH (total of four interviews).
The remaining R&D phase entailed arts organisations spending time in their partner home, getting to know people, learning about the care home environment, and experimenting with creative activities, building towards a longer residency in phase two.Online interviews with each care home and each arts organisation were held at the end of the R&D, reflecting on experiences and learning so far and considerations to take forward (total of eight interviews).An online interview with Magic Me (Director and Programme Director) explored the context and motivations behind ARCH, their role in supporting the R&D, and their reflections on the collaborations so far.

Phase Two: Artists' Residencies
As phase one ended, the COVID-19 pandemic hit with significant impacts on care homes and ARCH, which was paused until restrictions began to ease and it was safe for the work to continue.Short online interviews were conducted pre-residency with arts organisations, care home staff leading ARCH (usually the Lifestyle Coordinator and/or Care Home Manager, sometimes joined by wider care home staff), the care home management company, and Magic Me to explore what might have changed since the end of phase one and their expectations for phase two (total of ten interviews).
The arts organisations then began residencies in the care homes, delivering participatory workshops, performances, and staff training using various mediums including dance/movement, textiles, music, performance, film, virtual reality, digital storytelling, science experiments, and photography.
During the residencies, researchers were unable to observe the creative practice due to COVID-19 restrictions and safety precautions on the number of visitors to the home; however, the intention of the research was to understand best practice for working together from the perspective of the artists and care home staff.Artists recorded their reflections on different sessions and the progression of their work in any format they liked (e.g., written summaries, recordings of post-session conversations between artists), which were subsequently shared with the researchers.After the residencies, online interviews were conducted with each care home and each arts organisation, respectively, reflecting on the experiences, including enablers and barriers to understand best practice (total of eight interviews).

Phase Three: Legacy and Embedding
An evaluation session brought together 16 people online from Magic Me, the arts organisations, care homes, and the research team.The 'sticky notes' method [27] was adapted for the online space to reflect on what would have been useful to know at the start, what have been the key learning points, and what will be taken forward.At the end of the session, online focus group discussions were conducted with the arts organisations (six participants), care home staff (six participants), and Magic Me (Director and Programme Director), respectively, reflecting on the ARCH programme overall.The legacy phase is ongoing but has so far included the publication of a care home's guide to creativity based on approaches and ideas from the residencies to be disseminated to Lifestyle Coordinators across the county.

Data Analysis
All interviews and focus groups were audio recorded and professionally transcribed.The dataset from each phase was explored through thematic analysis guided by Braun and Clarke [28] to draw out key themes and identify good practice and challenges.Analysis was conducted by all members of the research team and involved deep and prolonged data immersion, thoughtfulness, and reflection, through the steps of familiarisation, initial coding, review of themes, theme definition, and labelling.Here, we present key findings that are most relevant to the focus on collaboration and sustainability under three overarching themes: setting up for success, collaboration in delivering creative experiences, and legacy and embedding for sustainable creative practice.
The thematic analysis intended to look across the four partnerships between arts organisations and care homes to find common enablers, barriers, and best practice that would be widely applicable, rather than specific to a particular creative practice or care home context.Because of this, and to protect the anonymity of the participants, the findings do not go into detail about the creative practice itself and all quotes have been broadly attributed to 'arts organisations' including individual artists and artistic directors across the four organisations and 'care homes' including care staff, Lifestyle Coordinators, and Care Home Managers across the four homes.

Setting Up for Success
The findings highlighted elements of setting up ARCH that intended to support successful and sustainable residencies, including leadership and forging new partnerships; understandings and expectations of ARCH; and building trust and relationships.

Leadership and Forging New Partnerships
Magic Me provided leadership throughout the programme, acting as "the broker, as the connector for the arts organisations and the homes" and helping to build trusting relationships between partners.In relation to forging new partnerships, the concept of "bringing two worlds together" from the arts and care sectors emerged, which presented challenges in terms of different priorities, expectations, approaches, languages, and ways of working.Magic Me and the care home management company worked together to consider the arts organisations' motivations and the care homes' culture to match partners as well as logistics and practicalities such as size and capacity, resources available, and geographical location.Artists felt that delivering authentic practice that reflected their values was essential, as the residency flowed better when this aligned with the care home values.

…[the care home's] ethos and their attitude to that was very…reassuring in that I felt it aligned with what I was hoping for and my sort of assumptions about how we would
work in that setting.By that I mean their warmth, their humanity in terms of those relationships, their playfulness…our work fits very well with that.(Arts organisation, pre-residency) Although artists and care home staff initially felt well-matched, issues arose later.Magic Me acknowledged the need for more time for understanding arts organisations outside of traditional settings to enhance the matching process.It was also suggested that care homes, especially management, should familiarise themselves with artists' work beforehand to ensure compatibility with their context.Improved consideration of approaches, values, and personalities would have laid the foundation for stronger relationships, with some artists expressing a desire to be involved in the decision-making process.
Magic Me responded organically to the needs of each arts organisation, providing encouragement along with constructive and sensitive creative feedback, which required a delicate balance of stepping in where needed but also stepping back and allowing the work to emerge authentically.Further structures of support included monthly online group meetings for the arts organisations where Magic Me facilitated creative sharing that was hugely valued by artists.
They've been incredibly supportive the entire time…I think they really understand how to support organisations in a way that works for them and their practice.(Arts organisation, pre-residency)

Understandings and Expectations of ARCH
Differing expectations of ARCH required careful negotiation.While some artists were used to working in different contexts, others had not worked in care homes before and were unsure what to expect.Some care home staff did not have specific expectations, but others were accustomed to "entertainers" coming into the home for performances or oneoff sessions, which shaped pre-conceived ideas about what an artist is and does and led to them wanting clear plans and structure.This disparity between pre-conceptions and the fluid approach of ARCH sometimes led to anxiety, resistance, and rejection of ideas.
Divergent expectations emerged regarding the time commitment and care home engagement: arts organisations anticipated high levels of involvement, but some care home staff did not view this as part of their role.This concern was foreseen by a Care Home Manager in the R&D phase.
So, the staff members that have easily accepted any changes, they are playful, and they are not so over-protective…other staff members, they are a bit, "Ah, this is not for me.I am here to work.I am here to care for this resident, not to play around.I am not here to dance or to sing." …that is our major challenge.(Care home, R&D) In some cases, there was limited awareness of the vision for ARCH, largely amongst wider care home staff, partly due to staffing and management changes during COVID-19.Better understanding may have increased engagement, and it was suggested that staff should be reassured that they were not expected to be or become experts in dance or theatre, for example, but that engaging with the creative practice may support different ways of communicating and caring for residents.However, the timing of the pandemic made communicating and embedding the values and vision of ARCH challenging, with some care homes missing their final R&D sessions.
Though some care home staff maintained their initial stance, many actively engaged in the creative and collaborative processes and experienced a shift in perspective.This underscored the need for clear communication and sufficient time to establish shared understandings and manage expectations.

Building Trust and Relationships
Central to ARCH was the emphasis on building relationships, collaboration, and communication.Introductory days facilitated mutual understanding between artists and staff, where care home staff were enthusiastic and welcoming, and artists valued insights into staff practices and the care home context.The care home tour played a pivotal role in fostering learning, as staff became more at ease sharing their knowledge, and artists observed staff interactions with residents.Meanwhile, the artists' taster activities allowed care home staff to comprehend the nature of the creative activities and artists' intentions.
The important thing, initially, is to get to know those people as people, that home as a home.What happens, what they're interested in, that's much more important…that layer of building the relationship with everyone in the care home-staff, residents, families, and your team.(Arts organisation, post-residency) Building trusting relationships was emphasised by both artists and care home staff as crucial for meaningful collaboration.Care home staff needed to trust artists proposing innovative ideas, even when the value was not obvious, but artists sometimes faced challenges in gaining trust, creating barriers to the desired impact.Artists stressed that building trusting and collaborative relationships took time and was facilitated by being actively present in the homes, though this sometimes caused friction.
[Building] trust…time for me is always a huge part of that.You can't expect to do that over Zoom…over a cup of tea for an hour.That comes with time, and little by little…[care home staff] noticed…we took the time with individual residents.So that allowed them to go, "We trust these people…" (Arts organisation, post-residency) Effective communication was also vital for fostering trust and relationships.While communication within sessions was good, maintaining contact between sessions posed challenges, especially during the pandemic.Having a key point of contact was useful, but staffing changes inhibited sustained communication and eroded relationships.For example, one arts organisation and one care home had a completely new team once the residency commenced, and only one Care Home Manager remained throughout.

Collaboration in Delivering Creative Experiences
Collaborative working was essential in delivering ARCH, with particular findings around the role of Lifestyle Coordinators, Champions, and wider care home staff engagement.

Collaborative Working
Collaborative working was deemed crucial to ARCH, emphasising adaptability over rigid plans and the necessity of recognising and appreciating diverse skills and expertise from each partner.It was acknowledged that not all staff would want to participate, and some may need encouragement and time to understand and adapt to new approaches.The importance of artists adopting a human and empathetic approach was emphasised, for example, by considering how residents and care home staff might feel about artists coming into their home.Creating time and space within the structure of ARCH for artists and care home to come together was identified as best practice.
…our structure…of what we planned allowed that equality of that relationship to be there.There was enough time for us to reflect with them, listen to them, check in with them and make sure that that day-to-day impact on their home worked well… (Arts organisation, post-residency) Frequent check-ins before and after sessions enabled care home staff to communicate any changes that might impact the work, mutual feedback, and idea-sharing, which promoted equality between the partners, and collective reflection on what had been successful so far, deemed as "key to the development" of future sessions.However, though artists encouraged care home staff to share ideas and give constructive feedback, there were concerns about staff lacking confidence to express when something was not working well.
Artists highlighted the need for flexibility and being able to adapt their approach for the care home, to be responsive to their needs, and to be open to change.
In a care home, you can have a plan, but you have to be totally prepared for that to change completely…it's the most person-centred project I have ever worked on…it has been so responsive to each person on every level involved in it.(Arts organisation, post-residency) Artists found collaborative work challenging at times due to care home staff perceiving their role primarily as providing care, which was compounded by the pressure of workloads and staff shortages.Some suggested greater involvement from care home management was needed, and a shift from acting as the host for artists towards a more collaborative role.This was embraced by one Care Home Manager who stated, "you've just got to roll with it… if you all work together, it will work".

Lifestyle Coordinators and Champions
Lifestyle Coordinators were pivotal to ARCH, with one care home highlighting their challenging role in "trying to keep the spirits up" during and after the pandemic.They kept the momentum going and encouraged engagement from wider care home staff, supported in some cases by the Care Home Manager.They also served as the lynchpin in the partnership with arts organisations, acting as the main point of contact and support; however, this meant they were often perceived by wider staff as having sole responsibility for ARCH.This put a strain on Lifestyle Coordinators, and one reflected on how they felt unable to dedicate the time needed to the programme.
I just wish we had more time to be able to really take this to the next level… we've not been able to put as much input as we would have liked to have put in.And it's only in the last recent months that we've been able to get really involved, and we can see the impact it has had… I'm just so gutted now, because I feel like I've wasted that time… but I just had to prioritise other things…it was like, "I just really don't have time", and it was just awful.(Care home, post-residency) It also meant that artists received less support from wider care home staff and management, with one reflecting that if the Lifestyle Coordinator was not there "you just have to do it on your own".During the R&D phase, specific care home staff members were designated as ARCH Champions, with the intention that they would collaborate with the Lifestyle Coordinator on the residencies and learn new skills through the experience to support legacy.However, due to staff changes and increased workloads, for the most part, the role was not utilised in a defined way during the residencies.

Care Home Staff Engagement
Artists emphasised viewing both residents and care home staff as creatives, challenging the perception of their caregiving roles as solely "clinical" or "task focused".ARCH granted permission for care staff to engage in arts activities, encouraging creativity and providing an opportunity to imagine and "think beyond what they already know".
Many staff initially lacked confidence in their own creative abilities and were sceptical about residents' interest in the creative activities.However, introductory days and staff taster sessions were instrumental in overcoming these uncertainties, with care home staff actively participating during R&D and leveraging their experience and knowledge of the residents to support their engagement.

All staff really engaged with the creative arts sessions and the residents in a remarkable way. They were very willing to join in with the activities and had unique ways to engage the residents. (Artists' reflections, R&D)
Arts organisations and care homes stressed the importance of care home staff engagement in and commitment to ARCH.Key facilitators included artists spending time in the home, as well as support from Lifestyle Coordinators and Care Home Managers advocating for staff involvement.…you've got to put that work in…if you're going to take on this project, you need to be committed to it…to give time to it…because you get so much more out of it when you do.(Care home, post-residency) However, significant challenges in terms of staff shortages, high staff turnover, and time pressures led to difficulties in care staff fully engaging, which was frustrating for both partners.Long, busy shifts meant that the time artists were present was sometimes their only opportunity for a break; when they did participate, they were often pulled away into caregiving duties.On occasion, artists found themselves supporting overwhelmed staff and acknowledged the demanding nature of working in the care home.

I don't blame them for not being there…the demands on the care staff…they don't stop. And it's really difficult for them to find that space and that time. (Arts organisation, post-residency)
Instead of a consistent group of care home staff, those involved in the residency often varied based on availability, including agency staff without prior relationships or knowledge of the residents.Artists adapted by considering how staff could be involved as a one-off or whenever possible, and staff reported positive connections when they did engage.

Legacy and Embedding for Sustainable Creative Practice
The ARCH programme promoted legacy through thinking about this from the outset and ongoing; artists spending time and sharing skills in the care homes; cultivating creative outputs and sensitive endings; and embedding creativity in care home culture.

Legacy from the Outset and Ongoing
ARCH was designed to create a lasting impact and legacy by advocating for the value of arts in care homes and embed creativity into the care home culture to promote residents' wellbeing.This goal was iterated by Magic Me and the care home management company and was echoed by a Care Home Manager during the R&D phase who expressed hope for "a lasting legacy from it" and cultural change in terms of attitudes of the wider care home staff.The focus on legacy was also evident in the artistic approach.

…[we hope to] develop a relationship with the home, the staff and the residents that would allow us to develop something which felt meaningful to that place and something which felt could exist beyond the life of the project. (Arts organisation, pre-residency)
This involved "a continual thought process and challenge" of embedding creative practices throughout the programme, seen in some care homes where skills and activities from the R&D phase were used during the pandemic; one Lifestyle Coordinator shared their plans to align their everyday activities with the artists' ideas and themes during the residencies.
Magic Me encouraged ongoing communication between artists and care homes, for example, leaving physical reminders in the care homes and finding creative ways, such as Zoom sessions or sending resources, to stay connected between sessions and phases and, where possible, during the height of the pandemic.Both care home staff and artists emphasised that communication and support for embedding creative practice needed to be ongoing, which was achieved to some extent through the legacy phase.For one arts organisation, this was about providing the Lifestyle Coordinator with practical support, structure, advice, and accountability, whilst encouraging further support from the Care Home Manager.
One care home expressed a need for significant help in delivering creative practice, highlighting their stretched resources and diminished staff morale due to increased workloads and the impact of COVID-19.Recognising this, ARCH identified the necessity of further funding to sustain ongoing collaboration between arts organisations and care homes and maintain the momentum and impact of creative practice; as one artist put it: "we just should be here all the time".I just feel there should be…something in place.That we've got the resources to be able to have artists coming to the home on a regular basis, or even a couple of times a year.There should be that facility.Because we know what they can bring to the table and the impact it can have on residents' and the staff's wellbeing.(Care home, post-residency)

Spending Time and Sharing Skills
Spending time physically in the care home was identified as vital for embedding legacy, as one artist remarked "there's something in the meeting of the flesh and the minds and the sensory spheres of me being here".Artists explained how just leaving resources may not work, but immersing themselves in the homes and talking with staff about their ideas for what could happen in the future helped staff to develop skills and confidence in creativity-for example, embracing technology or feeling free to be silly with residentsand encouraged them to take ownership.Care home staff reported seeing things differently, such as wheelchairs having a "different purpose" as tools for dancing, showcasing a newfound creativity.Additionally, they learned new ways to communicate, discovering residents' capabilities and life histories through artistic practices.

Even as carers, we kind of know [there are different ways to communicate] but we never really push the boundaries. We kind of keep in this bracket of how you can communicate with people…we've learnt so much from our artists… to do with communication… (Care home, evaluation day)
In addition to spending time in the homes, some arts organisations offered structured training sessions for care home staff that strengthened learning.This focused on "finding little moments" to incorporate easy creative activities into the daily routine-such as playing with balloons and scarves or putting on music and dancing-that they would be more likely to be able to continue.Overall, spending time and sharing skills whether informally or through training enabled care home staff to witness and recognise the impact of the arts, which encouraged their continued engagement with creative practices.

Creative Outputs and Endings
Leaving creative outputs from the residencies behind was important for building a lasting legacy beyond the programme.The tangibility of outputs was seen as "really powerful" for residents and "had ripple effects" for involving family members and care home staff.Photographs and photobooks were a useful tool to capture "moments" and "fond memories" for the residents and for future reminiscence.Similarly, films created by two arts organisations focused on the experience of residents and care home staff, storytelling, celebrating the residents, and ensuring a lasting memory, which had a significant impact on care homes, enhancing their engagement and appreciation for the arts.Film screenings brought the entire care home community together, creating powerful moments, particularly for residents who saw themselves on screen but also for staff who reflected on their roles and relationships with residents through seeing the films.These events also celebrated the end of the programme, with endings described as "really vital, very valuable".One arts organisation explained how this is wrapped up in the creative outputs that continue to develop impact.
Of course there will be an end…but there will be something more that we get…we learn more about [the residents].We are able to leave something even more special and interesting.More about their lives rather than just dance sessions.(Arts organisation preresidency) In addition to the resources and props left behind for recreating creative sessions, these tangible creative outputs were seen as crucial to impact beyond the life of the ARCH programme; as one Lifestyle Coordinator remarked: "you've got it forever".The care home management company have used them to promote what is happening in the care homes to the local community and to other homes in the region.Furthermore, the arts organisations and Magic Me have used these creative outputs to advocate for arts in care homes and demonstrate what is possible.

Embedding Creativity in Care Home Culture
Embedding creativity and influencing a cultural shift in care homes was predominantly approached through building relationships with care home staff, involving them in ARCH and engaging them with the power of the arts.One Care Home Manager noted that ARCH had invigorated her staff with "more ideas" for future activities, though the execution still relied on the Lifestyle Coordinator.It was considered more beneficial to involve staff members who were genuinely interested and enthusiastic, as they could then be given greater support and resources to take the creative practice forward.
Rather than extensive training, participants suggested it was more important to "break down this idea that they can't do it" by building the confidence of care home staff to engage with creative practice and challenge the tendency to "take things very seriously" and "become very clinical".The support of Care Home Managers was crucial in legitimising the programme and encouraging broader engagement.
[The Care Home Manager has] learnt that by working in partnership collaborating with [the arts organisation]… the home is getting way more from the project.And it needed that change for her to be involved for the project to work, it was absolutely crucial… there's been such a turnaround in how they've worked together since she's been onboard.(Magic Me evaluation day) However, there were some concerns there may not be "the understanding of what it takes" regarding the effort needed for collaboration and embedding creativity and there were concerns that the enthusiasm and positivity of some care home staff may have been obscuring the real picture.Meanwhile some artists felt that the legacy they had envisioned had not been achieved, with one stating: "I don't know if I've seen a massive change in the culture of the organisation".
Nonetheless, in the care home discussion during the final evaluation day, staff talked about how they had already implemented some of the learning from ARCH and how they intended to continue.This included references to changing processes and incorporating creative approaches into care plans, which represent modest yet meaningful shifts in culture.Participants noted personal changes in their approach to activities and highlighted a shift towards bringing desired experiences to residents, emphasising a more supportive and adaptable care approach.

Discussion
The findings give insight into the structures, support, practicalities, and processes that led to the success of the ARCH programme.In particular, they show how the focus on and support around building trusting relationships from the R&D phase and throughout the residencies enabled collaboration between artists and care home staff that, in turn, supported the embedding of creativity in the care homes.This builds on our previous research [26] by elaborating on how artists and care home staff can foster such trusting and collaborative relationships that subsequently lead to more sustainable creative practice.We discuss how these findings align with the collaboration and sustainability principles in relation to the recently published Quality Cycle within the Creative Health Quality Framework (CHQF) [21], which shows how all stakeholders can work together to deliver the principles in a continuous process of learning and development across five project stages: developing your idea, building strong foundations, making detailed plans, delivering the work, and learning from the work.We also consider how the findings relate to the wider literature culminating in the argument for collaboration as critical to the sustainability of creative practice and subsequent impacts in care homes.
The first theme of setting up for success resonates with the quality cycle stages of 'developing your idea' and 'building strong foundations' from the CHQF [21].Under 'developing your idea', a collaborative approach is described as "solutions to identified needs have been developed through collaboration", "ideas draw on shared expertise", and "the approach to collaboration is appropriate to the context, scale and aims of the project" (p.21).Under 'building strong foundations', a collaborative approach means "there is agreement around a shared vision, aims and outcomes", "the vision for the work has been informed by wider, relevant health and social care policies and agendas", and "sufficient time and resources are in place for collaboration and partnership development" (p.23).Our findings exemplified the importance of these aspects, particularly in the structure around the ARCH programme developed by Magic Me, the deliberate and considered approach to forging new partnerships between arts organisations and care homes, and the reflection on the need for shared understandings and expectations.At the practice level, the need for dedicated time for setting up the partnerships and the residencies has been echoed in the literature.For example, research has identified the importance of artists having time and support to understand and adapt to the care home environment [5] and care home staff taking part in planning meetings to discuss practicalities and their role during the creative sessions [29].At a strategic level, these aspects also contributed to key factors in cross-sectoral collaboration for arts and health, as outline by Fortier and Coulter [19], such as considering the capacity and resources of partners, navigating complex care systems and policies, and alignment of the programme with wider care agendas, particularly in response to the pandemic.
Our findings relating to 'building trust and relationships' are represented in the framework under the later quality cycle stage of 'making detailed plans', whereby a collaborative approach means "there is buy-in and trust from all parties", "there is open and honest communication between all parties", and "democratic decision-making is in place" (p.25).However, our findings suggest that building trust is important from the very start of the project cycle and central to promoting the sustainability of creative practice in the care home.Trust has been widely acknowledged as fundamental to human relationships and, thus, interprofessional collaboration within healthcare (e.g., [30,31]).Flood et al. [31] suggested that when 'getting to know others' within interprofessional relationships, building 'trust' interplays with 'authentic dialogue' that goes beyond information sharing and 'respect' through recognising that each person has useful expertise that together would lead to something 'more than' what could be offered individually.Certainly, evidence shows that time to develop working relationships based on a foundation of mutual trust was important for collaboration between NHS professionals and care homes [32] and may be even more important for working across sectors.For instance, trust between artists and care home staff may be intertwined with personal and professional perceptions about the value of the arts.Relationships were one of the key factors found by Fortier and Coulter [19] to affect cross-sectoral collaboration for arts, health, and wellbeing activities.Cross-cultural and institutional differences in values, goals, practices, and language may create barriers to collaboration, but interpersonal facilitators included engaging in coproduction, using the skills of people who can navigate sectoral boundaries, and having stakeholders experience the arts interventions [19].These barriers and facilitators were evident in our findings on setting up for success as the partners developed shared understandings of the purpose of ARCH and artists spent time in the care homes, delivering a taster activity and interacting with both residents and staff to build trust.Magic Me could also be considered able to navigate sectoral boundaries given their extensive experience working with and in care homes, acting as a broker between the partners and advocating for the value of the arts, which may, in turn, strengthen trust.
The second theme of artists and care home staff collaboration in delivering creative experiences aligned with the quality cycle stages of 'making detailed plans' (as above) and, particularly, 'delivering the work' from the CHQF [21].Under 'delivering the work', a collaborative approach is described as "diverse skills, experience and resources are equally valued", "resources are pooled to ensure the creative experience is inspiring and transformational", and "all parties come together at key intervals to review progress" (p.27).This is reflected, for example, in artists valuing the knowledge, skills, and experience of care home staff and encouraging their engagement in developing ideas and reflecting on the work, as well as artists being bold and ambitious but also adapting their creative approach to the care home and responding to resident needs.However, at the same time, our findings highlighted how challenging it could be for both partners to collaborate in delivering the residencies.Specifically, despite intentions, it was often difficult to engage wider care staff due to time pressures, resulting in an overreliance on Lifestyle Coordinators.This resonates with the consultation that found time along with staff structure and dynamics to be amongst the greatest constraints to providing creative activities [21].
This has been reflected in the literature, with a review from Broome et al. [33] identifying the care home context as important when involving care staff in creative arts interventions.For example, they found practical and logistical challenges, staff shortages, and limited financial resources were a barrier to involvement, and creative arts interventions should consider the daily routine of the environment.Such issues were likely to have intensified during the ARCH programme due to the impact of COVID-19.Broome et al. also found that incorporating training sessions could facilitate the involvement of care staff in creative arts interventions and benefit their professional development in terms of learning techniques for non-verbal communication and person-centred care, especially for residents with dementia [33].Certainly, workforce development is a key care element in the 'Framework for Enhanced Health in Care Homes' [3], but this does not consider training in supporting or delivering creative arts interventions.Nonetheless, the Baring Foundation conducted a rapid mapping of arts in care homes training provisions [34] and identified 65 providers offering various forms of training to both artists and care staff.Overall, the training aimed to develop skills and ideologies that artists and care staff could apply to their practice, with a focus on "person-centred arts experiences that value process over product, supporting residents to experience the arts in whatever way they can in a failurefree manner" (p. 7).
Under our sub-theme of spending time and sharing skills, care home staff reflected on learning from the residencies and, while some structured training was provided, this learning often occurred through watching artists and engaging with creative activities.Artists spending time in the home along with care staff spending time with artists are pertinent examples of 'boundary work' that is often invisible, slow, and difficult but crucial to cooperation within arts and health [35].In the context of an intergenerational arts project in a care home, De Kock et al. [36] discussed boundary work at a personal level in terms of personal values and goals that often involve emotional labour; at a relational level in terms of attuning to those you are working with and navigating their often unspoken expectations, values, interests, or beliefs; and at the organisational level in terms of the customs, practices, epistemic traditions, power structures, and historically grounded values of different organisations and systems.They found that goals often needed re-evaluation throughout the process as expectations and desired outcomes changed, which required attentiveness, empathy, flexibility, and time for critical (self-)reflection in collaboration with partners.This is reflected across the ARCH approach in terms of developing shared understandings and expectations, building trusting relationships, communication and check-ins for collaborative working, and spending time together.Accordingly, the artists' experience of collaboration is a clear example of how boundary work can promote sustainable creative practice.
The third theme of legacy and embedding provides the opportunity to discuss how working collaboratively is essential for generating sustainable creative practice and impacts in care homes.Importantly, despite this being the name of the final phase of ARCH, the findings represented processes and activities that happened throughout the programme, such as forging new partnerships, building legacy from the outset, and artists spending time to develop the deep connections required for embedding creative practice.In terms of the CHQF [21], this is reflected in the quality cycle stage of 'developing the idea' where a sustainable approach means "all parties-participants, creative practitioners, partners, and other stakeholders-are involved in deciding what a meaningful, longterm legacy will look like" (p.21) as well as 'building strong foundations' where a sustainable approach means "partnership working supports the delivery of sustainable impacts" (p.23).The ARCH R&D phase ensured time to build relationships, while the collaborative, participatory approach of the artists specifically intended to shape a residency that would result in sustainable creative practice in the homes.Such an approach is supported by research from Hatton [37] that advocated for slowness in collaborations and, specifically, slowness as a partnership model for artists and care homes.
Additionally, the legacy and embedding of ARCH are also seen in the CHQF quality cycle stage of 'making detailed plans' where a sustainable approach means "progression routes and follow-on activities are identified to support participants' continued creative engagement" and "endings are planned to help participants transition to a range of activities or support" (p.25).This is particularly true in terms of our sub-theme around creative outputs and endings and the collaborative approaches to empowering care home staff and preparing them for embedding aspects of creative practice into their everyday routines.Furthermore, in the quality cycle stage 'learning from the work', a collaborative approach means "all parties come together to review learning and consider how to take the work forward", while a sustainable approach means "where possible, impact and outcomes are tracked beyond the end of the project" and "learning informs practices that create better futures for people and the planet" (p.29).The ARCH programme is currently in this stage of learning from the residencies and taking the work forward, led by Magic Me with various initiatives such as developing the care home's guide to creativity and strategic dissemination of outputs and best practice.Indeed, this demonstrates the crucial importance of Magic Me and their leadership and vision in both collaboration and sustainability aspects of ARCH.Specifically, their bringing together of arts and care sectors and brokerage of the partnerships between arts organisations and care homes paved the way for the relationships and residencies that unfolded.Such findings have also been demonstrated by Farrer et al. [38] who explored the role of a university in facilitating an intergenerational, interdisciplinary community arts project.They found the university was able to mediate between different sectors of the community, offer resources and support structures, and promote the project, which was significant in facilitating development beyond what could be achieved by smaller partner organisations independently and in a way that was more sustainable and resilient to the changing pressures across the arts and health sectors.
There were two further issues that warrant discussion in relation to sustainability: the care home culture and ongoing funding.The overarching culture of the care home has been identified as the most important factor in determining how successful artists would be in engaging residents in meaningful creative activities [5].Similarly, care providers have acknowledged the need for a cultural shift in terms of attitudes around the need for creative engagement [20].This emerged in the ARCH findings, particularly in the challenges of involving wider care home staff and artists' reflections on their impact in the homes.While this can, to some extent, be mediated by the selection of partners and through the early stages of forging partnerships and developing shared understandings and goals, ultimately, it will require a greater shift across the care sector supported by the growing momentum of the creative health movement.Arts programmes such as ARCH can contribute to the cultural shift required by demonstrating what is possible, for example, through the dissemination of creative outputs and research findings, and by building partnerships to advocate for the value of arts in care homes.However, it is important to recognise that care home culture has been shaped by wider structural influences such as the medicalisation, marketisation, and chronic underfunding of residential social care for older people [39,40] and such influences also need to be challenged in order to effect social change.
One way to challenge these influences and support a cultural shift is through increased funding for creative practice in care homes, which would increase the legitimacy and sustainability of the work.While the care home management company was supportive of incorporating creative practice in their homes, they face many competing priorities-particularly in the wake of the pandemic-and their budget for this work was limited.Accordingly, the need for funding to establish ongoing programmes of work was emphasised in the findings by both care homes and arts organisations, and securing funding is a constant objective for Magic Me.This is reflected in the CHQF [21] recommendations for policy makers, commissioners, and funders that state, in relation to collaboration, "develop joined-up approaches to policy and funding, informed by wider health needs, priorities, and inequalities" (p.15) and, in relation to sustainability, "prioritise investment in long-term programmes, partnerships, and practices that deliver sustainable social and environmental impacts" (p.18).These recommendations also highlight the need to budget for the time and resources required to build strong, sustainable relationships between partners, thus aligning with the argument around collaboration between arts and care sectors for sustainable creative practice and impacts in care homes.
A key limitation stems from the impact of the COVID-19 pandemic, not only on the ARCH programme but also on the research.While the findings showed difficulties in engaging wider care home staff in the residencies, this was also reflected in their participation in data collection, linked to staff shortages and high staff turnover.While all care home staff involved in ARCH were invited to participate in all phases of the research, it tended to be only Care Home Managers and Lifestyle Coordinators who took part.Additionally, the presentation of findings draws more heavily on quotes from the arts organisations rather than the care homes in illustrating the themes.Arts organisations were perhaps more comfortable reflecting on their practice and discussing how they worked with the care homes as such collaborations were commonplace for them.Meanwhile, care home staff were keen to provide positive feedback on the programme but were perhaps less reflective on ways of working together, particularly as their priorities changed since the COVID-19 pandemic, and they were grateful for any external input to the homes.

Conclusions
This article illuminates the importance of collaboration between artists and care home staff for the sustainability of creative practice and impacts within care homes in the context of the ARCH programme.The findings align with the Creative Health Quality Framework collaboration and sustainability principles and resonate with the wider literature, especially around best practice and challenges for artists working in care settings, the importance of boundary work, training for the involvement of care staff in creative activities, and valuing structures, time, and support for relationships and collaborations to develop and thrive.This has important implications for the ways in which arts organisations and the arts and culture sector are involved in interprofessional collaborative practice in health and social care and indicates the need for a cross-sector cultural shift and comprehensive funding to enable the effective bridging of these two different but potentially complimentary worlds.