Residential Care Services
for Older People
1: BUILDING A POSITIVE IMAGE
The public perception of residential care as institutional care is so pervasive and so strong that the negative image has become firmly rooted in collective consciousness. In turn this negative image serves to strengthen prejudice against residential care as a service of positive choice. Prejudice against residential care has become ‘institutionalised’ in policy directives, by professionals and as a consequence the potential contribution to community care services has been marginalised and devalued. Nevertheless residential care for older people remains a significant service option.
Despite the evidence from regulators that service standards in residential care have significantly improved in recent years the negative image has proved remarkably resistant to change. As the traditional boundaries of residential care for older people have shifted with services responding to increasingly complex needs the purpose has become more difficult to define. Clarifying the purpose of residential care is imperative if a more positive interpretation of its contribution to the spectrum of community care services is to be properly acknowledged and further developed.
The role of residential care in offering additional choice, promoting independence, supporting early intervention and intermediate care along with meeting the needs of those requiring specialist services has to become an accepted part of the mainstream of provision for the positive potential of residential care to be achieved. Redefining residential care as a positive choice is a necessary prerequisite to harnessing its potential to:
- empower people
- demonstrate user focus
- challenge ageism, and
- be at the cutting edge of innovative services and best practice.
2: PART OF A SPECTRUM OF SERCVICES
Residential care is best described as a service with a purpose rather than a description of a physical form of care provision. Modern residential care services for older people are appropriately integrated into local community services. They complement primary health and acute care provision. They offer a range of services to deliver personal care and support within the spectrum of community care provision. The best examples reflect the diversity of other services such as domiciliary care and day care services.
Increasing specialisation of residential care services is evident, as the proportion of people with complex needs admitted into care has risen. Policymakers and commissioners insufficiently acknowledge this. The successful delivery of personalised care must not be seen as the antithesis of residential care.
It is important to recognise the changes occurring within residential care (including care homes with nursing) with an older and frailer population of service users. In part, this can be seen as the result of the success of domiciliary care designed to support people in their homes and to maximise their independence. Residential care services have changed and developed in response to external factors and market forces. The age on admission for older people has increased along with levels of frailty and complexity of need.
Buildings and facilities are an important aspect of residential care services enabling quality of care and support but they are only one component of residential care.
Residential care for older people covers a wide diversity of services provided by a wide range of providers – private, public and not-for-profit. This includes large corporate operators with national coverage, small single homes and a variety of interest groups with forms of not-for-profit status.
3: ASSESSMENT AND CARE PLANNING
Assessment is fundamental to the effectiveness of all residential care services. Decisions about suitability and the ability of services to meet individual needs require a consistent process. The development of a single assessment procedure has helped to demonstrate that an informed and professional process is achievable. However, the fact that eligibility criteria are used by councils in an arbitrary way to ration services undermines confidence in the arrangements.
There remains a need for a standardised assessment tool across residential care services for older people. In the absence of an agreed means of measuring and assessing needs there is no national benchmark against which to make judgments about services and trends.
There was discussion within the workshop of the need for an agreed way to understand better the experience of residential care from the different perspectives of:
- service user
- staff, and
- significant others
easy to say – difficult to pull off!
4: EXERCISING INDEPENDENCE, CHOICE AND CONTROL: IMPROVING THE QUALITY OF INFORMATION
To exercise positive choice for residential care services requires appropriate information to be provided at the right time along with any necessary guidance and support. Successive reports have highlighted the importance of information as a necessary requirement for informed choice. It is essential that information is accessible, accurate and available when people need it.
Inspection reports are a valuable source of information for people making decisions about care services. It is vital that the information they contain enables choice and control for people using services and their families.
5: OUTCOMES AND SATISFACTION MEASURES
The introduction and development of national minimum standards has arguably contributed to a general raising of standards within residential care services. The notion of defining and understanding quality from the perspective of people receiving services and giving greater prominence to the importance of outcomes (rather than inputs or outputs) has become accepted within care provision.
More recent policy initiatives such as ‘Our health, our care, our say’ and ‘Independence, well-being and choice’ have sought to develop further the means to ensure choice and control for people receiving services and to evidence achievement by defining satisfaction through outcomes. At the current time our understanding and ability to put this fundamental principle into operation remains somewhat aspirational. Partnerships with service users, advocates and relatives are a necessary step to ensuring that services are properly built around the needs of individuals. Moves towards user-defined outcomes and satisfaction as a measure of quality need to be underpinned by agreed minimum standards.
It is acknowledged that thinking in terms of outcomes as a means of evaluating the quality and effectiveness of care services, will require particular changes for residential care services. There is likely to be a need for transitional services which support the shift to different models of service whilst maintaining an appropriate level of existing provision. It is the view of the Residential Forum that continued development of residential care for older people and the attention to continuous improvement would enable this goal to be achieved. Further monitoring and evaluation will, of course, be necessary as these changes are put in place.
6: MEANINGFUL INVOLVEMENT AND CONTINUED LINKS WITH THE COMMUNITY
Well-being and quality of life for most people is enhanced through meaningful involvement and activity. The same aspects are true for older people in residential care settings. The opportunities to be involved in decisions that affect them are crucial. There are many ways in which such involvement can be facilitated and encouraged.
Good residential care services recognise the importance of social contact and companionship and on-going links with social networks. The involvement of relatives and friends needs to be a decision led by the individual. The care home should support continued community involvement, easy access to transport and the opportunity to participate in social and leisure activities.
Maintaining (and even extending) social contact and the potential for wider contribution both within care settings and outside is also important to social identity and fulfilment. Such a contribution should not be underestimated.
7: TELECARE AND TECHNOLOGY
The use of technology to support care services has arguably been slow to develop within social care. In part this is the result of initial suspicion that telecare would be used simply to replace staff or staff time.
Technology moves at a rapid pace and as a consequence telecare and its potential have been transformed in recent years. Costs have been significantly reduced. It is important that care service providers recognise the value and contribution of telecare to offer additional privacy and thereby protect dignity. Equipment can provide additional security.
Residential care services need to harness the benefits that technology can bring to enhancing independence, choice and control for older people.
8: A ROLE IN END OF LIFE CARE
Older people living in care homes are often frail and many have complex healthcare needs. Access to the services of healthcare professionals is essential to quality of life and well-being.
Residential care (across all care homes for older people) is increasingly operating as a specialist facility that provides End of Life Care. Such a shift in practice has occurred as a result of changes and developments that enable people to live in their own homes in the community for longer.
Lessons from hospices in terms of models of respect, reciprocity and humanity are likely to be valuable to staff working in care homes. A person-centred approach in which personalised care ensures individual dignity is maintained is at the heart of good social care practice. Involving families and encouraging an open approach to the awareness of dying is likely to be valued. There are implications for training and skill mix, as well as the nature of care services provided.
9: LEADERSHIP AND WORKFORCE DEVELOPMENT
Leadership capability and front line management skills are key components for ensuring a quality service in residential care. In anticipating a future with modernised services and new ways of working there will be a particular need for development in the management of change.
Staff are the most important asset in every work setting. However, in care services where the relationship between the people providing and receiving practical care and support is such a fundamental one, the notion has particular resonance. In residential care settings relationships between service users and staff are central to quality of life. Therefore the attitudes staff hold and express are crucial. Ensuring service users are treated with respect and dignity is underpinned by a value base and a proper understanding of rights and responsibilities. Opportunities for on-going training, learning and development are also essential to ensuring care staff are equipped with the competence and capability to enable and empower service users to maximise their independence.
Maintaining motivation and morale requires that staff receive appropriate support and regular professional supervision.
10: A NEW VISION
It is difficult to graft good solutions on to old models. If residential care for older people is to assume a position within the spectrum of community care services some aspects will undoubtedly need to change and continue to develop.
Residential care services need to be acknowledged as contributing to a spectrum of care provision for older people. This should be characterised by the following principles:
- challenging ageism
- informed by a clear service-user focus
- giving control and power back to individuals
- at the leading edge of best practice
- committed to continuous improvement
- empowering of managers and staff to create and sustain positive change
- relationships between staff and service-users demonstrate dignity and respect
The boundaries of residential care have become blurred as traditional ways of providing services have been replaced by new models and ways of working. The Residential Forum acknowledges that for the most part such development of residential care services is positive. However, it is also important to recognise that the barriers between residential care and extra care (and other forms of social housing support) are artificial and unhelpful.
Residential care needs to be able to demonstrate that it can offer services and support that people actually want because they best meet their needs. Similarly, commissioners need to believe in the potential of residential care and its ability to deliver quality and choice which best meets specific needs. It seems that in order to ensure choice excess capacity will be required – and there will be cost implications.
The diversity of provision which now represents residential care services for older people is set to continue to be reshaped.
The Residential Forum intends to develop further the ideas that arose in the workshop. Amongst the issues which are yet to be assimilated are the following (in summary):
Why can’t people purchase a capital stake in residential care?
- Challenge of managing active lives in the context of growing frailty of residents
- Concerns about putting nursing and residential care together
- Economic drivers and funding issues
- Using what works as criteria to improve practice
- Living and working – residents’ and staff lives
- Include My Home Life, relationship-centred care and six senses approach
- Recognising loneliness in residential care settings
- Differences between men and women in exercising independence and choice
The residential Forum
Established in 1994, the Residential Forum seeks to promote high standards in residential care and to contribute to improving the quality of services and practice. The Forum encompasses all parts of the residential sector - statutory, voluntary, not for profit and private.