You have done your research or your Social Services Care Manager has given you a list of potentially suitable homes, and you have identified some care homes to view. Now comes the really important, and hopefully exciting part or the process.
How do I organise a viewing ? Actually our advice is not to ‘arrange’ a visit, but to turn up unannounced. This is a great way to see the home on a normal day and doesn’t allow the home to ‘put on a show’. A good home will usually be able to show you around and let you get a feel of the home, even when you turn up unannounced. You may then want to follow this up with another arranged visit, for example to meet with the Manager who may not be available at the time of your surprise visit.
What do I do when I view a potential home ?
There are a number of things we advise you to do when you visit a home and a good home will be perfectly happy to support you in this, and in fact encourage it.
Prepare yourself mentally. You may observe residents behaving in unexpected ways and you may observe residents in the later stages of dementia who are very dependent on the carers. You may find this shocking at first and it may make you feel very uncomfortable. Relax and give yourself time to settle into the atmosphere. In a good home you will observe that the residents are in a relative state of well-being, and that your discomfort may have more to do with your own feelings than those of the residents. A good home will support you in getting used to it.
Sit quietly and observe the life in the home for an hour or so. This will give you a good overall impression of the atmosphere in the home, and a good sense if your loved one will feel at home here. Consider not only what their care needs are now, but also what care they may need in the later stages of the dementia, and where you would want them to be cared for at those stages.
Talk at length with the manager about your loved one and what they need to be well supported. Ask lots of questions – hopefully this report will prompt you to ask some important questions. Some homes will do this first, before showing the home and this is good practice as this helps them to work with you to consider how the home can best support your loved one.
Talk with the home’s residents and their friends and family. Ask them about their experience. Perhaps one of the residents can show you around the home ?
Visit a number of times. Impressions can be overwhelming on a single visit and you may realise after your first visit that you haven’t asked all the questions that you wanted to ask. You should always feel free to arrange another viewing, perhaps over lunch or when some activity is taking place ?
Visit with your loved one. You may want to do the initial viewings yourself. Once you have narrowed down the options in most cases it helps to view the best homes with your loved one. You may be surprised by how enthusiastic they will be after a visit and how this can ease their transition into the home – though it may upset you that they are so keen!
Ask for information to take home with you. A brochure is great to get an overview of how the home presents itself to the world. The Service User Guide should give additional information about the home and the services it provides. If you do not already have a copy of their inspection report, ask for it now. And the home may be able to give you some recent newsletters, sample menus, their activities programme etc. These can help you when you get home and want to compare what the different homes can offer.
Gathering your impressions of the Home
As you view the home and perhaps sit quietly for an hour or so to observe life in the care homes, gather your overall impressions of the home. A lot of research has been done in the past few years on how to provide a supportive environment for people living with dementia. A supportive environment is one which is homely and which helps the resident to maintain their independence, dignity, and sense of wellbeing. Here are some of the things to look out for:
Does the home smell ? Occasionally accidents can happen in dementia care homes particularly where independence is encouraged. If they occur, they should be limited to a specific area and any accidents should be cleared up promptly. If large parts of the care home smell, then this indicates that continence is not well supported and that is not a good sign. There is no good reason why a dementia care home should smell.
How welcoming is the home ? A good home will make you feel welcome from the moment you step into the home. Do they offer you a cup of tea and do they give you plenty of time to look around the home and to answer your questions ? If you don’t feel welcome now then you won’t feel welcome when you visit your loved one, and this may discourage you from visiting. Have a chat with a couple of the visitors and ask them how welcome they feel in the home.
How homely is the home ? How do you feel when you are staying in hospital ? Most people would say that they feel somewhat passive and dependent on others, and not in charge of their own lives. On the other hand most people would feel more independent in their own home. So independence and wellbeing are promoted in Care Homes that feel more like a normal home. Is there a recognisable lounge with plants, pictures, side tables, a book case, perhaps a fire place ? Is there a recognisable dining room with clues to suggest that this is a place where people eat ? Are there table cloths on the table, and perhaps some flowers ? Do the bath rooms and toilets look domestic or are they institutional ?
Is there a relaxed pace ? Do carers appear to be rushed and task-focused, or is there a relaxed pace with carers being responsive to the needs and feelings of each resident (someone may need to be helped to the toilet or wanting a cup of tea) ?
Are residents supported to be active ? Are there residents who are actively engaged in meaningful activity like reading the paper, playing a game, reading a book, listening to music, peeling some potatoes, chatting with other residents or staff ? Not all residents want to be busy all the time but if none of the residents are actively engaged in some activity then this is not a good sign.
Is there a rich sensory environment ? Dementia Care Homes used to be quite clinical and ‘empty’, much like hospital wards, and many still are. New research has shown that a rich physical environment can help people with dementia stay engaged with the world. Are there book cases and side tables where residents can help themselves to books, games etc ? Are there flowers and plants around the home ? Does the home provide newspapers and encourage residents to read them ? Are there interesting pictures on the wall and does it look like residents have contributed to the decorations ? Are there signs that the home is ‘in touch with the seasons’ through celebration of important days ? Are there clocks and calendars to help residents keep track of time and the seasons ? Are there soft furnishings with different colours, patterns and ‘feels’ ? Is music being played and do residents have access to TV ? When they look out of the windows what is there to look at ?
Are carpets optimised for people with dementia ? Carpets can have a profound impact on the quality of life of people with dementia. The length of pile is important. Too high a pile, and people can find it hard to use mobility aids. Too short and it can increase the likelihood of injury when someone falls. The patterning is also important. Some people with dementia can find it hard to work out what they are seeing when a carpet is highly patterned and this can make them nervous about walking around. Changes in carpet, and carpet separating strips can be very confusing for some people with dementia, making them reluctant to cross the two carpets, so effectively imprisoning themselves in one part of the home. Carpets should be cushioned so that the impact of any falls is reduced.
Carpets need to be cleanable and vigorously cleaned to maintain a sense of dignity – who wants to live in a place with dirty carpets ? Ufortunately many homes avoid these complications by using a vinyl type flooring in some parts of the home, which inevitably ends up looking quite institutional and anything but homely. Our view is that people with dementia deserve the same homely comforts that we all deserve, and that includes great carpets.
Is there effective signage ? When you live with dementia the world can be quite bewildering, and it can be difficult to find your way around a home. Simple things like being able to find a toilet can make the difference between staying continent and becoming incontinent. Finding your way back to your own bed-room can give you a sense of being in charge of your own life and being able to have your own quiet space when you want it.
To promote independence it is important that there are clear signs throughout the home, particularly at places where people have to make a decision on where to go next. Signs should be high contrast (black on yellow is best) and be supplemented by pictures to help those who struggle with reading. And lettering should be a mix of upper case and lower case lettering (like in a newspaper), as this has been shown to be the easiest to read.
How individual are the bedrooms ? Ask to be shown one of the rooms that is already occupied. Do they ask the resident for permission (if not, what does that tell you about respect for their privacy ?). Have a look at their room. Have residents been encouraged to bring their own small pieces of furniture, photos, mementos etc ? These touches can provide comfort and a point of recognition in a confusing world and it also indicates that the home is promoting resident’s sense of identity.
How well do they try to understand the needs of my loved one ? Some homes will give you the hard sell and tell you all about how wonderful their homes is. But they may not ask you many questions about your loved one, about their life, and about their specific physical and emotional needs. That is a good indication that the home has a ‘one size fits all’ philosophy and that they are more interested in ‘selling a bed’ than in truly understanding the needs of your loved one and helping you to work out if their home is appropriate.
A good dementia care home starts any viewing with an in-depth discussion about your loved one, their life history, their diagnosis, and their current physical and emotional needs. This helps the home to understand that person so that they can help you work out if and how they can best support your loved one at their home.
Question to ask when you view the home.
How has the home changed since the last inspection ? It may have been up to three years since the last key inspection and many things may have changed since that time, for better or for worse. A new manager or a change in key staff can make an incredible difference to a home in a matter of weeks. Some unscrupulous operators invest in their home to achieve a ‘good’ or ‘excellent’ rating and then reduce operating costs in the safe knowledge they will not be inspected for another few years. So it is important to understand what has changed in the home since the last inspection.
What stages of dementia does the home support ? The different stages of dementia present quite different support challenges. In the early stages symptoms can include forgetfulness and disorientation, both in time (not being clear about the time of day, or the date or how old a person is) and in place (not knowing where you are or how to find your way around your home or outside the home). In the later stages, communication may be affected, as well the ability to walk, eat, drink, or use the toilet independently. Care homes have different policies with regards to the stages of dementia that are supported with the home. Some homes will only support people in the early stages of dementia, and so a move to another home will in most cases be required, possibly at a very vulnerable stage in that person’s life.
How does the home view aggression and other behaviours that challenge ? In most cases, aggression in people with dementia is a sign of frustration, of not being able to clearly communicate their needs. Life can be quite disorienting and sometimes scary for people who live with dementia and this sometimes can present itself as aggression. Good homes provide an environment that is therapeutic and support resident’s independence so reducing disorientation, frustration, and boredom. Good homes also take a ‘problem solving’ approach to challenges presented by dementia, and try and examine what situations trigger aggressive behaviour, and then aim to remove those triggers. Triggers can be as simple as un-diagnosed pain, constipation, or some infection. Or the triggers could be a specific situation such as being confused by the layout of a toilet, or not wanting personal care to be given by a member of the opposite sex.
What qualifications do the Manager and the care staff have ? Care Homes with nursing require the manager to be a nurse, but there is no such requirement for Care Homes without nursing.
The legal requirement for Care staff is that at least 50 % hold an NVQ 2 (National Vocational Qualification) in care. Good homes will exceed this requirement and will also have staff with NVQ3 and NVQ 4 qualifications. Qualifications are not a guarantee of quality though. Much depends on the ethos and management practices of the Care Home.
Sometime in 2010 a new system of vocational qualifications will be introduced called QCF, and there will be a requirement for care staff that work in dementia care homes to be trained in a dementia-specific vocational certificate. This is great news and one or two dementia care homes have already recognised this and provided in depth dementia care training in line with the new QCF qualifications.
How much agency staff does the home use ? Most care homes use agency staff occasionally, but regular use of agency staff can indicate that he home is unable to hold on to regular staff and that is not a good sign. Care homes are about people who support other people and an unhappy staff team is unlikely to be motivated to give their best to the residents. On the other hand, high levels of agency staff may also indicate that the manager is raising standards and that some staff are leaving who are not interested in raising the standards. So if the care home is using a lot of agency staff it is good to ask some questions about why this is happening.
What is the home’s activity programme like ? A great activities programme sets good dementia care homes apart from others, not least because this is one of the most difficult things to get right. Inactivity and a lack of stimulation leads to boredom and, unable to clearly communicate your needs, people can just give up. So what does a good activities programme look like ?
Communal activities should be structured around a regular pattern. If the choir meets every Sunday and the pub quiz is held every Thursday then this can help people orient themselves around the week. A regular pattern can help some people feel settled. Another advantage of a regular structure is that it makes it easier for friends and family to get involved with the activities.
Communal activities should be interactive and encourage participation by the residents. Rather than someone just singing some songs, it would be better if the home asks the residents what their favourite songs are and setting up a home choir where friends and family can also get involved.
There should be a range of communal activities that cater for people at the different stages of dementia. While a pub quiz or bingo are good activities in the early stages of dementia, more sensory activities are more appropriate for people in the advanced stages of dementia.
Research has shown that people with dementia retain the ability to enjoy music into the late stages of their dementia, and they often remember songs word-perfect. So music should be a strong element of any activities programme.
In addition to communal activities there should be a range of 1-1 activities that cater for the individual needs and preferences of each resident, and that are, in some sense, meaningful to them. This could be as simple as peeling some potatoes or watering plants. Or it could be more sophisticated like an outing to town to get some money from the bank. To work out what is meaningful requires the home to understand the resident’s life history, their habits and preferences, and their current capabilities. Someone who worked as a prison officer may enjoy going around with the night staff to check that bedroom doors are closed. Someone who was a teacher may enjoy marking up some papers. Someone who had a boxing career may enjoy being able to monitor their own weight. And someone who used to have their own vegetable garden may enjoy growing some vegetables in raised beds, or looking after some chickens.
Another important part of the activities programme is to use it as an opportunity to help residents orient themselves around the seasons. There are several ways of doing this. Celebrating special days is one great way of doing this. Not just the ‘big days’ such as Christmas and Easter but also days like St George’s day, pancake day, mothers day etc. And of course it is important to celebrate birthdays.
Our experience has shown that there really needs to be a dedicated activities coordinator who can work out what activities are appropriate for each resident and then encourage the care team and visiting friends and family to engage in those activities with the residents. It takes a lot of time and care to work out appropriate activities for each resident, especially since this changes as the dementia progresses. A resident may have initially enjoyed reading the paper and doing the cross-word but as their dementia progresses this may no longer be enjoyable and in fact become a source of frustration. So activities need to be re-evaluated regularly.
This does not mean that activities should be left to the activities coordinator. In fact it is quite the opposite. Everyday ‘tasks’ such as getting dressed and having lunch can either be approached by carers as ‘things to get done’ or they can be approached as opportunities for enjoyable activity. The difference between a task and an activity ? Tasks are focused on the end result, on ‘getting it done’. Activities are focused on recognising people’s feelings, the enjoyment of the activity itself and developing the relationships of the people that take part in the activity.
An excellent way to get a sense of the quality of the activities is to ask for the activities programme and then to arrange to visit during a couple of the activities that you feel your loved one may enjoy. Are the resident enjoying the activity and are they involved ? Also have a chat with the home’s activities coordinator about what kinds of communal and 1-1 activities may be enjoyed by your loved one, and how you can take part in these.
Do you have a key worker system ? Many homes have key worker systems. What this means is that each resident is assigned a key worker who takes a special interest in that resident. For example they may take care of their clothes and make sure old clothes are repaired or replaced, get involved in the planning of their care, buy them a little present for their birthday or Christmas, and generally ‘champion’ the resident and make sure that their needs are met. So ask the home if they have a key worker system and what key workers are responsible for. And if you decide to go forward with a placement, make sure you know who your key worker is and build a relationship with them. Tell them about your loved one, about their life (and your life together), about their personality, their likes and dislikes, their preferences. And if you feel your key worker is not taking a sufficient interest, then ask the manager to assign another key worker!
How can residents stay in touch with their community ? Just because someone moves into a care home doesn’t mean that they loose interest in the wider community. Are residents encouraged and helped to go shopping or to their local church ? How about a trip to the local theatre or museum ?
When can I visit ? We cannot over-emphasise the importance of regular visits by friends and family. Our experience shows that residents who are visited regularly maintain a much higher level of independence and well-being. Good care homes will not put any limits on your visiting time and encourage you to come as often as you like, and for as long as you like.
How does the home meet people’s physical needs ? Meeting resident’s physical needs is more of a challenges with people that live with dementia, as they may not be able to express those needs accurately or at all. This puts a responsibility on the care team to observe resident’s behaviour, mood, and well-being and to look for signs that all may not be well. Here are some of the key physical needs that need to be met:
Hydration. Dementia care homes are necessarily warmer than most people’s homes as residents tend to be less mobile. A range of 21 to 24 C is comfortable for most residents. It does mean that residents tend to dehydrate quicker and this can cause residents to become less active, and more seriously it increases the likelihood of urine infections.
Pain Management. People that live with dementia may not be able to tell care staff when they are in pain or they may not be able to clearly describe the location and nature of the pain. Care staff need to have good observational skills to identify behavioural and well-being patterns that can indicate pain which can be caused by something as simple as constipation. A good care home has these skills and works with GPs to implement a range of pain management approaches.
Nutrition. This can be a particular challenge for people with dementia. They may not be aware of the triggers that make us hungry, or they may no longer be able to eat independently, or find it difficult to swallow. Taste may be affected and so their appetite may be reduced. All of this requires careful observation by care staff and regular weight monitoring so any challenges can be identified early and managed.
Skincare. Our skin becomes more delicate with old age. Dementia may cause a reluctance to move around (for example because they are confused about where they are and unsure about how to get back to where they are now) and a loss of mobility, and incontinence may put additional strain on the skin. Ask how the home manages this. Should bed care be necessary, does the home have access to special mattresses ?
Continence. Incontinence is a common but not a necessary side effect of dementia and much can be done to prevent incontinence, such as making sure that toilets are well sign posted and that toilets can be recognised as such by the residents. Regular prompting can also keep people continent for longer which is much better for their sense of dignity and independence, and which is also better for their skin.
Diabetes Management. Diabetes is becoming more common now and it can be difficult to recognise the signs of high or low blood sugar levels. Are blood sugar levels regularly monitored and do care staff know what to do if blood sugar levels are outside their normal range for the resident ? Residents with diabetes also require specialist foot care – ask how the home provides this.
Mobility and fall prevention. Mobility can be affected by dementia and so falls are much more likely. The damage caused by falls can be reduced by wearing ‘safe hips’ which are special underwear inserts which disperse the force of a fall and can prevent fractures. ‘Bouncy’ carpets can also help. Once mobility is lost as a result of a fall and likely hospital admission, re-establishment of mobility is very unlikely. So fall prevention is very important. Ask the home what they do to encourage their residents to maintain their mobility and what they do to prevent falls and reduce the damage caused by any falls.
Body temperature. Many people living with dementia may not be particularly aware of their own body temperature or be able to alert care staff that they are either too cold or too hot. Good care homes will monitor room temperatures regularly particularly at night, to ensure each resident is comfortable.
How does the home meet people’s religious needs ? aith and religion can be a source of comfort for people with dementia, Even when perhaps they have lapsed in their religious practice, many people rediscover their faith later in life. Hymns and prayers can be very comforting and provide a point of familiarity, even when the full meaning is not entirely clear. Good homes will provide a regular in-house religious service with prayers, hymns and communion, appropriate to the religious beliefs of the resident.
How does the home keep in touch with relatives ? You may not be able to visit as often as you like, but you will still want to know what is happening in the life of your loved one. Good care homes will make sure you are contacted when things happen, and they will send you a regular newsletter to let you know about general developments in the home. You should also expect to be sent some photos every now and then. Does the home organise meetings with residents, family and friends to allow you to have a say in the development of the home ?
How can I get involved in the care planning ? Just because your loved one moves into a home does not mean that you have to let get go of their care altogether. You probably know this person better than anyone else and a good home will welcome your involvement in the planning of their care, and in your involvement in their day to day care to whatever degree you wish to be involved. Would you like to take care of laundering their clothes, or perhaps help with their bathing ? Perhaps you would like to have lunch with them ?
Care homes prepare care plans that document how the home meets the specific needs and preferences of each resident and good homes will encourage you to be involved in the care planning process. This can help your loved one adjust to a new environment by making sure that their habits and preferences are understood and supported. Habits are very important to us and none of us like our habits being broken after many years. When you are confused, being able to continue with familiar habits can be very comforting. So make sure these habits and preferences are recorded in their care plan, and that your loved one is supported to continue them as much as possible. Perhaps your loved one has a cup of tea before brushing their teeth. Maybe they like to go for a walk in the garden after lunch ? Watch the 9 O’Clock news ? Make sure the home knows about these things, they can make an enormous difference to their wellbeing.
Can I see the result of your most recent quality survey ? A good home will undertake surveys of residents, friends and family to get feedback from them about the quality of care provided by the home, and there should be a report that summarises the findings of that survey. Ask for that survey report, it can be very insightful. The home may also keep a record of testimonials by friends and family, and this is an excellent way to understand how others feel about the home.
Can I chat with a relative of one of the residents ? This is one of the most powerful ways of getting an independent opinion on the quality of a care home. Another relative can tell you about the quality of the care, the quality of the activities programme, and how welcome they feel in the home. A good home should be very happy to put you in touch with a relative, or you can always strike up a conversation with one of the relatives when you come to view the home.
How do residents get involved with running the home ? Good dementia homes will find ways to involve residents in the running of the homes. They may hold resident meetings to get resident’s views, and residents can be involved in practical tasks such as gardening and growing vegetables, cleaning, folding towels, hanging out the washing etc. All these initiatives can help resident maintain a sense of being in control of their own life