Living well in care homes

Care that meets your individual needs

Everyone is individual, with their own individual needs. In a ‘person-centred’ home, the staff will aim to meet those needs and to treat you as an individual. That will include listening to you, respecting your choices and understanding exactly what you need.

A care home is person-centred when:

• You are involved in developing your care plan and are asked about decisions around your care
• Staff have understood your life  history 
• You feel a sense of belonging within the home
• Staff adapt their approach to meet your needs 
• Staff listen and address any concerns or anxieties. 

Staff are person-centred when they:

• Treat you with dignity and respect 
• Listen to you and take time to hear your views and how you are. 
• Welcome your family and friends 
• Remember your likes and dislikes, interests, and who and what is important to you 
• Consider your culture and previous lifestyle 
• Remember your strengths and skills 
• Are aware of your spiritual needs and consider how these can best be met 
• Avoid making generalisations and assumptions about older people 
• Think about what it is like growing old and what it means for each person 
• Focus on the opportunities for being active 
• Encourage movement and physical activity. 

Being as independent as possible is key for your health and wellbeing. For example, if you’ve always enjoyed a daily walk, then it’s important that staff try to support you to carry on doing it.

Your care home is responsible for keeping you safe and staff have to consider the potential risk of an activity. For example, they may not encourage daily walks in case it leads to a fall. But just focusing on the physical risk, misses the emotional benefits you would get from walking every day.  

So it’s a balancing act between making sure you’re safe and giving you the opportunity to do as much as you can, and want to. Staff will also need to balance your wishes with the rights of other residents, the capacity of staff and the concerns of family and friends.

Staff will also consider: 

• The risks and benefits 
• The likelihood that risk might occur 
• The seriousness/severity of those risks 
• Actions to be taken to minimise the risks 
• Actions to be taken if the risks occur. 

Talking with staff is really important so they can support you with the activities you want to do. Talk to them about your strengths, routine, interests and wishes. And whenever possible, there should be an agreement between you, the staff, and your relatives. 

Why it's important to keep active:

It’s essential to keep active in your everyday life – for your emotional and physical wellbeing. And being active, doesn't necessarily mean exercise. It means actively participating in daily life. When we sit for most of the day, without moving or doing much, it can harm our physical and mental wellbeing.

What happens when someone stops being active?

• Muscles and bones weaken and joints stiffen.
• Breathing difficulties and chest infections are more likely.
• They may have trouble digesting food.
• Blood pressure increases and the heart weakens.
• They may be prone to urinary infections, which can lead to incontinence.
• Risk of pressure sores increases.
• Boredom, loneliness, irritability or anxiety.
• Less alert and difficulty concentrating.
• Loss of confidence and skills, which can lead to confusion and disorientation.
• Poor sleep patterns.

What happens when you keep active?

• Muscle strength, fitness and mobility are retained or improved.
• Appetite and digestion improves.
• Less likely to develop circulation problems.
• Immune system becomes more efficient.
• Tension is eased, and it becomes easier to relax.
• Balance, posture and coordination improve.
• Concentration and memory improve.
• Greater sense of wellbeing.
• Choice, control and dignity are gained.
• Social contact, self-expression and a sense of purpose and belonging are maintained or regained.

Here are some suggestions:

• Try to do as much for yourself as you can, so that people support you only when you really need help. That could be washing the top half of your body (but getting help with washing the lower half) or getting up and having a drink at the table rather than having one brought to you.  
• Think about your daily and weekly routine and talk to staff about how you would like to spend your time. Also talk about what help you might need.
• Set yourself goals to help keep fit and healthy. A goal might be to get up and move around every hour, or do a daily crossword or word search.
• Ask yourself ‘does my routine work for me?’ Have you got a balance between activities you need to do and activities that you want to do, such as self-care and leisure?
• Ask yourself if the balance of time alone and time spent with others is right for you.
• Talk to someone you trust if you feel bored, lonely, anxious or too sedentary, in pain or in discomfort. Staff are there to support you and can help draw up a personal plan to try to address any problems.
• Talk to someone if you are worried about your memory. There are many simple strategies that can help.

Ask to be referred to an occupational therapist. They can advise on ways to maximise your mobility and abilities.

The statements below may help you to think about how you are experiencing daily life. You might like to talk to a member of staff about what is working well for you and what you would like to change.

The home

• The dining room and communal rooms are clean and pleasant. The tables and seats are arranged so that I can chat with others.
• There is a mix of private, quiet and shared areas where different activities and social events take place.
• Rooms are well lit so that I can see.
• I can go outside.
• There are signs and cues to help me find my way around the home.
• Mealtimes are pleasant. I have a choice of where I sit, what I eat and drink, and my dietary needs are met.
• I can eat in my own room if I want to.

Staff

• Staff chat to me. They appear to take a genuine interest in my life.
• I trust the staff. They are friendly and I can approach them at any time.
• Staff support me to carry out day-to-day personal tasks, like watering my plants.
• Staff know what I like and dislike.
• Staff know how and when I like to receive help.
• My visitors feel welcomed when they come here.

Day-to-day routine

• I’ve been asked to give a life history.
• I was involved in writing my care plan and I have agreed to it and signed it.
• I can choose how to spend my day and what help I receive.
• I am supported to go into the community to take part in activities and events.
• I am free and supported to enjoy my hobbies and interests.
• Staff respect my ‘quiet’ time when I want to be alone.

In a good care home:

• There is a warm and welcoming atmosphere
• Your relative/friend feels safe and speaks fondly of staff and other residents
• Your relative/friend has opportunities to do activities and have responsibilities around the home e.g. caring for plants or pets
• The home has activity coordinators, it welcomes volunteers and organises trips and events
• Your relative/friend has been asked about their cultural and spiritual needs and the home is actively helping to meet them.

If your friend or relative can’t tell you how they are feeling, you can look for signs of wellbeing, such as:

• A relaxed posture
• Ability to express emotions
• Humour
• Pleasure
• Connections with other people.

What are the warning signs that the care home could be better?

• You don’t feel welcome. 
• You hesitate to approach staff to discuss your relative’s/friend’s care. 
• Residents routinely appear to be sitting with nothing to do. 
• Television is on but no-one is watching. 
• Staff are always busy with no time to talk. 
• Your relative/friend may speak positively about the home in public, but complain about it in private. 
• Your relative/friend appears bored, irritable, in a low mood and possibly depressed. 
• Your relative/friend tells you they want to die. 
• You have concerns about how equipment, like a wheelchair or hoist, is being used and maintained. 
• Your relative/friend is not supported comfortably when seated.

Ask to be referred to an occupational therapist. They can offer advice and guidance on how to make your friend or relative more comfortable.

If your relative has difficulties with communication, look out for the following signs: 

• Anxiety and fear
• Withdrawal
• Despair
• Anger
• Physical discomfort or pain. 

It is really important to have a conversation with the care team. There may be a reasonable explanation. For example, if your relative or friend is spending lots of time alone, it may be that they have chosen to. Talking to staff means that you may be able to work with them to improve the situation for your relative/friend.

What if I suspect my relative may be in physical pain or discomfort?

You can check if they are comfortable by:

• Noticing the atmosphere: the temperature, noise levels and smells. Look for signs of discomfort or stress. Can you or care staff make adjustments to make them more comfortable? Is there a quiet space they can spend time in?
• Looking at their seating and positioning: are they sitting comfortably? Are they well supported in their chair or in bed?
• Checking their clothing or footwear: do they fit comfortably on the body? Check for tightness or rubbing.
• Noticing their drinking and eating: checking and assisting to ensure regular habits. 

What action can I take if I have concerns about the care home?

• Talk to individual staff members. 
• Talk to the care home manager and follow up in writing if this helps. 
• Share your ideas and suggestions. Is there a residents' and relatives' meeting? Or a suggestion book? 
• Consider how you can contribute to the life of the home. 
• Do activities together (see our suggestions below).

I still have concerns. What can I do?

• Use the home’s complaints procedure – and remember complaints are an opportunity to improve.
• Tell the regulatory body about your relative’s experience.

Activities you could do together:

• Helping your friend/relative select an album, scrapbook or book to look at. 
• Sharing a poem, article or short story you think they might like (‘I saw this and thought of you…’) 
• Listening to music, the radio or watching the television. 
• Playing a game of cards/word game/board game. 
• Reading a newspaper or magazine together. Reading out loud. 
• Going for a walk in the garden or exploring other rooms in the home. 
• Supporting your friend/relative to keep a scrapbook or photo album and helping them to add pictures, mementos or photos. 
• Offering a hand massage or manicure.
• Looking at bookshelves and where activities are kept: Is there something your friend/relative would like to borrow? Does anything spark a memory? 
• Helping your relative with small jobs, for example dusting their room or refilling the bird feeder. 
• Attending events and volunteering to go on trips. 
• Bringing in a take-away for a special occasion. 

Activities you can do with someone with later stages of dementia:

When people are in the later stages of dementia, we use the terms sensory ability and reflex ability (Pool 2012)[1]. Here are some suggestions of activities you can do with a relative or friend at these ability levels. 

Sensory ability level:

Your friend or relative may hum, chuckle, moan or call out. They may pace and keep repeating actions. People at this level of dementia are aware of others, but they are mainly concerned with their own needs and sensations. Typically they respond to conversation through body language, for example by turning towards you or reaching forward.  

Your friend or relative will respond to sensations. You can help them by using touch, and being warm and reassuring. When talking to them, keep your language simple and use short sentences. Using actions can also help to show them what you are talking about. 

You could try:

• Singing, clapping, dancing or rocking to music 
• Activities that involve single step movements – sweeping, polishing, folding, winding wool 
• Walking together 
• Encouraging them to hold and turn the pages of a book, tablet, magazine or newspaper 
• Stroking the back of their hand or arm or cheek and using moisturising lotion to massage 
• Stroking a pet or a toy pet 
• Listening to music they enjoy
• Watching favourite television programmes 
• Looking at pictures, photographs and postcards 
• Holding and feeling different objects – you could make an activity or memory boxes by wrapping up objects in tissue paper and placing them in a box, then encourage your relative to unwrap, explore and rewrap
• Smelling herbs, plants and flowers 
• Sharing favourite food, snacks or drinks.

Reflex ability level:

Your relative or friend may call, rock, cry, hum, or mumble to themselves. They may not be aware of their surroundings or their own body. But they may respond to direct sensory stimulation, such as touch.   

Here are some activities you could try: 

• Make direct eye contact, use touch and give single word directions. For example, to support the person to drink, place their hands around the cup, put your hands over the top of theirs, and guide the cup to their mouth saying ‘Drink’ 
• Reassure them by smiling and nodding 
• Stroke the back of their hand, arm or cheek, keeping pressure gentle but firm 
• Singing, swaying, clapping and rocking to music 
• Stroking a pet or a toy pet 
• Gently fan their face 
• Play music that you know they like 
• Hold and feel objects of different colours, shapes, weight, textures and size 
• Eat and drink; for example, you could share pieces of fruit, sweets, and cheeses.

References:

[1] Pool J (2012) The Pool Activity Level (PAL) instrument for occupational profiling: a practical resource for carers of people with cognitive impairment. 4th ed. London: Jessica Kingsley.

Frail, older people cannot do exercise – not true! 

There is increasing evidence that even frailer older people age 85+ can take part in regular physical activity and rebuild some of their strength. 

It needs to be done gradually and within pain limits, and with some caution for certain conditions (maybe just in bouts of 5–10 minutes a few times a day at a lower intensity). 

For some people, chair exercises are the only option possible. These can improve balance and trunk flexibility, while working on shoulders, arms and wrists. For ideas, visit the NHS webpage on sitting exercises.

We don’t have time to fit in exercise with all our other tasks – not true! 

Think about your existing routine and fit exercise in around it. In a typical day, how many opportunities are there for people to get up and get moving? For example, residents could be encouraged to go to another part of the lounge for refreshments, rather than the trolley coming to them.

We are not experts in exercise – true! But…

There are plenty of resources out there to get ideas and you can bring in an exercise instructor, a physiotherapist or an occupational therapist who can teach a safe routine.

If someone is experiencing pain then they should stop.

Get advice from a doctor or a health professional, such as an occupational therapist or physiotherapist if a resident has:

• Heart problems
• High blood pressure
• Dizziness or fainting episodes
• Breathing problems
• Balance problems or frequent falls.

It is important that you respect every resident’s free will and choice. So if someone refuses to participate in an activity or an outing, they should never be made to do it. 

However, always think about whether the person has anxieties or concerns that might be stopping them from getting involved (for example, they may be worried about being able to access a toilet when out and too embarrassed to mention it). 

Sometimes you might need to use a different way to approach the situation, like those listed above. 

References:

Royal College of Psychiatrists, British Geriatrics Society (2018) Collaborative approaches to treatment: depression among older people living in care homes. London: RCPsych, BGS.

• Always believe that communication is possible. 
• Show respect in your tone of voice and the language you use. 
• Try to focus on the non-verbal signs as well as verbal. 
• Avoid making assumptions: check things out with the person. 
• Let your face be seen. Face the person squarely at eye level and make eye contact. 
• Speak clearly. Avoid using jargon or complicated explanations. 
• Be a good listener. Give the resident your full attention and resist the temptation to finish their sentences or talk at them. 
• Be calm, unhurried and patient. 
• Don’t be afraid to try or say ‘I don’t understand’.
• Check hearing aids and glasses are in good working order. 

Care Services Improvement Partnership (2007) Older people’s mental health programme

• Know who regularly visits each resident. 
• Be open and invite opportunities for visitors to talk in a private space about their relative and their life in the home. 
• Remember relatives are making that transition too. They may be feeling guilty if they are no longer the main carer and need opportunities to talk. 
• Remember relatives and close friends would like to hear about the life of the home and how their relative or friend is coping. Whenever possible discuss with the resident how they would like this to be done. 
• The resident may not remember what they have been doing this week and cannot share this with their visitors. 
• Relatives and friends can help contribute to their friend’s/relative’s life history. 
• Relatives and friends may be able to help shape the resident’s preferred daily routine. 
• Visitors may have their own communication difficulties.

Since living in the home, Mrs Smith’s Alzheimer’s disease has progressed. She has always gone for an early morning walk taking the same route. Her family recognise how important this is for her health and wellbeing. 

Staff can’t go with Mrs Smith every day, and there are now concerns about her memory and getting lost. Mrs Smith and her family meet with the care home staff. A risk enablement plan is drawn up and they all agree that stopping Mrs Smith from taking her daily walk would cause her great distress. 

They all agree that she still has the mental capacity to decide whether to take a walk or not. Staff continue to support her to go out by making sure she is dressed appropriately and noting the time she leaves. 

The family buy Mrs Smith a GPS location tracker with an integrated fall sensor which she wears when she goes on a walk. If Mrs Smith is not back within half an hour, there is an agreed plan that a member of staff will go to find her.

When making decisions around risk, remember that:

• Knowing the person, their strengths, routine, interests and wishes is vital. 
• People’s perception of risk will be influenced by their personality and life experiences.

Image

Whenever possible, there should be a shared agreement between the resident, and with their consent, their relatives. 

As care home staff, you need to understand your responsibilities under the Mental Capacity Act 2005 for England and Wales [1], Adults with Incapacity (Scotland) Act 2000 [2] and Mental Capacity Act (Northern Ireland) 2016 [3].

A person’s ability to make decisions may change from day-to-day, so it’s it’s important that you, as a member of staff, have a good working knowledge of the legislation.

References:

[1] Great Britain. Parliament (2005) Mental Capacity Act 2005. London: Stationery Office.

[2] Scotland. Parliament (2000) Adults with Incapacity (Scotland) Act 2000. Edinburgh: Stationery Office.

[3] Great Britain. Parliament (2016) Mental Capacity Act (Northern Ireland) 2016. London: Stationery Office.

To identify whether the existing culture within your care home enables activity, use the following questions: 

For residents, relatives and staff, what are:

• Three wishes you have for the home? 
• Three things the home does well? 
• Three ideas to improve the residents’ experience of life in the home? 

Once you have identified people's aspirations within the care home, you need to ask the following questions: Does it need a new culture? If there is more than one culture, and can the cultures be integrated to achieve the best possible fit or can two cultures sit alongside each other to achieve an acceptable balance? (Child et al 2005).[1]

Exploring culture can also help to evaluate what the organisation is doing well, and provide a baseline to build on. The next step is to decide areas for improvement and to: 

• Define appropriate quality standards to work towards 
• Agree actions to meet these standards 
• Establish monitoring to ensure quality is maintained.

For these steps to work, it is important to understand the needs, fears and motivations of staff at all levels and establish improvement activities. Therefore, the agreed actions should: 

• Include clear measures and accountability. 
• Highlight benefits for residents and rewards/benefits for staff. 
• Utilise motivators for staff. 
• Be supported by procedures and the environment. 

(There are examples of action plans under ‘Measuring quality’, below)

The following questions may help to get ideas on how to move forward in creating a new active culture within the home.

For residents, what are:

• Three ways you are supported to do activities? 
• Three things you would like support to be able to do? 

For relatives, what are:

• Three things you would like to see your relative supported to do? 
• Three ways you might like to be involved in the life of the home? 

For staff, what are:

• Three ways you support residents to engage in activity? 
• Three things you would like to do to support residents to engage in activity?

References:

[1] Child J, Faulkner D, Tallman S (2005) Cooperative strategy: managing alliances, networks and joint ventures. Oxford: Oxford University Press.

To establish a positive activity culture: 

• Be aware of current legislation, policies and guidance in relation to dignity, choice and staying active. 
• Review the service’s current policies and procedures and the environment of the home – do they support activity? 
• Support the activity coordinator and grant them status and a degree of authority. An acknowledgment of the importance of this coordinating role sends a message to all team members about activity being essential to the experience of the residents’ daily life. 
• Encourage the role of other staff through including enabling activity within everyone’s job description and making enabling activity a fixed agenda item in staff meetings, supervision sessions and staff appraisals. Any ideas need to be recorded as part of an action plan with a measurable outcome, date for completion, and named responsibility. 
• Design in-service training that promotes discussion to allow staff to share ideas, encourage each other and challenge existing practice. 
• Encourage staff to feel able to contribute ideas and suggestions to the activity programme and progress new ways of working. 
• Review existing supervision arrangements. Regular supervision for staff can guide them on best ways of working, offer support, outline their responsibilities and manage risk. It can be carried out on an individual, group or peer basis. Supervision supports the process of change by giving staff the opportunities to ask: What am I doing well? What areas do I need to develop? What can I do differently? How can I make changes?

It is important to recruit the right staff: people who believe that it is everyone’s responsibility to support residents to make choices and to be fully involved in the life of the home. 

• Understand the beliefs and roles of all team members and identify each team member’s strengths and motivators. 
• Include enabling activity within everyone’s job description. 
• Develop team-working skills to facilitate cooperation from others and good working relationships with other members of the team. 
• Encourage staff to think of possible solutions to barriers they perceive or encounter. 
• Encourage ideas and creativity in all levels of staff. If staff have a particular interest or set of skills, work with them to consider how they can use them for the benefit of the residents. 
• Review the environment and current procedures – do they support activity? 
• Active participation in daily life needs to be discussed regularly – what is working well, what is not, the barriers, possible solutions and new ideas. For example: consider making enabling activity a fixed agenda item in staff meetings, supervision sessions and staff appraisals, or hold regular meetings with staff, residents and relatives with activity as an agenda item. 
• Establish a suggestion book or box and actively explore proposals. 

Forming a support system for staff groups

Change can be welcome, but it may cause some staff members to become anxious and resistant. One way to support and involve staff is to establish a structure that offers processes they can use, such as meetings and checklists. This will encourage shared responsibility, the exchange of ideas, and tackling problems and barriers. 

Ideas for establishing a support system:

• Hold regular meetings for staff. 
• Consider the time and frequency of meetings: who should be involved, when and where they should take place, and what should be covered. 
• Establish ground rules of confidentiality. 
• Develop a framework to include: 

1. Behaviour – ‘I have a problem’. 
2. Effect – ‘I find it difficult to make tea, run activities and when doing both...’ 
3. Feelings – ‘I am worried about leaving the residents unattended, how can we deal with this?’ 
4. Space to ask questions – provide fertile ground for people to come up with solutions. 

• Evaluate the usefulness of the meeting and plan the next one. 
• Hold a special meeting to discuss any stress points in the organisation that are preventing progress, and work out ways of providing help. 
• Draw up a ‘help list’ for all possible problems, indicating who to turn to for help and which resources to draw upon. 
• In stressful times, hold a short wind-down meeting at the close of each shift to tackle work/communication difficulties and stressful situations.

If you find that progress has stalled or is limited, consider seeking advice from an occupational therapist. Occupational therapists have expertise that will help you to embed a culture that enables residents to participate in activities and daily life.

This section considers how to measure residents’ experiences of home life and offers a range of materials to ensure they receive a high-quality service. 

It is necessary to collect evidence in a variety of ways, especially when people are unable to verbalise their views. This can be done by: 

• Observing what is happening in the care home. 
• Listening to residents, relatives, friends, staff and managers talk about their experiences with regard to the social life of the home and activity provision. 
• Reading supporting documentation. 
• Observing the behaviour and interactions between residents, staff, visitors and managers. 
• Observing people engaging in activities. Do they look content, happy, frustrated, animated, withdrawn or agitated?
• Carrying out an audit.

• Collect evidence by using the different methods already suggested.
• Record the evidence in the evidence box. Use the evidence to rate the performance for each quality indicator.
• The audit will highlight what the service is doing well and areas for possible action.
• Agree a list of actions to be taken.
• Use the Action Plan Forms. Agree and record who will take responsibility for completing each action and a timetable for implementing them.
• Agree a review date to repeat the audit to measure and record improvements.

Example: Enabling everyday activities audit

Image

Enabling Everyday Activity Audit - Process (PDF, 159.9KB)

Enabling Everyday Activity Audit - Staff responsibilities (PDF, 153.7KB)

Enabling Everyday Activity Audit - Embedding activity (PDF, 189.45KB)

Audit summary (PDF, 67.38KB)

Outcomes should be designed to evaluate practice and performance. An action plan can be developed and implemented and then used to monitor changes and review ongoing performance to develop best practice. 

Outcomes can be used: 

• To provide evidence of best practice for enabling activity within the care home. 
• To improve the quality of choices and activities available within care homes. 
• To raise awareness among staff about their own and their colleagues’ performance. To increase understanding and improve working practices between residents, staff and management. 

The first person (i.e. ‘I’) is used because an outcome should be written with the resident and reflect their point of view.

Image

Asking residents, relatives and the staff team:

• What makes a good home life?

Then asking the group(s):

• What do we do well / what are our strengths?
• What could we develop further?
• Can we use our strengths and resources to agree possible actions?

Strengths and needs table:

Image

Sometimes further advice and support is required when a resident’s needs are multiple and complex. Specialist advice may be required from an occupational therapist and other specialist services, such as physiotherapy, speech and language therapy and podiatry.