Care homes: coming out of the shadows?

In Untold stories Alan Bennett draws on the experiences of his mother, who had dementia, to capture his unease that ‘something is not right around care homes for older people’. He wrote ‘a home is not a home but neither is it a hospital nor yet a hotel. What do we call the old people who live (and die) there… residents? Patients? Inmates? No word really suits. And who looks after them? Nurses? Not really since very few of them are qualified. As Mam pointed out early in her residency: “They’re not nurses these. Most of them are just lasses”.’

Ten years on, these persisting ambiguities were reflected, albeit in less inimitable prose, at our recent conference on the role of care homes in delivering integrated care. David Oliver has described elsewhere why care homes are hugely important to the prospects for our health and social care system – their places outnumber hospital beds by about three to one. So it was not surprising that the event attracted an enthusiastic and engaged audience of more than 200 people, many drawn from the care home sector. The diverse range of presentations and case studies will no doubt elicit different reactions and views. I was struck by three strong themes that emerged.

The first is the transformation in the level of acuity and complexity of the needs that most care homes for older people now face. Dementia, frailty and complex co-morbidity are now the norm among people in care homes. Yet the way their care is commissioned, organised, delivered and funded has not kept pace. One example is the difficulty of ensuring residents can receive good health care – aimed at essential needs such as podiatry, continence and good primary care management of long-term health conditions. ‘The NHS does not stop at the door of the care home’, Andrea Sutcliffe, the Care Quality Commission’s Chief Inspector of Social Care, reminded us

The second theme is workforce recruitment and retention. A big worry is the growing difficulty of recruiting qualified nurses from a limited pool with stiff competition from hospitals that offer higher status, esteem and career opportunities. The ability of providers to pay little more than the national minimum wage for mainstream care staff also acts as a huge brake on career progression and opportunities to improve the quality of care.

The third theme that stood out is there is much good practice to celebrate, as Professor Julienne Meyer pointed out to much applause. The conference heard many examples of innovation in areas such as reablement, supporting nursing in care homes, and housing-based models of care. NHS England’s programme of vanguard sites for developing enhanced health in care homes excited great interest, though it is pause for thought that this was the first time many attendees had heard about it.

All of these issues were brought into sharp focus in the final panel discussion involving people who are at the coalface of residential care, directly managing or owning care homes. What was top of their wish lists for good joined-up care? They wanted care homes to be accorded the same respect and esteem as other valued public services such as hospitals; to have more staff to respond properly to the growing needs of residents; to be able to pay staff more than the minimum wage; and to have better access to quality – adding services such as physiotherapy.

That none of these ‘asks’ seems unreasonable reflects how long care homes have operated in the shadows of public and political awareness, with policy attention focused on reactions to service failure rather than the promotion of good care.

Historically, care homes have received but a fraction of the time and resources bestowed on other parts of the health and care system. Many, but not all, of the sector’s woes are fuelled by under-funding, of which low staff pay is one symptom. The NHS’s £30 billion funding shortfall has created much noise, but the sound of silence surrounds the deeper funding malaise in social care. And though the NHS five year forward view vanguard programme is a welcome starting point to treating care homes as part of the whole system of care, a much more ambitious programme will be required to reflect the scale and diversity of the care home sector. Care England and the National Care Forum have each offered a clear prospectus for improvement and reform. If our event is any guide, care homes are eager for change. But what about everyone else?

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Comments

#544308 George Coxon
Various inc care home owner
Various

We are seeing much appreciated positive stories and coverage of the value of 24/7 care Dementiaville for example has been rightly celebrated and gave us care home ambassadors a welcome opportunity to say 'look , there are those amongst us really believing in reflective positive proud working with our older citizens'. People deserving of kind good humoured full time care. My three themes to add to this excellent blog (not wishing to detract from Richard's here) are:

1) TIMELINESS of the right care & support at the right time promoting & preserving choice for people wanting care home life.

2) there is a lot of mixed EMOTIONS in the sector - frustration, determination & pride in our work most commonly ( it is 'work' but it's also about a genuine desire to make people laugh, smile & feel looked after & valued doing things they want to do as much as being independent in care homes which is quite doable as we know).
3) SUSTAINABILITY is a critical factor Few care homes are receiving outstanding CQC inspection outcomes - we know there is always room for improvement. So in truth we should always get yellow lights in our inspections at best but this would be deeply damaging to us all. Staff morale is dependent on being part of innovative team work & success. There is a great deal of doubt & suspicion of the sector from those who believe there are too many bad care homes. Yellow or red light homes reinforce this combined with many media shock stories Paying the living wage for all staff plus the differentials for senior staff is another sustainability challenge where we are also seeing social care funding squeezes & cuts.
All of our happy & safe futures as we live into our 90s & beyond will depend upon lots of great quality 24/7 care rather than reliance on mostly family support & limited home care support. Let's all find more positive stories and blog more like Richard on the subject. Sorry about my vociferous outpourings here. It's just important Many thanks

#544322 Patrick Morreau
former chair of charity running 25-bed care home in north London

I wholly endorse what Richard says in his blog and George in his comment. One challenge that neither mentions is that presented by the Government's immigration policy: who will replace the caring carers from the Philippines, Africa, and elsewhere, who will now be barred entry to the UK?

#544336 george coxon
various inc care home owner and Devon kitemark lead
various

It's always good to be endorsed ! thanks Patrick stakes are high and yes workforce is a challenge 'tell me about it' as the expression goes - I have 2 great, small, dynamic,'safe and fun focused non nursing care homes (thank goodness we are non nursing as this I see as one of the major pinch points well outlined recently in various reports and acknowledged in one of Andrea Sutcliffe's recent blogs) and we are very aware of the issues in getting and keeping good staff.
Exchanges like this always have me wanting to share and confer in a positive and solution focused way - perhaps naively. I am however doing some linked in work with Skills for Care and Skills for Health including an interview tomorrow night with them, meeting colleagues in our 2 local universities and having a bit of input to the HEE work 'Raising the Bar - Shaping the Future' the document setting out the intentions for nurse and HCA training into the future - I'm also meeting our local CQC supported Care Certificate Project lead this week where no doubt I will be making a case for some really 'can do' planning on addressing the point you are making about workforce horizon anxieties.

#544378 Peter Davis
Care Assistant
BB Healthcare

If you will forgive the liberty of my copy and paste comments, this is the answer I wrote when asked in a training question 'How to Promote Values' in Care Homes. It has gone no further than my computer and the office, gathering dust, but was the response of my growing frustration of many points raised here by Richard. It may have some interest, as written by someone actually at the thick end of it with the residents, and though not 'qualified' is awake nonetheless. -

'The promotion of values requires recognition of the elderly as equal in their own right to all members of society regardless of their situation, age and ability. In an ideal world these would be givens. In the real world, realising that those we look after are simply further along the same road of aging that we all must travel and that they give us a glimpse of our own possible future and how our culture deems the end years of life are to be spent when we’re frail and less independent should be humbling enough to evoke an active interest in recognising and promoting the values in question.

The confidence to give our full attention and consideration to the needs of each individual in our care without succumbing to the commonly felt anxiety of a perceived or real sense of overwhelming pressure to attend to as many people as possible in a given time will help to promote these values. Simply being fully present and attentive with each person in our care, listening to their wishes, understanding their needs and responding realistically and supportively allows them the confidence and belief that they and their values are being acknowledged. This helps to promote a degree of autonomy and dignity in an environment now more structured, limited and controlled than they have been used to. Helping those now less able to recognise and accept their diminishing abilities/mobility whilst encouraging them to adapt realistically to alternative activities and possibilities to achieve fulfilment is also important for qualities they value to continue to have any meaning.

None of this means anything if the reality for residents (and staff) is simply conformity to the Home’s own structured agenda (institutional abuse) despite clients’ realistic wishes and preferences. Conversely, residents need to be encouraged to maintain their own initiative, interests and also accept responsibility for engaging themselves where possible in activities and interests where options are offered, rather than succumbing to the path of least resistance (and decline) - passive routine.

However, we cannot escape the difficult fact that the wider cultural and economic values that underpin our lives in general are inextricably linked to the value we will place on the elderly if regarded economically as having outlived their usefulness to society, save for the profit of private care homes. If we as a culture and society fail to value and accept the significance of human life in its full context as a continuum from birth to death through progressive stages it will be difficult for the owner’s of a Home to realistically promote values in their business plan, and for the elderly in society to retain any meaningful belief in them. Our ability to meaningfully promote values is entirely dependent on the framing conditions of the institutions and wider culture in which we operate. It is crucial that staff themselves feel valued and informed in their employment for failure to do so will undermine morale and the interest of a carer to care about values. This is not the nice easy format answer, but simply a reflection from the coalface.'

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