What makes residential care good?

I was asked this morning on Twitter what I felt made a ‘good care’ in a residential home. Sometimes it’s hard to elaborate in 140 characters so thought it would be useful to explain my thoughts in a little longer form.

I’ve worked in social care for a number of years, either as a care worker/support worker in a couple of residential homes (and as a ‘bank’ carer in even more) and as a social worker in adult and mental health services.

I’ve been into a lot of residential care homes and I’ve seen massively varying standards  from the home the time I left a home with such heavy concerns that I left a message for the CQC inspector on my way back to the office to the homes I would both be happy to live in myself and would be happy for any of my family members needing care to move into immediately.

So how do I judge what is ‘good’ (and these aren’t necessarily in order!) – especially in the time limited fashion that often involves me walking in and out in an afternoon.

Culture – which can be hard to quantify but you know it when you see it. From the decor and the welcome you receive when you walk in or when you call on the phone to the small interactions you might see in the lounge area and the amount and type of items you might see. Is the lounge empty except for a few paperbacks that look untouched and are mostly large saga-type romances with little variety? Are the (as there was in a home I went to earlier this week) lines of VHS videos stacked up next to the TV? (without a video recorder, incidently)? These things show care, or lack of it to the details.

Feedback – I listen to people who use the services. Communication can be at different levels and there are sometimes people in care settings who don’t want to be there but often users respond to kindness and listening to the feedback of those who use the services and family/friends who visit is vital to understanding the quality of the service. Of course, it’s useful to read the official reports but they are so rare now and often out of date – while issues around quality of care can change quickly, that we need to look in other areas and understanding how well homes respond to individuals and their needs, wishes and wants is fundamental.

Staff – How am I greeted, that’s one this but more importantly are the interactions I see between staff and residents and not necessarily the residents I’m there to visit. Is there eye contact, is there any touch involved? Are the staff sitting in the lounges responding in conversation rather than requesting things are done/not done? Is there any interaction between residents? How is this facilitated? What is the staff turnover like? I might ask the member of staff showing me round how long they have been working there, do they enjoy it? Often they’ll say yes, anyway, but sometimes you get a glimmer of something else.

Size – I have an issue with stacking up older adults in large residential homes in a way that we wouldn’t in other user groups. We have residential and nursing homes now with 50+, 90+ residents. There can be good care in these places but are they ‘homely’? Are they able to meet individual needs? Or is it a hark back to institutionalisation and long stay hospital type settings. It feels like it is about cost and age discrimination. I would be happy to care delivered in small settings. Large doesn’t necessarily mean bad and small doesn’t necessarily mean good but do we really think there is a justification for 100 bed ‘units’ in the current day. The only justifications are cost and economies of scale. I don’t think that’s good enough.

Individualised responses – are the residents individuals? Can they pursue different activities if they don’t want to sing music hall songs? What if I resident moves in who prefers Led Zeppelin to Knees up Mother Brown (real story, incidently!). What if they wanted to do things or go places that weren’t on the ‘programme’? Yes, individualisation can cost but it doesn’t need to – it can be able to things that don’t necessarily raise a charge. How is this done? I want examples in every home of how individual needs are met.

Those are some of my initial thoughts. I’d welcome thoughts from others about what and how they make judgements about what good care in a residential setting involves.

Thanks for Bill Mumford for inspiring me to write!

12 thoughts on “What makes residential care good?

  1. Hi Ermintrude- I really like your attention to the details- interactions such as eye contact and touch, the small environmental clues- all examples of engagement and person centredness. I also agree with your comments about size- it is not always the case but it is much much more likely that the staff will be more people centric in smaller settings and staff centric in larger ones.

    I should certainly want to be playing Led Zepplin if I were there- perhaps I should look for a place called Stairway to Heaven rather than Dazed and Confused!

  2. Hi Ermintrude

    A very timely post for me. I have been thinking a lot in the last few weeks about how “quality” can be measured (as part of a normal process, not an additional burden) and simply reported and I have been struggling.

    The only two data points you mentioned which are readily available from systems which you could expect to already be in use are Staff Turnover and Size (and surely ratio of ’empowered’ staff to beds is the thing here – plus you would expect some kind of trade-off, as in schools, between homeliness and facilities).

    Your insights are a great set of things to look for when people visit homes to make a choice (though even then they depend to some extent on your professional experience), but it would be better if they could get down to a short list based on some simple indicators. Any ideas?


    • Thanks Mark. I think that might have to be another post although I do tell people things like asking about how long the staff have been there for when they go and visit. Happy staff and stable staff often are a very swift indicator..

  3. Hi Ermintrude
    I certainly agree wtih your comments with regard to large care homes. In the 70’s – early 80’s the rationale was to reduce the size of care homes to smaller ‘homely’ homes with of aboui 40 – 50 people. The next thing, its all up size, particularly when the LA started to sell off council run care homes. The norm now is up to and above 120 older people in one home! What are as a society thinking of, when as you say we appear to be going back to institutrional living, but with the trappings of 21st Century decor. How can a large setting such as this be managed? I see this as a step back in time. This is what happens when care is sold out to private companies for profit. And how much of that profit is put back into enhancing residents daily lives ? The good care homes are usually those that are smaller, more personalised and the manager puts the residents first and not the profit that can be made.

    • I worry about the way that older people and people with dementia are dismissed as being less worthy of individual care – but I’ll keep banging on about it!

  4. See, Dear Heart? You can write succinctly when you try! 🙂

  5. Hi Ermintrude
    This is a great list. One of the things I always ask when reviewing a client is to ask the key worker or person who knows them best ” Tell me about John/Sue/Mrs Smith. What are they like as a person? What are their likes and dislikes? What makes them smile? Responses can be very telling, especially as I find clients who have been referred by their solicitor have often been placed in the home without any background or personal information being given to the home to personalise their care.

  6. I will explore how we can begin to assess culture of a care setting based on staff and environment

  7. Great to see your succinct list of things that would make life more tolerable in a care home! Your comments on the Culture resonates with me. The place my dad ended up in was fusty and old-fashioned, and yes lots of wartime classics being sung accompanies by a cheap casio synth. On sundays service users and visitors were all subjected to terrible church group-led hymnathons (they wrongly assumed the residents were all Christians) and none of the Folk music or Pink Floyd which he was into. It was hard to tell what dad thought of it all but its painful enough to recollect. Not everyone like group activities, and dad was certainly an individual who tended to prefer his own company or small friendly groups. Shame the managers of this home didn’t feel able to provide more individualized approach, whether involving favourite food and drinks, music, films or activities – it was up to the family to sort this out during visits.

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