Watching care behind closed doors: upward and downward accountability mechanisms in nursing home services

Nursing homes (NHs) play a critical role in caring for vulnerable people, yet their operations often remain hidden from public scrutiny, potentially causing a negative impact on service quality. We investigate upward and downward accountability mechanisms in NH services, examining how relatives of NH residents assess these mechanisms and what influences their assessments. We conducted an original survey in Spain (n = 1009), targeting direct relatives of NH residents. Our findings show important insights about the influence of private ownership, performance during COVID-19, and knowledge on the two types of accountability. The study demonstrates that downward and upward mechanisms are closely intertwined.