It Ain’t Necessarily So – 20: Should going into a care home always be seen as the last resort?
with JOHN BURTON
A good care home is a real home, a place to call home and feel at home. People do choose to move into a care home before there is no alternative to doing so, and a few people move back into their own accommodation. For them, a care home isn’t “the last resort”.
But what’s wrong with a last resort anyway? Having spent most of my life working in and with a wide variety of care homes, I’m an enthusiast for them. I’ve seen many poor homes, some of which I’ve helped to improve, and I’ve seen and worked with some brilliant homes that I could imagine as my own “last resort”.
My father, having done time in Stafford General Hospital (Mid Staffs) after breaking a hip, and contracting MRSA, discharged himself before things got even worse, tried living at home with his partner (not my mother) who had quite advanced dementia, but found he couldn’t cope. He chose a nearby care home as their last resort.
While there were some very good staff, there were also some who treated him badly. The care was poor and the inspectors were ineffectual, and I lived a long way away, looking after my mother. With several pressure sores and some sort of stomach “blockage”, my father was readmitted as an emergency to Stafford General (out of the frying pan into the fire) and died a week later.
So, like many people, I have a strong personal negative experience of a care home as a last resort, but I still know how good care homes can be.
Published in 1964, The Last Refuge: a survey of residential institutions and homes for the aged in England and Wales by Peter Townsend had a profound influence on public policy. The huge old geriatric wards and former workhouses crammed with beds two feet apart were closed and local authorities built new “sunshine” homes for up to 120 residents where no more than four people shared a room. (I was manager of one of these homes in the 1980s and was threatened with disciplinary action for refusing to allow more than two to share, and for insisting on adequate staffing.)
Thirty-five years ago, in one of my first published articles on residential care, written with Roger Clough, and after a training placement in a local authority care home, I asked similar questions of the “standard model” of residential care when thinking ahead to the possibility of my own “last resort”.
In the early 1990s, care home inspection units were set up in local authorities, and some of them refused to register new homes for more than 40 residents. Now, after about 12 years of having a national regulator, homes for more than a hundred are quite common, and national standards for care homes have been rewritten several times, but one effect has been to “standardise” and to limit the possibilities of care homes being interesting, exciting, unique communities.
Many of the modern “last resorts” are as institutional and institutionalising as their predecessors. Two homogenising forces produce this stultifying sameness: finance and regulation. Whoever runs the home, it has to survive commercially, and there are set formulae of income and expenditure that must be followed while complying with regulations.
Can it be right that the same standard, “compliant” policies and procedures, and statements of purpose are shared by scores of homes? They are bought off the internet shelf and they owe their existence only to inspection. Thirty years ago, we created our own in response to the needs of the residents and the home.
As needs changed we adapted our practice and adjusted our policies and procedures. The home developed through handovers, team meetings and community meetings. This meant that residents and staff together created the working and living culture, philosophy and practice of the home. In this way, each home could become the unique last resort of choice.
Now, it’s very difficult to run a care home that is truly responsive to and guided by the residents’ needs. The public perception of care homes for older people is still a negative version of the last resort, of a way of life that is empty, dull and institutional, and to be avoided if possible. Of course, there are hundreds of homes that are not like this, and that is because they dare to be different. They are led by managers who use their imagination and are prepared to question conventional wisdom, but they still have to comply with requirements that they don’t believe in.