A Better Home Life - A code of good practice for residential and nursing home care - Centre for Policy on Ageing.

Entering care

3.1 Introduction

People move into continuing care in a variety of circumstances but for each person it is a major life event. Wherever possible, it should be the result of an individual's own informed decision but this may not always be the case. Some will come direct from hospital because a decision to discharge the patient into a supported environment where care is available has been made on the basis of multidisciplinary assessment. Some may come in as the result of decisions made by their relatives or as a result of a crisis. The clinical and other care needs of individuals will vary substantially. In many cases, residents will have been assessed by their local authority social services/work department in consultation with medical and nursing colleagues as requiring residential or nursing home care and some of them will be paid for wholly or in part by the local authority under the NHS and Community Care Act 1990. Others will be paying for themselves.

A prospective resident is likely to be anxious that the decision is the correct one, however it was arrived at. Coming into a home may mean a move away from a familiar area, away from neighbours and friends. It almost certainly means a move into smaller accommodation and the giving up of many personal possessions. Moving into residential care may be occurring at a time of other significant change in the person's life of crisis or emergency. That change may be due to the loss of a partner or carer with all the accompanying grief which that will entail. To be moving into care may itself sometimes feel like a bereavement.

3.2 Choice

Individuals should make their own informed decision to come into care. However, if they themselves cannot make the decision, then those with authority to do so must ensure that the best choice is made on their behalf. Other non-residential options should be considered for example, packages of care organised after local authority assessment by a care manager which enable both health and social care services to be delivered in the individual's own home.

3.2.1 Making the decision

People contemplating entering care should have the opportunity to explore the advantages and disadvantages. A sympathetic and knowledgeable person such as an advocate, social worker or older people's health visitor may be appropriate especially if they have no relative or friend to offer advice. Relevant questions to ask will be:

All people have the right to an assessment of their needs by the local authority social services/work department and this should form part of the decision-making process. Under the Carers (Recognition and Services) Act 1995, their carers also have the right to be assessed by the local authority.

3.3 Reasons for moving into continuing care

The reasons for deciding to move into care may be varied. Some people may feel they have no other option because of their current circumstances. Some may be faced with the decision suddenly; others may have planned the move for some time.

It may be a combination of several of the following:

The reasons why people come into continuing care have changed in recent years. More are coming in because of failing health and increased dependency than for social reasons. This has consequences for the levels of care required in homes. Managers and staff will need to bear in mind the varying reasons why, and in what circumstances, residents have come into care. Some individuals may need more support than others in coming to terms with the major change in their lives and the home should be sensitive to this. In all circumstances, however, new residents should be made welcome and supported through the period of adjustment which all will experience as newcomers.

3.4 Assessment prior to care

Increasingly people moving into care come via the route of a social services-led assessment under the NHS and Community Care Act 1990. They may have been the subject of a joint assessment between social services and the health service prior to hospital discharge. The social services/work department may also have instituted an assessment of their needs while they were still living in their own homes. There will also be an assessment of their financial means.

The assessment of needs should cover a wide range of topics so that an appropriate home can be identified and, once the person has moved in, a comprehensive care plan drawn up. Topics to be covered in the assessment should include:

Copies of the assessment should be given to the home as part of the admission process and form the first stage of care planning. Wherever possible, this should begin before the person moves into the home. Planning should start as early as possible.

3.5 Preparation

People planning to enter residential or nursing home care should be able to visit the home and, ideally, stay for several days. Similarly, it is desirable if so wished that the manager of the home should visit potential residents to establish a personal relationship, gain information about their way of life and advise them about what possessions can be taken with them into the home. Many people may be too frail to visit homes in person. One way of overcoming this problem may be for homeowners to arrange for a video to be made (this does not need to be made professionally). This can then be taken (with video player) and shown to potential residents.

3.5.1 Sources of advice

There are a number of organisations which can offer advice to people thinking of entering care. Information about them should be made available by social services/work departments, at GP surgeries, clinics, citizens advice bureaux, community health councils (England and Wales), local health councils and councils of social service (Scotland), health and social services councils (Northern Ireland) and other advice agencies (see Appendix 3 for further details).

3.6 Information

The right decision can only be made if people are properly informed. Under the Registered Homes Act 1984, all homes must make available a brochure or prospectus which sets out the aims and objectives of the home, including the type of resident catered for (for example, those with mental health needs or nursing care needs) and the category of registration (residential, nursing, single, dual), the degree of care offered, the extent to which illness or disability can be accommodated and any restrictions relating to age, gender, group affiliation or religion. In detail, the information should cover the following topics:

  • a general description of the home, perhaps with photographs as long as they are realistic;
  • details of location and accessibility by public transport (for residents and visitors);
  • numbers of residents and living arrangements (for example, small group living);
  • availability of single rooms (and double rooms for residents who want them);
  • the type of care provided;
  • arrangements with local services (hospital consultants, GPs, community health services, voluntary organisations);
  • numbers and categories of staff, including nurses in the case of nursing homes;
  • food and dining arrangements;
  • smoking/non-smoking policy;
  • activities (entertainments, religious services, craft activities, outings);
  • extent of private space and scope for autonomy within the group environment;
  • statement of fees and terms and conditions of residence;
  • availability (or not) of trial periods;
  • restrictions relating to age, gender, group or religious affiliation;
  • conditions under which a resident may be expected to leave;
  • category of registration.

    It should also be considered good practice to make clear the ownership of the home.

    3.7 Terms and conditions

    A clear statement of the terms and conditions of residence should be given in writing to the resident before moving in. They may be included in the brochure or drawn up separately. The statement should include:

    3.8 Appropriateness

    The first two months, or longer, should be mutually recognised as a trial period to allow time to see how well the new resident settles in. Many people will come into care as the result of a crisis or direct from a period in hospital. Relatives or others concerned with their welfare should be made aware of the nature of the trial period. Residents coming from their own homes should be careful to delay selling their houses or terminating their tenancies until they are certain they want to remain in residential care. (This statement is made in the full recognition that for many people there will be considerable pressure placed on them to sell their properties in order to meet accommodation fees. Such pressure does not assist informed and appropriate decision-making.)

    3.8.1 Reviews

    After a trial period, the suitability of the arrangements should be discussed fully with the resident and whoever is the individual's key supporter (relative, friend, care manager, key worker). The possibility of transfer if the arrangement is turning out to be unsuitable should be considered. Review decisions should be recorded and implemented.

    Once the individual has become an established resident, a programme of regular reviews to monitor progress and to ensure the resident is satisfied with the home should be agreed and their purpose explained. These reviews will become part of the care plan.

    3.8.2 short-term stays

    It is generally assumed that once individuals enter a home, they will not return to their own homes. This is not, however, always the case. A short stay may be planned for convalescence, rehabilitation or respite. In other cases, some people's health may improve so that they are able to return home. Appropriate treatment and rehabilitative services should be arranged to ensure that maximum recovery takes place and that the condition of residents does not deteriorate. The aim of rehabilitation (which should be available to all residents) is to retrieve a person's functioning and to maintain it at its highest level.

    3.9 Funding for individuals coming into residential and nursing home care

    3.9.1 By the social services department (social work department, health and social services board)

    Older people who qualify for statutory funding retain the right to choose which home they would like to live in even though the social services department in England and Wales (social work department in Scotland, health and social services board in Northern Ireland) is wholly or partly funding their care. The department will put an upper limit on the level of fees it is prepared to pay, but it must be sufficient to fund a home able to provide the services required by the resident. If the resident wishes to go into a home with a higher fee level this is still possible provided that the difference is guaranteed (usually by a relative or another organisation).

    3.9.2 By district health authorities in England and Wales (health boards, health and social services board)

    Health authorities, and boards in Scotland and Northern Ireland, will be involved if someone is entering nursing home care from hospital. They may also be wholly or partly funding it if there is a specific medical need. Eligibility criteria agreed by all statutory parties will determine the level of involvement and financial support to be provided. Good hospital discharge arrangements should be in place to ensure a smooth transition from hospital to the home. This includes the prompt transfer of information about any treatment plans or medication. In the case of some patients discharged from psychiatric in-patient care, the 'care programme approach' (special arrangements for someone coming out of psychiatric in-patient care) will have to be observed. Once in the home, continuing professional support should be available if necessary, for example from consultants and physiotherapists. Most trusts and social services/work departments or boards have agreed protocols with each other and local residential and nursing homes about discharge procedures. These should always be observed.

    3.9.3 Support for residents paying their own fees

    Where individuals are paying full fees themselves and are likely to continue to do so throughout their residence, it is not necessary for the statutory services to be involved. However, in these situations it is important that (potential) residents receive similar help to make fully informed and considered decisions and social services/work departments should provide it. This will also be available through independent organisations which specialise in helping people find suitable residential care, through welfare organisations or advice agencies. Care homes associations sometimes provide this service.

    Homeowners should make clear, before admission, what their policy is when self-financing residents run out of resources. Prospective residents should also make clear their own financial position.

    3.10 Good practice

    As a matter of good practice the process of entering care should:

    The homeowner or manager should: Prospective residents should: