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Modernising Residential Care

The Residential Forum, established in 1994, has sought consistently to promote high standards in residential care and to contribute to improving the quality of services to users and the public. The Forum has always benefited from the fact that it encompasses all parts of the residential sector - statutory, voluntary, not for profit and private. It has produced influential publications, among others Creating A Home from Home, Managing a Home from Home, Training in Social Care, Care Staffing in Homes for Older People and Care Staffing in Homes for Younger Adults.

The future of residential care has been subject to much comment in political, media and social care settings and the Residential Forum concluded that the time was right to bring together a wide range of people to discuss the subject over a 24-hour period. Over 30 people contributed from all four countries of the United Kingdom, including representatives of Government Departments, regulatory bodies, registration authorities, training organisations, promoters of excellence in social care, relatives and service users, providers, academic institutions, practitioners and members of the Residential Forum.

The themes and issues that were raised before the meeting included:

  • Is there a future for care homes and if there is can we drive up standards?
  • Residential care still has a poor reputation – what can we do about it?
  • How will long term care be valued?
  • Can we deal effectively with residential care for children and adults?
  • Does increased specialisation make this impossible?
  • How do we ensure users have a real voice and choice?
  • Is the end of residential care now in sight?
  • How can we best address recruitment and retention staffing issues?
  • How do we best meet the skills and training needs of the staff?
  • How can we create a confident workforce?
  • Future workforce needs, including management, are vital for the future - what are we doing to prepare for the changes we expect?
  • The role of regulation as a positive force

This paper brings together the main themes discussed. They are not necessarily the views of any individual who attended or any organisation represented.

Improving the reputation of residential care

Most children, young people and adults prefer to stay with their families and in their own homes and this is the basis of social care legislation and guidance. For a minority this is not possible. Surveys suggest that most adults and their relatives with direct experience of it see residential care as positive. The benefits it offers them when care at home is not an option are that they feel safe, risks are reduced and they have the best chance of maintaining their quality of life or slowing down their loss of independence. For young people residential living can be a haven from repeated breakdowns in their care and experiences of abuse. It provides them with a chance to recover and increase their life chances.

The characteristics that give people a positive experience of residential living are:

Independence, Empowerment, Choice, Dignity, Respect, Flexibility, Consistency, Competence, Courtesy and Safety

However, residential care has a persistently poor image and is often best known to the general public from media reports of abuse and serious failures.

Even in the trade press there are very few positive reports on residential care (Brindle, 2004) and politicians often portray residential homes as places to be avoided at all costs. The ‘warehousing’, ‘last resort’ picture persists of institutions where children, young people and adults were ‘put away’ to stay. ‘A Positive Choice’ (Wagner 1988) still seems far away in the minds of the general public.

No one associated with residential care can ignore serious failures that continue to occur in some homes in spite of National Minimum Standards, repeated efforts to increase the number of qualified staff and to make training relevant to the work. Although there have been significant improvements, a gulf remains between the public perception of residential care and the first-hand experience of residents, their relatives, staff and managers. There are indications that this may be slowly changing. Positive publicity is beginning when relatives and residents have been vociferous in arguing against home closures. The public is becoming more aware that residential care may at times be the most positive option open to them, their relatives or friends. This gives them a vested interest not only in its survival, but also how the best can be maintained and developed.

This paper addresses two questions:

1. How to promote a modern vision of residential care that recognises the many different forms it takes?

2. What needs to be done to get a more balanced reputation for residential care, where there is acknowledgement of its contribution as well as keeping the alertness necessary to prevent and to challenge any failures?

A new vision for the Twenty First Century

Our vision is that residential living should:

Centre on the person
This requires seeing an individual as a whole person and not a set of problems. It means looking at the different aspects of their lives and what they want to achieve in the short, medium term and longer term. Holistic frameworks already exist for all the different professionals and organisations that need to be involved to tailor support as closely as possible to an individual’s aspirations. The challenge is to make this a reality and to increase choice and the range of options. A person-centred approach contrasts starkly with a ‘one size fits all’ approach still found in much institutional care.

Change the balance of power
Individuals needing support and accommodation have a right to be treated with respect, to maintain their dignity, to exercise their rights as citizens and to make choices about the way they live. Currently a move into residential care means loss of rights as tenants in contrast with those living in supported housing. This loss of rights, coupled with often needing support to carry out daily living tasks and intimate personal care, changes the balance of power whether or not the individual is paying fees. Systematic steps are required to change this power imbalance, for example, by direct involvement in the governance of the facility or through independent advocates. The Codes of Practice for Social Care (2003) provide a framework that should banish such statements as:

‘We would like people who care for us to know our names before they wipe our bottoms’

‘My mother in law has lived in a nursing home for two years… she has never, ever eaten cheese… yet time and time again she is served, for tea, a cheese sandwich. When her family are there and protest against this, the cheese is grudgingly swapped for jam. She is paying nearly £700 a week for her care’.

Challenge established ways and promote new forms of provision
There is already a wide range of different forms of ‘residential care’ or ‘supported living’ apart from the residential care home. They include:

  • Groups of older people who own the property who have chosen to live together to give each other support or to purchase it collectively when necessary
  • Extra care housing and supported housing where support is provided on a temporary or permanent basis that is available on request or for up to 24 hours
  • Purpose built communities where collectives of people own or rent their accommodation but have access to more intensive support when necessary within the community
  • Residential homes that provide additional facilities to the local community such as day care, recreational facilities and outreach resources.

Innovations such as these that promote choice, flexibility and independence should be developed. Conventional thinking based on inputs and processes rather than outcomes must not be allowed to block innovation and creativity. Direct payments have been a way of promoting greater choice, flexibility and independence. The extension of this option into residential care should be considered. A starker phrase for this could be ‘Give them the cash’. Many might continue to use that cash towards the provision of their residential care. It would, however, be a definite choice based on what they need to achieve maximum flexibility and independence.

Promote people’s connections with family, friends and community
A move into residential care is often a change in the way support needs are met rather than an end to care from family, friends and community. Relatives and parents often want to share, not stop providing, care and support. The challenge is to enable these relationships and the activities to continue whenever possible. Connectedness with family, friends and community is particularly important where people are from a minority ethnic group different from the majority of other residents. Loss of contact with ethnic heritage and community has a profound effect on our self-esteem and identity.

Be integrated with the local community
All residential accommodation takes place within local communities. Residents have often lived locally as do family and friends and the majority of staff. Breaking down isolation is part of preventing abuse. Promoting family and community participation enriches the lives of residents or tenants and means that staff and managers have to be able to explain and justify major differences between the lives of residents or tenants and ’ordinary life’ and expectations about choice.

Getting local commitment is not easy. Many residential homes have to compete for local community support with other more attractive local organisations that give more of a ‘feel good factor’ to the local community.

Be part of a spectrum of services
Many children, young people and adults combine residential living with periods of time in their own or their families’ homes. Others need intensive support for the short term. Seeing residential care or supported living as terminated only by reaching adulthood or death is not only far from reality, but has an impact on the expectations of individuals, their families and staff.

One task is to change the public perception to recognise the diverse contributions that residential care and supported living make to people’s lives. A second is to increase the use of residential care for periods of re-assessment, planning interventions to cope with changed circumstances and conditions - a pattern used by the hospice movement.

A small group of children, young people and adults will remain who will need some form of residential care for their own safety and well being and/or that of others. They may prefer this option because they need a haven or a refuge within which to recover or because the skills required for their support cannot be provided on an individual basis within their own family or home.

Residential support takes many forms and may be used intermittently or for short, medium or longer periods of time.

Achieving a transition to a positive choice

1. A public debate
The future of residential care and supported living affects over half a million people in the United Kingdom currently, and many more who may wish to consider it at some time in their lives.

There is a major challenge to shift public perceptions of residential care and supported living from the position existing today. Without a public debate creating a vision for the future, residential care and supported living will remain in the ghetto of the social care profession.

2. Change the name
A growing number of people are arguing that ‘Residential care’ is no longer adequate to describe the wide range of provision that exists. It conjures up images of large institutions isolated from local communities and where people are put away. Alternatives such as ‘accommodation with support’ have been suggested, but changing the name without changing the approach would serve no useful purpose. It is in the context of modernising residential care that the search for a new name needs to continue.

3. A planned reduction in outdated provision
Some outdated provision has already gone, in recognition that it could not meet future needs and more remains that will need to be phased out. New and innovative forms of support, including residential care, that are consistent with the principles underpinning our vision should be actively promoted. The implementation of this strategy must recognise people’s current needs and not leave them or their families bereft of support.

4. Increasing the range of preventative support and community based services
Few choices exist currently and most decisions are made based on assessed needs, availability and cost. This situation will change only when more people can choose to remain in their own homes because intensive support from community based services exists. These need to be flexible, reliable, available earlier and to support family carers and parents in ways that are consistent with the outcomes people want to achieve. Encouraging people to say what is their best outcome helps develop new provision and sets a base line for tailoring what is available to come as near as possible to what people want to achieve through support (Nichols and Quereshi 2003). Choice, even if constrained, gives people a sense of control over their lives and this in turn promotes well being.

5. Environmental and technological changes
Environmental and technological changes can enable people to remain in their homes or be supported by their family for longer periods of time. Improvements to pavements, accessible buses that use their technology effectively to reduce falls and pain for people with restricted mobility, IT systems that connect people’s homes to support systems, SMART housing – these already exist and could be used more intensively. All require a more inter-disciplinary and inter-organisational approach that crosses the divide between the public, private and voluntary sectors.

6. Commissioning and regulation
Commissioners and regulators will have to have an eye to a future vision when carrying out their work, and at the same time ensure that people choosing or requiring residential care now are not sacrificed to some future utopia. Commissioning that concentrates on the quality of life for individual residents or tenants should be developed. We already know that people want consistency, continuity, contact with family and friends and control from residential and supported living arrangements

7. A skilled and experienced workforce
A smaller residential care sector and an increase in community based services and supporting housing mean that the skill base of both workers and managers will need to rise. Since most people will choose to remain living in the community for as long as possible those living in residential care will tend to have the most complex and intense needs for support. Creating a sufficient base of expertise will require more stability in the workforce and training to assist in the transfer of skills from one area of work to another. There are a number of questions that will need to be addressed:

  • Is the required workforce going to be available?
  • Are the rates of pay commensurate with the skills required?
  • Can the training and qualification demands be met and do they reflect the vision for the future of residential care?
  • How can we encourage the leadership that is essential to good management and promoting quality services?

Summary

When the Residential Forum planned the 24 hours discussions, there was no expectation that participants would come up with answers. We wanted to stimulate debate. Government Ministers in all four countries demand an innovative approach to social care. We argue that if these innovations are to succeed, residential care must be part of the future. It does, however, mean significant change.

Whatever its form residential care gives enormous strength and support to some people. At its most intensive residential care is 24 hours a day, 365 days of the year; for others the support will be less and for some minimal. Whatever the timescale it is the quality and appropriateness of the support and the staff providing it that matters.

Innovative and flexible care will require more risk taking than is permitted at present. Managing these risks will require commitment from national governments, local government, trainers, providers, regulators and the workforce.

We have deliberately not given priority to funding, not because we are unaware of its importance, but because many of the necessary changes are in attitude, many cost nothing to implement and new approaches could bring about changes that lead to new avenues for funding.

Residential care faces great challenges and in some areas is under threat. Doing nothing is not an option if it is to survive and offer high quality care. Its reputation will only improve when there is a new modern vision and the focus is centred on people using these services and their quality of life.

The Residential Forum will contribute to the generation of fresh thinking. It will seek to offer to the four countries of the United Kingdom a forum for debate and discussion and real, achievable outcome-based suggestions for the future.

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