Contextualising English generalist day centres for older people: operational characteristics and typical days. Findings from case study research

Contextualising English generalist day centres for older people: operational characteristics and typical days. Findings from case study research Katharine Orellana (  katharine.orellana@kcl.ac.uk ) King's College London https://orcid.org/0000-0002-1315-3706 Jill Manthorpe King's College London https://orcid.org/0000-0001-9006-1410 Anthea Tinker King's College London https://orcid.org/0000-0002-0305-7198

Recent reviews of English language day centre literature have recommended research on day centres' characteristics to better contextualise their outcomes (Lunt,   . Literature not included in these reviews devotes little space to contextual descriptions while reporting experiences, outcomes, centres' acceptability as a short break/respite, attender characteristics, access routes, programming, person-centred-ness, potential to support hospital discharge planning and posthospital care , evaluation and planning (Thompson and  Apart from the study discussed in this present article, the most detailed contemporary data about English day centres for older people with multiple long-term conditions are reported by Lunt's (2018) doctoral thesis. Contextual data (funding, charges, places available, transport, opening times, activities, target/current attenders, access, referrals, sta ng) are heavily summarised and blended across day centres for older people, people with dementia or learning disabilities as the study's purpose was to analyse impact by sta ng model (Blended -staff and volunteers; Voluntary -run entirely by volunteers; and Paid -staffed by paid workers).
Finally, the NHS Long-Term Plan (NHS 2019) details plans for increasing numbers of social prescribing link workers (community navigators) often based in NHS primary care networks. These workers make 'social prescriptions', referrals to or actual assistance with connecting people with social, emotional or practical needs to non-medical interventions (e.g. local groups, support services, community activity, volunteering) with a goal of improving their outcomes (NHS England 2020). Outcomes include individual health and wellbeing improvements, and reduced use of primary and secondary healthcare (Polley, Whitehouse, Elnaschie et al. 2019). Although an enactment of personalised care and support with demonstrated potential to economically bene t the NHS, stakeholder buy-in is key (Fixsen, Seers, Polley et al. 2020).
Both in England and in countries where day centres are integrated into health and care systems, little is known about social care and health professionals' perceptions of day centres, particularly those commonly in contact with older people in need of care and support (e.g. family doctors, nurses, social workers, occupational therapists, social prescribers) (Orellana, Manthorpe and Tinker 2020b). Referral, commissioning or funding decisions may be in uenced by individual knowledge and pre-held assumptions about speci c service types, perhaps resulting from professional background. Given English local authorities' role in shaping the care market (HM Government 2014), increased social prescribing plans, and the efforts to build back better services following the Covid-19 pandemic, there is a need to highlght the evidence for day centres along several dimensions.

Aim of this article
This article provides rich descriptions of the four English day centres for older people that participated in a pre-pandemic mixed methods study (Orellana 2018), thus aiming to further understandings of this face-to-face, out-of-home care setting.

Methods
This article draws on ndings of a study of 'generalist' day centres 2 that used a case study approach to paint an in-depth and contemporary picture of four English day centres for older people, in the environment of 2014-2017, by investigating what they offered, their use, relationships with local health and care services, and professional perceptions (Orellana 2018). The study gathered the perspectives of 69 stakeholders.
Case studies are well-suited to capturing complexity as they involve empirical investigation of a contemporary phenomenon in its real-life context using multiple sources of evidence (Yin 2014, Stake 1995). Generalisability is enhanced by strategically selecting cases (see Hyett, Kenny and Dickson-Swift 2014, Flyvbjerg 2016); generalisability, however, is less crucial than the use made of the case studies (Ruddin 2016).

Sample and recruitment
Using maximum variation non-probability sampling (Cresswell 2013), four day centres in different local authority areas were recruited against a matrix of characteristics (provider, building designation, admission criteria, attender numbers, target users) in areas with different population characteristics, deprivation levels and local political administrations. Time and funding constraints meant centres were recruited from South-East England.
Centres were identi ed by consulting older people's service directories, local authority websites, web pages of known providers and by using internet search engines and mapped onto the typology matrix. A selection of centres was contacted inviting managers to discuss the study in person. Subsequent centre visits enabled further evaluation of day centres' suitability prior to recruitment. Local authorities were approached directly about in-house day centres. Both participating voluntary sector day centres were recruited via the organisational manager, one of whom also managed the day centre; one also required a committee's approval. Approval from the housing association day centre manager's manager and a local authority commissioner was needed.

Data collection and analysis
Data, collected between October 2015 and December 2016, derive from eldnotes made by the rst author during 56 days spent at the day centres (same day each week for 14 weeks), documentation provided by managers (e.g. newsletters, activity programmes), and interviews with day centre/provider managers (n=6), frontline staff (n=10) and volunteers (n=7). Following ethical approvals, interviewees gave written consent after receiving information about the study.
Managers were asked about their centres and provided background documentation. Staff and volunteer interviews covered their roles, amongst other topics.
Fieldnotes (spanning centre operations, potential participants, attendance, notable incidents, interview plans and researcher re ections) aimed to inform an objective, non-evaluative account of the setting and contextualise interview data, thus were less detailed than for an observational ethnographic study reporting a researcher's interpretative perspective.
A donation of £100 was given to each centre following eldwork, a strategy intended to enable all attenders, carers and centre personnel to feel appreciated whether or not they were interviewed.
Fieldnotes were typed up resulting in 72 pages of notes. Interviews were audio recorded, transcribed and anonymised. Data were then distilled into four individually presented case studies. For this article, the data are presented thematically, with anonymity protected.

Involvement
Involvement was via an Advisory Group of people with experience of day centres assembled for the study, which met three times, and an Advisory Group that acts as a critical friend to the rst two authors' workplace. Groups were consulted about study materials and interpretation of the ndings. Case study site representatives attending a workshop were also consulted about interpretation of the ndings.

Findings
After outlining the day centres' main characteristics, aims, model and their locality, centres' internal environments are described, and formal and informal care provided summarised. Next, operational hours, daily timings and available 'extras' are set out. Finally, charges made to attenders are then set out.
Contextual aims and funding models Table 1 provides an overview of the case study day centres organisational and funding characteristics.
All centres aimed to improve their attenders' quality of life by focusing on their mental and physical wellbeing, mainly by making available social opportunities and a range of activities. Additionally, two aimed to offer nutritious meals and physical rehabilitation (DCLA, DCV2), two to provide information and advice (DCHA, DCLA) and one to support family carers and be a resource for the local community (DCLA). Two set their overall aims within a framework of enabling attenders to remain at home (DCLA, DCV1). Centres' differences extended to their providers, premises, operational days and hours, access arrangements, attendance numbers, funding and charges, activities, sta ng, meal provision, links with the voluntary and community sector, social care and the NHS. One voluntary sector centre speci ed that it also aimed to work in cooperation with other agencies for the bene t of its attenders. Table 1  . Likewise, being located in, and part of, the local community can be an important consideration in providing a sense that such a service is a community resource. Therefore, data were collected on the local environment, noting indications of being part of local communities or otherwise, visible in localities or set aside and segregated (Goffman 1961).

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DCHA was near a busy road of shops in an urban district close to former heavy industry sites and near large public housing estates, in an area being developed and increasingly gentri ed. DCLA was in a residential urban area, midway between two district High Streets. Both were in poorer communities, classi ed as being in areas included within band of the 30% most deprived areas, according to the English Index of Multiple Deprivation 3 (IMD) (Ministry of Housing 2015). DCV1 was in the middle of a small town in an area of socio-economic extremes with more social housing than the national average. DCV2 was close to the middle of a rural town surrounded by villages, and in area of socio-economic extremes, classi ed by IMD as being in the middle band of deprivation.
The day centre environment One distinction between day hospitals and day centres lies in their ambiance and the messages it gives about the building's purpose, the role of staff and volunteers, and the people who go there. Day hospitals are sites of treatment and clinical activity with single use and purpose (Smith and Cantley 1985); day centres may convey a sense of socialisation and multiple usage. Some are purpose built; others adapted to new functions.
DCHA's purpose-built building was designed to have exible usage by having an activity room and three main areas that could be separated by folding doors (which were left open): one was the television area with upholstered armchairs, coffee tables and a gold sh tank; the second a recreational area, with wooden tables and plastic-cushioned wooden chairs, equipment and games cupboards, a small pool table and a table tennis table; and the third a dining room shared with the extra care facilities' residents. The main room overlooked an accessible garden. Toilets were off the corridor to the centre; one had a ceiling hoist track. The centre had been recently decorated in bright, homely colours. At the building's entrance were two sofas, another sh tank and a lea et stand. Facilities communal to the extra care building also used by the centre were a hairdressing salon, the bathroom with a hoist and a Consultation Room. Tenants were able to join attenders for lunch in the dining room, and, for a small fee, could join the group for afternoon refreshments and bingo. The building thus shared aspects of a communal age-speci c building; with attempts to spatially separate different domestic activities; recreation, eating, and relaxation.
Similarly, standalone DCLA's central area was a large L-shaped room (the 'dining room'), set with groups of tables with plastic-padded wooden chairs, surrounded by recreational activities: a dedicated jigsaw table, a games table, shelves with more games, books and playing cards, a pool table, a table tennis table and a two-seater sofa. Leading off this room were an arts and crafts room (with a piano), a computer room, a conservatory, a small meeting room with a kitchenette, a television room, a quiet room with books and videos on shelves, a treatment room (housing a hair-washing sink, a bed, lockers and a massage table), a large kitchen with heated serving containers and a serving hatch to the dining room, and toilets. The room overlooked an accessible garden. Down a small corridor were a small o ce, a room with a bed for attenders feeling tired or unwell, and a bathroom with a toilet, an accessible bath and a changing table; both the latter had mobile hoists. Through this was a laundry. Fabric-upholstered chairs suffering continence 'accidents' were steam-cleaned by staff. At the entrance was the receptionist's and staff o ce.
In contrast, the long, rectangular hall where DCV1 operated adjoined the church's main worship area via a folding partition wall, making use of a community asset. With a high ceiling and windows, the room was bright and airy but not cold. There was a raised stage and a kitchen with a serving hatch. Toilets, shared with other building users, were across the lobby through the main hall entrance door. The hall was set up in the morning by a volunteer and one 'active member' (a status assigned by the centre's manager to people indicating a wish to be actively involved in providing the service). Three trestle tables were laid out at different angles for lunch and dressed with owery vinyl tablecloths, small blue vases with arti cial daisies, cutlery and owery plastic tumblers containing a folded napkin providing an atmosphere of hospitality. On the other side, near the stage, was a semi-circle of fabric-upholstered wooden chairs with small, folding tables in front of pairs of chairs. On the stage was the day's paraphernalia (e.g. magazines). This fully accessible building also had several meeting rooms, a café (opened twice weekly), a vestry, the church o ce and the provider's o ce. Although in a shared building and in a hall with three doors, attenders did not get lost. However, at the end of the day, vigilance was key for the volunteers and managers as one attender with dementia repeatedly tried to leave before the driver was ready. Occasionally, chairs suffered continence 'accidents' and were placed aside to be cleaned by building maintenance staff.
The 'community hub' building DCV2 operated in was the site of a variety of community facilities and organisations and may be one of those buildings increasingly described as an 'anchor institution' (Jackson and McInroy 2015). Shared users included a library, a church, a housing association's o ces, an Advice Bureau, a young people's organisation offering recreational activities and advice, a sensory room and a day centre for adults with learning disabilities that operated in the room used by DCV2 on its non-operational days. The hub also hosted sessional activities (e.g. blood donation sessions, health and wellbeing drop-ins run by charities, NHS Health Trainer support with healthy eating, stress, wellbeing and managing smoking and alcohol intake, and an outreach sexual health clinic), a young carers' group, an active retired group and classes (e.g. pilates, yoga, dancing, singing and children's activities). At times, local authority advisors assisted with, for example, nancial and bene ts advice, disability equipment information, and death registration.
DCV2's entrance led off the library, beside the centre's reception/library desk staffed by two local authority employees. It was a large, bright room overlooking the garden. Furniture was arranged by day centre staff each morning. At the far end, brightly coloured, fabric-upholstered armchairs and two two-seater sofas were arranged in a small circle (with entrance/exit gaps) with small, folding wooden tables beside them. A wall-mounted television screen was next to glass re doors leading to the garden and car park. Nearer the entrance were sofas, the tombola and sweet shop tables, and two six-seater lunch tables. Off the room was a cloakroom, two accessible toilets (one with an adult changing table, a shower and screen), a kitchen with a hatch through to the main area, a small meeting room, a therapy room, equipment cupboards and double doors to a sensory room.
Being part of a busy building brought challenges to cohesiveness and security. People constantly came in and out to use the kitchen and fetch items from the small meeting room. A learning disability centre attender often visited to take magazines and needed guiding back to another room. During eldwork, the manager introduced provider-branded t-shirts to improve security. In the mornings, background noise came from children using the sensory room and the baby and toddler groups in the library. An additional staff member had been employed when the centre moved to this location because of its numerous access points. Despite the accessible toilet and therapy room having two points of entry/departure, no attenders had got lost, although staff needed to keep an eye on the only attender with more advanced dementia. The provider's manager indicated the problematic nature of shared facilities, for example, some of the twoseater sofas were too low, and fabric chairs were not suited to a group with occasional continence 'accidents'.
Formal and informal care and support Using Lunt's (2018) categorisation, there was a mix of frontline personnel in centres. DCLA had one part-time volunteer in addition to its paid staff. DCHA was fully operated by paid staff. DCV2 was managed by a paid staff member who ran the service with two paid staff and one volunteer. DCV1's manager was also the manager of the provider organisation; volunteers provided the service, supported by the manager and assistant manager.
Centres with paid staff provided more personal care (help with continence/toilet, eating); this was formally undertaken in two centres accepting only local authority referrals, but all staff roles were varied, described by one as a 50/50 care and social role. Work involved personal care; planning, running and supporting activities, playing games with attenders, organising occasional events; providing emotional support; monitoring attenders' wellbeing and health, often by chatting on arrival or during the day, and acting where necessary; making/serving refreshments; practical support; attending to logistical requirements and acting as a key worker for named attenders and maintaining paperwork.
With reference to domestic work, staff and volunteers at all centres set and cleared tables and served meals; at DCV2, they also washed up and loaded the dishwasher. Dedicated kitchen staff at DCLA and kitchen volunteers at DCV1 prepared meals (see Table 2 for further lunch details).

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All staff had received a range of training (see Table 3).
Volunteers' roles involved taking initiative in supporting attenders to enjoy themselves, thinking of stimulating activities, supporting attenders during activities, reassuring anxious attenders, making and serving refreshments, serving lunch, helping people walk to the toilet, moving furniture, chatting with attenders, collecting money and 'troubleshooting' (e.g. sewing on buttons, buying birthday cards locally). Volunteer and staff outcomes are reported elsewhere (Orellana, Manthorpe and Tinker 2021b). Volunteers speci cally mentioned having received training in moving and handling people, rst aid, food hygiene, falls prevention, dementia awareness, and in the Mental Capacity Act 2005.
What is in a 'day' Opening hours ranged from 4.5 to 6 hours. All centres differed, but all built in informal time at the start for arrival, refreshments and chatting, lunch, midafternoon refreshments and optional organised group activities, with programmes in uenced by facilities available. Tables 4-7 outline the research day at each centre and models of provision. DCHA and DCLA ran regular, timetabled activities whereas programmes at DCV1 and DCV2 varied, and DCV1 had an informal, semi-structured session. Activities included some with a therapeutic or rehabilitative nature, although this was not always explicit. Not all attenders participated in all activities. Additional services were available at some centres on request or through links with social care and health services or local community and voluntary organisations; these are summarised below and set out in the next section. Supplementary Online File 1 provides a narrative description of a 'typical day' and fuller details of the variety of activities taking place at each centre, as observed and recorded in eldnotes.

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Charges to attenders Full nance details, including individual payment methods, were not made available. Centres charging systems, attendance, meal and transport charges varied (see Table 8). Voluntary sector centre charges were lower as they were subsidised by grants, contracts and fundraising.

Discussion
We have provided contemporary and rich descriptions of four distinct English day centres for older people. Operational descriptions and narrative accounts of days provide greater depth than other accounts and highlight centres' diverse nature, thus furthering the understanding of these services and providing background for debates about day centres and their optimisation which have been newly stimulated by the Covid-19 pandemic.
We have clari ed what makes 'the day centre' a multi-faceted intervention that each attender is likely to experience differently due to its complexity and heterogeneity. It incorporates door-to-door accompanied transport to a xed venue with varying facilities, a meal, refreshments, a group of peers, trained staff/volunteers (some of whom may be older themselves; see Orellana, Manthorpe and Tinker 2021b) who provide both care and emotional, physical and practical support, the opportunity to socialise and participate (or to witness without participating) a variety of structured or unstructured activities or be entertained, group outings, and access to other services or activities local partnership working has facilitated. Contextual data presented here support interpretation of other studies' ndings, such as outcomes for day centre attenders, volunteers and carers, and the service's focus on relationships (e.g. Increased numbers of people sought support from other social care services due to temporary pandemic-related service closures (ADASS 2021a). One local voluntary sector provider blogged that "admission to residential care for eight of our [day centre] service users was disappointing for staff, of concern to relatives and an added nancial cost to the local authority (…) but also an ironic indication of the preventative value of day care, which is sometimes viewed as an outdated service" (Lee 2020). Another reported re-opening its day centres as early as possible because its members said they would rather risk infection than be consistently at home (Newton 2021).
Giebel et al.'s (2020) study of carers and people living with dementia, undertaken during the early part of the pandemic in the UK, concluded that "nothing can replace the face-to-face human social interaction and the impact this has on someone's well-being." Despite some providers maintaining contact with day centre attenders and carers via regular phone calls or internet-based activities, the latter were not always successful particularly for people with dementia living alone or with more advanced dementia ( At the time of writing (October 2021), the English day care sector is still not fully operational despite national guidance allowing formally organised support groups for up to 15 people since July 2020, and 30 people from May 2021. In April 2021, estimated commissioned day centre places, for all adults, had reduced to two-thirds when compared with February 2020 places (pre-pandemic) (ADASS 2021b). Operational challenges to re-opening for the not-for-pro t sector include substantial income reductions due to reduced fundraising activity, unavailable volunteers due to Covid-19 vulnerability, and di culties ensuring a Covid-safe environment (Groundwork UK 2020, Townsend 2021).
Greater need for voluntary sector services, post-pandemic, has been mooted due to increased isolation and anxiety among older people, reduced physical activity affecting health and wellbeing, and increased carer stress (Groundwork UK 2020). With residential care reported as a less attractive option post-Covid (Quilter-Pinner and Sloggett 2020), alternative options, such as day centres, will increase in importance, particularly given high digital exclusion among older people and because internet-based provision does not enable a change of scene or personal care, something day centre attenders value (Orellana, Manthorpe and Tinker 2020b). Within this context, day centres' suitability to support recovery has been proposed (Lunt et al. 2021, Green, Orellana, Manthorpe et al.

2021).
We now brie y comment upon centres' aims, local collaborations and nances.
Contrary to Tester's (1989) nding, centres' aims were clearly de ned but differed in speci city. Aims addressed English health and social care policy target areas and were consistent with recent literature (Orellana, Manthorpe and Tinker 2020b).
This article links with the current English policy agendas of ageing in place (growing older at home with changing needs), prevention and early intervention and partnership working (HM Government 2014), planned growth in social prescribing (NHS 2019), and interest in the potential of community assets. Under an asset-based approach, day centres can be considered 'anchor institutions' which promote the health and wellbeing of individuals in a local community (Daly and Westwood 2018). Social prescribers, social care and health professionals, including those who are peripatetic or community-based (e.g. undertaking outreach or medical visits), may wish to make themselves aware of their local day centres, the services they offer and facilities available.
Exploring potential future collaborations is recommended. Most local authorities want to invest in prevention and new ways of working; these are an important way to deliver savings whilst recognising that statutory funding for local services continues to be problematic (ADASS 2021b). Some examples of additional services or support for attenders resulting from local links have been provided here. Most had been developed by DCLA, something possibly linked with its larger size, exible, standalone premises, ve-day operation and more stable funding.
A hindrance may be "di culties in obtaining accurate information on costs", also experienced by Tester (1989

Limitations and strengths
The research was undertaken at a time of nancial cuts and service reviews. Reviews, reduced numbers of centres and lack of publicly available information meant some typologies were not represented, for example, small, entirely volunteer-run day centres without national a liations and for-pro t centres (all of the latter identi ed specialised in dementia care).
Centres' typological and location diversity helped compensate for the study's limitations which relate to the small number of participating centres in one region and the inclusion of data from the agreed research days; other days may have differed in attender pro le, activities and sta ng. International comparisons are di cult as models differ between, and within, countries.
Strengths lie in the study's in-depth nature, resulting an in-depth snapshot of one day at each centre, and focus on generalist day centres. Risk of disruption to normal activity and practises was minimised by regular full-day visits which habituated attenders, volunteers and staff to the researcher and led to a trusting rapport. A risk of bias is that poor-quality day centres may not have agreed to participate.

Conclusion
This article has updated the English evidence base about older people's day centres not specialising in the care of older people with dementia by setting out the details of what happens in these services and local links in place. It shows how 'the day centre' is a multi-faceted intervention within a local context encompassing many different planned and unplanned elements. Some may be part of anchor institutions, others offer opportunities for asset-based community development, drawing on mutual aid and volunteering support.
One Covid pandemic legacy is a greater understanding of the need for in-person, face-to-face (relational) contact and the di culties experienced by certain groups of older people when their supportive relationships delivered via day centres were halted. Given the importance of relationship based public services (Mackenzie 2021), it may be timely to re-examine the value and broader use made of these services, and their buildings/activities, which have tended to remain invisible to scrutiny due to their smaller scale, exclusion from regulatory frameworks and patchy online presence (Green et al. 2021). Rather than focusing on these as resource-heavy services, consideration could be given to what they do, and could offer -to individuals, their staff and volunteers, the social care sector, the wider community, local authorities, the health service, and the education sector -within the context of a preventive and early intervention approach espoused by policy. Five-day operation on ground floor of extra care housing (supported living apartments); accepted local authority referrals only; for older people with eligible needs (social isolation and needing support with personal care and transport) referred by the local authority and funded by a 10-year block contract. A local authority day centre review document stated that annual running costs were £304,300 excluding transport (February 2015). Manager (on secondment) reported not always having sight of the centrally-held budget. Paid frontline staff. Capacity of 20 (14 registered attenders at time of research); 9-12 people were observed to attend daily during the research period.

Tables
Local Authority Day Centre (DCLA) Five-day operation in a purpose-built centre; accepted local authority referrals and drop-ins (without assistance needs) for activities and/or lunch; for older people with eligible needs. Funded by an internal budget; 2015-16 expenditure £679,588 excluding transport. Paid frontline staff and one part-time volunteer. Capacity (with unchanged staffing levels) of approximately 25; 22-28 people were observed to attend. It was also open to drop-in users who were self-sufficient and without eligible needs; up to 10 daily were observed to join the group for lunch.

Voluntary
Sector Day Centre 1 (DCV1) One-day operation in a church hall, provided by the local arm of a national charity; open access for people of any religion, race or ethnic origin aged ≥60 years and housebound, socially isolated who may be in receipt of care from statutory or voluntary agencies, but not for people needing lifting, personal care or nursing, or people needing specialist care for mental illness; funded by a three-year Service Level Agreement (SLA) (national provider body) of £5,054 annual maximum 2014-2017 (for 20 weekly attenders, released for actual numbers). Fundraising. Office rental cost (approx. £5,000) donated by church which allowed hall use free of charge. Annual core grant from the local authority (with Service Level Agreement) for all services provided, not just day centre. Frontline volunteers. Capacity of approximately 25; 12-14 people were observed to attend. Closes for three weeks over Christmas and the New Year.

Voluntary
Sector Day Centre 2 (DCV2) Two-day operation in a multipurpose community hub, provided by a local charity affiliated to national charity; accepted both open and local authority referrals; for socially isolated older people with transport needs. Not for people with personal support needs (only assistance is provided e.g. to get into shower or go to toilet); funded under an annual SLA with the local authority (extended annually for the previous 3 years after its 3-year contract ended) for up to 15 per day. Income and expenditure are integrated for provider's 3 centres, with each place costing the provider approximately £19. Raffle is a small fundraiser. Paid staff and volunteers. Capacity of approximately 25 (11 registered attenders at time of research); 6-11 people were observed to attend. Closed Christmas Day to 5th January.  Other practical training Medication administration/storage (n=6), safeguarding awareness (n=3), manual handling in emergencies (n=1), mental health first aid (n=1), dementia and mental health awareness (n=4), learning disability awareness (n=1).

Specialist training
Infection prevention and control, nutrition and hydration, diabetic awareness, epilepsy and pressure sore/ulcer awareness.
Diversity and inclusion (n=2). Trusted Assessor certification enabling assessment for community equipment to assist with activities of daily living (n=1). Working relationships and information handling (n=1). Dementia (one staff was the internal dementia specialist, delivering short training sessions to other staff where time allowed).

National Vocational Qualification (NVQ) qualifications
Level 3 NVQ in Health and Social Care (n=3). Level 2 NVQ part-completed (n=1). NVQ level 2 in Health and Social Care equivalent (from another country). NVQ assessor (n=1).    Available on request A staff member was trained to file and polish nails (charged at £2.50) and, as a hairdresser, also gave haircuts for a donation to the centre (usually £5). Shower. Two attenders regularly visited the library. One used the co-located advice service after staff arranged appointments.
Available through local links Self-employed chiropodist visited fortnightly, providing heavily discounted treatment. Optician visited twice yearly. District nurse visits individually arranged. More regularly, the centre hosted a local charity-operated Monthly Hearing Aid Clinic (open to local residents of the area and attenders), Self-employed masseuse (six-weekly for attender and external bookings). Visiting artisan who sold jewellery. Local authority-employed Community Warden visited occasionally to check if attenders had concerns needing addressing. Provider website stated eye tests are also available on request. with an Information Sheet and the opportunity to ask questions, all participants gave informed consent to audio recording of the interviews and pseudonymised use of the data.
Role of the funding source Funders had no input to the study design, recruitment, data collection, analysis or interpretation, or in writing this paper.

Contribution of authors
Author 1 jointly developed the research proposal for this study, undertook the research reported in this article and wrote the manuscript. Authors 2 and 3 supervised the project. Author 2 was involved in developing the research proposal and contributed to the content and editing of the manuscript. Author 3 commented on drafts of this article.

Transparency statement
The lead author a rms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted.