Reimagining the care home

'Boredom’, ‘loneliness’, ‘illness’, ‘isolation’ and ‘uncaring’ are among the words most associated with care homes by members of the public. While only 39% of care home workers would consider moving into a residential home in their own older age.* This reflects a crisis of confidence in the support and care available for older people, but as things stand there is no clear articulation of how we value care as a society, or how to address the growing challenges the sector is facing.

In 2016, a record 75 residential care homes went out of business, and the most recent Autumn Statement failed to respond to the growing challenges facing the social care sector, which is estimated to face a £2.5billion funding gap by 2019/20. The number of over-65s in England is projected to increase by 36% by 2030, reflecting an aging population that will require more care as it experiences higher rates of complex (and often multiple) illnesses including diabetes, cancer, heart disease and dementia.

Skills for Care estimates that up to 700,000 additional workers will be needed across the social care sector between now and 2030 to meet growing need, but the sector is in the midst of a recruitment and retention crisis, and facing an additional loss of EU workers post-Brexit. In addition, scandals in the wider care system have increased anxiety around the quality of residential care, at a time when in some areas of the country, half of available beds are in homes rated as requiring improvement or inadequate.

As part of the RSA’s work on the Health as a Social Movement programme, we have been working with the Airedale Social Movement project in Yorkshire to explore how care homes can be improved on the ground. This project is led by the Alzheimer’s Society and is working with local care homes to listen to their residents, staff and local communities about what they want and can offer, and to trial new ways of doing things.

A large part of the work has focused on engaging young people and providing inter-generational activities so that young people experience the benefit of spending time with the older generation.

Children and young people from local schools, colleges, pupil referral units and the National Citizens Service have been visiting care homes to work on various projects including storytelling, arts activities and to take part in work experience and make improvements to a care home garden. Work experience has involved not just health and social care students, but also those studying subjects across the arts, beauty and medical courses. 

In one care home, volunteers have been teaching residents how to use the internet to share photos, video-call loved ones that live far away, and shop online. In another, weekly boccia and ping pong sessions have proved a particular hit with residents. An allotment society for green-fingered residents has been set up and others have worked with a photography group on a local history project.  An emphasis of all the projects has been engaging the local community and ensuring that new visitors are regularly interacting with residents and that lonely members of the community feel welcome in the care homes.

This work has highlighted that while additional funding and better workforce planning are clearly important, using these resources to prop-up the status quo in care homes is not enough. Better resourcing needs to be underpinned by shifting to new day-to-day practices which recognise two key factors: 1) that quality of life depends on more than being fed, washed, clothed and medicated, and 2) that care homes and their residents have a lot to offer, and gain from, each other and their wider communities.

In order to progress with what was being learned, the RSA held a workshop with the Alzheimer’s Society and care home staff to develop ideas for what further changes the Alzheimer’s Society could support in the care homes they work with. These ideas were developed by focusing on three key questions:

• How can we give people living in care homes more choice and control over their involvement in the communities in their lives?

• How can we support inclusivity in care homes?

• How can we enable care homes residents and spaces to be assets to the wider communities they are situated within?

The discussions and ideas developed in response to these questions drew on the expertise and experiences of all participants.

How can we give people living in care homes more choice and control over their involvement in the communities in their lives?

We were told repeatedly that an important working principle for care homes is the ‘Mum Test’, in which those involved in providing care should ask “Is this good enough for my mum?”

This represents a fundamental shift in mind-set that requires a number of changes, including the way that staff work and are valued; how residents are treated and interact with their communities; how care-home owners operate; and where researchers should focus their efforts to gather evidence in support of better services in the future.

We explored four key approaches for giving residents a greater sense of choice and control. The first of these was training for staff, which was seen as integral, in that staff practices need to incorporate more personalised and collaborative approaches to meeting residents’ needs, rather than one-size-fits all approaches which constrain residents’ ability to shape their day to day lives. It was also felt that improved training for staff should be matched with employers, and society as a whole, better valuing the work that they do.

Developing skill sharing initiatives which enable residents, staff and people from the local community to share their skills and knowledge with each other was also identified as an important option. To support this, the growing practices of using the ‘This is Me’ approach and ‘Red Bags’ for each individual resident were highlighted as examples of good practice, which recognise residents as individuals with their own personalities, life stories, likes and dislikes.

A third approach explored was how resident-led employee award schemes could enable residents to recognise and celebrate staff whose work they particularly value, and would provide a mechanism for incentivising cultural change within care homes while also empowering the residents as part of this process.

The final factor which this group discussed was developing new ways of communicating with care home residents. The participants highlighted how there are significant opportunities to improve the use of non-verbal, digital communication in the practice of care. This includes improving residents’ access to the internet and use of apps on tablets, but dementia-friendly innovations such as ToverTafel also provide interesting tech-based options.

How can we support inclusivity in care homes?

Two key principles were drawn out through the discussion around this question.

Firstly, that it is important to resist common characterisations of people in care homes – we shouldn’t assume that everyone wants to listen to Vera Lynn, as new generations enter care homes many now want to listen to the Beatles or the Supremes, for example. Secondly, it is important for staff and residents to be inclusive of everyone across a range of ethnicities and sexualities, and this should be reflected in appropriate and respectful language.

Staff training was again identified as being particularly important, as the workshop participants spoke about how little many care home staff know about dementia, as training is not mandatory. It was felt that this is something which families and the general public are not aware of, but is a significant issue in the care home system.

Linked to this is the issue of recruitment. The discussion covered successful examples of value-based recruitment - where care home staff have been selected according to their personal values and core competencies, rather than their existing care experience. It was stressed that to be successful, this approach must be followed-up with ongoing workforce management which reinforces the importance of core values in the workplace.

Another factor the participants were keen to highlight is how important families are to residents, and that more involvement in activities and collaboration between staff, residents and their families to meet the needs of residents would be a key positive change. However, there was also a recognition that experience to date indicates that this can be particularly challenging to put into practice.

Finally, this group also emphasised the importance of bringing care home owners into discussions about inclusivity and shared values, in order to ensure that these principles are built into their business strategies, as well as at the delivery level in care homes themselves. This underpins other key principles, such as improving training in order to ensure that staff are better equipped to connect with the wider community and establish sustainable relationships with them.

How can we enable care homes residents and spaces to be an asset to the community where they are situated?

A number of externally-focused community building activities and ideas for how to open up the physical space and facilities of care homes to the local community were considered. These included hosting cooking classes, resident storytelling, music events, health and safety training, and incorporating children’s centres, shops, hairdressers etc. However, it was noted that not all care home buildings are suited to the kind of physical upgrades or retrofitting that might be needed to make this possible.

This issue led the participants to explore how it is important to factor in a range of uses when designing new care homes, or renovating older ones. However, a major barrier is that most existing properties are privately owned. Given this, there are limited incentives to invest in costly changes, but longer-term examples of innovation and best practice could provide powerful blueprints for how it can, and should, be done.

In terms of enabling residents to become assets in their community, the participants felt that involving residents in decision-making, interview panels and staff training sessions would help to empower them with a sense of ownership and better integrate them into their care home community as a whole.

An activity which the group discussed in some depth, and which could bridge both internal and external community building, was identifying what assets - such as shops, parks, classes, community groups, schools etc. – are in the local area and how they map against residents’ interests. This would draw on the knowledge of people living inside and outside the care home and could be made visual and easily accessible for residents. This asset mapping was identified as a key idea for change, alongside involving students, volunteers and businesses with Dementia Friendly Communities, and exploring options with organisations such as Scouts or Girl Guides to create a new badge for activities with residents in care homes.

From all of these workshop discussions, it is clear that there is no shortage of ideas for how to bridge the gap between care home residents and their communities. There are many ways in which our society can meet the needs of care home residents beyond the basics of being kept fed, clothed, clean and medicated, in order to enable them to live the richer, more fulfilling lives that we would all like in our older age.

But it will require persistence and collaboration to drive change in a care home system which is often entrenched in its current practices, and stretched by financial and workforce pressures.

This is, of course, not an easy task. But when considered through the lens of the RSA’s emerging model of change, it is important to understand the current system, with its incentives, values and norms. A key challenge is to imagine what change could be possible and to make the most of all opportunities to move towards that future, however imperfectly it may be defined, and however complex doing so may seem.

We characterise this approach as ‘thinking like a system, and acting like an entrepreneur’, and argue that it is sometimes important to gain momentum through incremental change, sharing and celebrating successes along the way to generate further energy for change.

Projects such as Airedale Social Movement are exciting examples of how to imagine a better future for the ways that we look after our older people, and are identifying opportunities to put these ideas into practice. In doing this, they are taking action and making a tangible difference to the lives of the care home residents they are working with and their wider communities.

Airedale Social Movement is currently recruiting Community Connector volunteers who will adopt a care home and find ways to link residents to their local community, so if you live or work in or around Leeds, Airedale, Wharfedale or Craven, and are interested in how you or your organisation could get involved with Airedale Social Movement’s work, please get in touch with Laura Cope at Laura.cope@alzheimers.org.uk.  

If you have any queries about the RSA’s work on the Health as a Social Movement programme in general, please contact Becca Antink (Becca.antink@rsa.org.uk).

* Commission on Residential Care survey findings:  https://www.demos.co.uk/project/the-commission-on-residential-care/