A Better Home Life - A code of good practice for residential and nursing home care - Centre for Policy on Ageing.
Moving into care is often accompanied by negative feelings and
a sense of loss of status. This needs to be understood and taken
into account by those providing care, to minimise as far as possible
the loss of self-confidence and the failing sense of self-worth.
Receiving intimate care in a new setting, often away from loved
ones, especially at a time of adjusting to the 'home' as home,
may be particularly difficult. Some people may resent their increased
dependency, the need to receive care in a new and different environment
and their reliance on staff. Their sense of loss may be similar
to a feeling of bereavement. Staff sensitivity to these feelings
will be required in order to enable residents to come to terms
with their changing needs. For people with dementia, with impaired
memory and reasoning, the transition may be bewildering.
Living in a home in no way diminishes residents' rights of access
to health and rehabilitative services available in the community.
This includes the right to choose their own GP and to see him
or her in private. Managers, with the consent of the resident,
should be kept informed of any necessary changes in the resident's
care. In the case of residential care homes, the rights of residents
to have access to community nursing services does not in any way
put at risk the registration of the home as a residential care
home. Managers have a right of access to available community resources
and advice in the interests of their residents.
The care which is provided within the home should be tailored
to meet the needs (social, personal, nursing or medical) of each
individual. It should be provided on the basis of an assessment
which is both timely and comprehensive. At all times it should
be provided with respect in a manner which is sensitive, maintaining
the dignity of whoever is receiving care. The privacy of individuals,
particularly in all matters dealing with intimate care-giving,
should be ensured at all times and their cultural and gender needs
and sensitivities should always be recognised.
Care should be given by, or supervised by, skilled (professionally
qualified where necessary) and trained people; training opportunities
should be provided for staff at all levels who should be encouraged
to take them up. The importance of early recognition of symptoms
particularly mental health problems (for example, depression
and dementia) cannot be over-emphasised. The first essential is
to try to ensure that the causes of any symptoms are diagnosed
and any necessary treatment given. Many kinds of physical illness
can give rise to an acute confusional state, as can over-sedation
or other inappropriate medication. Dementia is the condition which
generally gives cause for most concern but depressive illness
is very common in old age and can be mistaken for dementia. Delusional
symptoms can develop in an otherwise intact personality. All these
conditions can be cured or at least alleviated and it is essential
that managers take responsibility for seeing that no such illness
is ignored. Junior staff should be trained to recognise symptoms
as they appear. The importance of calling in outside expertise
via the GP should also be recognised.
Care-giving should never be coercive, and should always guard against
abuse and restraint. Nothing should be done which makes individuals
lose their self-esteem. Even at their most frail and vulnerable,
individuals should be helped to make choices about the care they
receive.
The Registered Homes Act 1984 makes a distinction between residential
care homes (in Part I) and nursing homes (in Part II). Under the
Act, residential care homes provide accommodation and personal
care while nursing homes provide care which requires the skills
of, or supervision by, a registered nurse. In practice the differences
are sometimes hard to define, particularly because of the changing
needs which an individual may experience while remaining in the
same setting. Dual registration with the local authority and the
health authority overcomes some of the legal problems but it is
acknowledged that some flexibility is required to take account
of fluctuations in residents' health. The registration authorities
will need to review the position periodically to determine whether
changes in registration are required. In residential care homes,
any nursing care provided must be under the control of a community
nurse with an agreed protocol relating to named individuals within
the home.
5.3.1 Types of care
Care should be provided holistically that is, looking at the
whole needs of residents as individuals and not isolating different
elements of care into separate unrelated tasks. However, for the
purposes of this code it is useful to identify different elements
to help clarify roles and responsibilities.
Social support
Social support within the home is the support which is provided
to older people to enable them to function as social beings. It
includes social activities designed to enhance residents' sense
of well-being, moral support, care and attention paid to ensure
individuals can maintain contact with family and friends in the
community, and making advice and advocacy available to help individuals
deal with their personal, financial and legal affairs if desired.
Attention to the spiritual needs of individuals is also important
and care should be taken to identify what those needs may be for
particular individuals.
The provision of social support is an integral part of many of
the daily activities of the home. It forms an element in getting
up, eating and drinking, being involved in social activities within
the home, having spiritual needs attended to, getting around the
building and garden, and going to bed. Other sections in this
code deal with these aspects in more detail. Staff should be alert
to the needs of residents and should spend time listening to their
views on what sort of activities they may wish to become involved
in or stay away from.
Personal care
Personal care is the intimate tending of physical needs, which
the individual finds difficult or impossible to do alone. Some
sorts of personal care will be given during the normal pattern
of daily life helping a resident to get around, helping at mealtimes.
Other aspects will require privacy and sensitivity washing and
bathing, going to the toilet, nail-cutting. The individual should
always be able to choose where and when these activities are performed
they should not be the subject of rigid routines. Equipment which
is used should be personal to the individual (flannels, soap,
scissors).
Nursing care
Nursing care encompasses both social and personal care but qualified
nurses who provide or supervise the provision of care also offer
distinct knowledge and skills which derive from their professional
education and experience. They can thus help to balance the health
or clinical needs of older people in care with their daily activities
and aspirations.
Many of the functions categorised as nursing care are also carried
out by other care staff under the supervision of a qualified nurse
within the nursing home, or in a residential care home under the
supervision of a community nurse or the resident's GP (as would
be the case if the resident were still living in his or her own
home).
The holistic approach which modern nursing adopts looks to the
needs of the whole individual. Following assessment of care needs,
nurses may work closely with individual residents, or supervise
care delivered by others. Nursing involvement is essential for
the overall assessment, monitoring and coordination of health
care.
The care component of a home should be structured to include all
or some of the following and will be undertaken by a nurse, or
by a care worker under the supervision, where appropriate, of
a nurse:
As important as these is the need for health promotion and health
maintenance within the home on a continuing basis. Advice and
help should also be available for oral care, nutrition, sight
and hearing. In addition to these is the ability to empathise,
to listen, to think creatively and to communicate.
On occasions nurses who have specialist expertise and experience
will be required to attend residents who, for example, have cancer,
diabetes, a psychiatric illness, challenging behaviour, a stoma
or who are dying. Agreements and protocols with local trusts will
ensure the availability of nurses in these situations.
Medical care
Medical care may be required on a regular or intermittent basis,
either from a GP or specialist consultant after referral by a
GP, depending on specific medical needs. Close links with GPs
are essential. Residents should retain their own GPs if they wish,
and they are willing, without feeling pressure to register with
a local one who acts as the home's overall GP. However, in some
cases, where the person's GP does not want to continue looking
after the patient after entry into a home, this may be the only
option. Whatever arrangement is arrived at it is important that
GPs involved in providing medical care and advice to residents
have some extra experience and proven interest in the care of
older people. Where there are difficulties in involving GPs with
the home, the local health authority will need to advise. GPs
should be involved in the assessment of patients on admission
to a home, and in reviewing their care and medication.
The split between residential and nursing home provision has often
meant that different sorts of care have been restricted in each
setting. Dual registration may in some cases overcome the problem
but sometimes residential care settings have been unable to provide
nursing and medical care, although needed, while nursing homes
have tended to concentrate too little on providing social care.
It also means in some instances that residents in nursing homes
have had less access to the primary health care team and specialist
community nurses than those in residential homes. Bridging the
gap is one of the most important objectives for all care providers.
Relationships with outside health services
Protocols should be drawn up with GPs and local hospital consultants
for dealing with discharges from and admissions to hospital, clarifying
the roles and responsibilities of all parties and for visiting
residents in their accommodation. Staff from the local psychogeriatric
service such as the consultant psychiatrist, the psychologist
and the community psychiatric nurse (CPN) can be very helpful
in planning and reviewing the care and treatment of people with
dementia and depression. Local GPs and/or their practice staff
and attached staff should be encouraged to lay on health promotion
advice and activities for their individual patients and for general
availability within the home. Health promotion advisors from the
local health authority should also be involved in developing activity
programmes for residents.
Community nursing and specialist nursing care
Where the home does not have qualified nursing staff (that is,
in a residential care home or sheltered housing) protocols should
be drawn up setting out arrangements for local community nursing
services to be available for residents when they need nursing
care. Clear lines of communication should be established which
are known to all staff about when and how to call in community
nursing services. Similar arrangements may need to be established
with specialist nursing services (Macmillan and Marie Curie nurses,
CPNs, or specialist nurses from the community nursing service
for diabetes, stoma care, for example) which will also be available
to nursing homes.
5.4.1 Safety
Staff need to take meticulous care over the administration of
drugs. Only nominated and trained staff should be involved in
giving medication to residents. Procedures should be put in place
to ensure the wrong drug is never administered. Attaching a picture
of the individual to the drug chart can be a safeguard against
making mistakes. Some conditions, for example diabetes or Parkinson's
Disease, require a strict drug routine which may not fit into
the daily meal pattern. These routines must be observed.
Medicines must be kept safely, with full records of their receipt,
administration and disposal. Medicines should be administered
directly to the resident and recorded as taken (or not) and should
not be transferred to open unnamed containers for distribution.
If the medicine is not taken it should be disposed of and accounted
for in line with the registration authority's disposal of drugs
policy. The district health authority's pharmaceutical officer
will advise.
5.4.2 The NAHAT guidelines
The National Association of Health Authorities and Trusts (NAHAT)
has produced guidelines for the handling, storage and disposal
of drugs as appropriate. Homes should be familiar with these and
abide by their requirements as appropriate.
5.3.3 The dangers of polypharmacy
A common problem amongst residents is the large number of drugs
(polypharmacy) which they are taking, often over a period of years
without any proper review. Sometimes this leads to unwanted effects
or unnecessary confusion. The use of sedatives and sleeping pills
is sometimes prescribed as a matter of course. The problem may
be caused by drugs being prescribed from hospital without any
proper feedback to the resident's GP and vice versa. It may be
eliminated if the GP reviews the medication on admission to the
home and reviews it regularly thereafter every two or three months.
5.4.4 Non-prescribed remedies
Non-prescribed remedies should be purchased separately by each
resident for his or her own use (or someone else should do it
on his or her behalf).
Communal supplies of non-prescribed remedies and creams should
not be kept. This does not preclude the home from keeping proper
first aid supplies, which it must do by law.
Wherever possible, and depending on their capabilities, residents
should take responsibility for their own medicines and a monitored
dosage system, in which a week's supply is divided up into separate,
sealed compartments, may be helpful. A positive decision should
be taken as to who (resident or home) is responsible so that no
false presumptions are made. The home should have a policy on
self-administration of drugs. It should always be remembered that
in law homes have a duty of care and managers should be clear
under what circumstances GPs will be informed of residents' serfadministration.
The district pharmacist is a useful source of advice on any matters
to do with medication.
Care plans for individual residents, in both nursing homes and
residential care homes, are essential to ensure that each resident
receives the individual care he or she requires. They are a necessary
part of the record-keeping of any home and facilitate good communication
between residents and internal and external staff. Residents (and
their relatives where appropriate) should take a lead in saying
how they would like to be looked after. Care plans should form
the basis for daily care and they should be referred to regularly
and updated as appropriate. They should be available to relevant
staff at all times. Consistency in their implementation is particularly
critical in dementia care. Residents should have direct access
to them, preferably retaining them themselves where possible.
Their permission must be sought for people other than the responsible
care staff to see them and use the information they contain. With
the individual resident's permission, the care plan may be used
by inspectors as one means of checking on the quality of care
provided in the home.
5.5.1 Drawing up care plans
Care plans should be developed by each home according to its type
and the condition of the residents. They are likely to be more
complex in nursing homes. The process is a developmental one and
includes the following stages:
Content of care plans
The following areas should be considered for the care plan although
not everything needs to be included for every person:
Wherever possible, clear and attainable goals should be set out
in the care plan which the resident and care staff can follow
on a planned basis, with a time-scale (which should not be too
far distant) for achievement. In this way progress can be monitored
and incentives given to both resident and staff.
Advice about drawing up plans may be sought from the registration
authority.
5.5.2 Key workers
Depending on the size of the home, it may be considered appropriate
to establish key worker arrangements. Key workers take responsibility
for individual residents and ensure that 'their' residents are
attended to and looked after in accordance with their particular
needs (especially as laid down in the care plan). If this approach
is not adopted, alternative systems should show that they fulfil
the requirements for personal attention. Where a key worker system
is in place, residents should be able to have the key worker changed
without difficulty or recrimination if they request It.
5.6.1 In the case of physical illness or disability
It is important to be alert to signs of physical illness in people
with dementia. There is a danger that they may be overlooked.
Emotions and intellectual functioning are affected by a person's
physical health. This is particularly important for people with
dementia because:
Staff responsibilities
Staff have to be alert to changes in behaviour or to indirect
verbal explanations which may indicate that there is a problem.
Urinary tract infections, for example, may make someone suddenly
more confused, or constipation may make someone shout for help.
The possibility of pain should always be considered if there is
a change in behaviour. In general, staff should always beware
of assuming that people with dementia do not understand. With
patience and perseverance, staff will be able to establish relationships
of mutual understanding.
Caring for someone with dementia who is physically ill can be
problematic in that they may not understand that it is important
that they stay in bed or stay inside. More generally, staff have
an invaluable role in drawing attention to changes in behaviour
which may help the doctor's diagnosis. A knowledge of the person's
past can be useful in understanding how they cope, or do not cope,
with illness. Relatives too can be helpful in sharing their knowledge
and understanding of the resident.
Regular monitoring and review of a resident's condition is essential
to ensure that the correct treatment and care is being given.
5.6.2 Personal care
As far as possible people with dementia should undertake their
own personal care because:
It is always much easier and quicker to help people rather than
let them do it for themselves and people with dementia can be
very slow indeed. Staff may also have to suppress their own views
on, for example, the advantages of a bath over a strip wash favoured
by many older people.
The assessment skills of staff are very important. They need to
be able to break personal care tasks down into small steps and
assess which ones the resident can or cannot do. People with dementia
may not be able to dress themselves, for example, because they
have forgotten which order clothes go on but if the clothes are
placed in the right order they can manage (the right order being,
of course, the order they prefer and are used to).
The same careful assessments are needed for all personal care
activities. Some people may be able to eat a meal if the right
implements are put into their hands, but not otherwise. Another
person may be able to use the toilet at night if he or she can
see it; so a light needs to be left on. A creative problem-solving
approach is required and success can be rewarding for staff and
resident alike.
For the individual, much of the experience of dementia is an experience
of constant failure. Remaining abilities need to be identified
and recognised to enhance confidence and self-esteem. Mealtimes
can provide many opportunities to identify and make use of remaining
skills even if it is just those of pouring tea out of the teapot.
When help has to be given, for example in actually feeding a person,
it needs to be as one adult helping another. Time to achieve a
rapport and dignity in such a situation is essential. A great
many actions which humiliate, diminish and de-skill people with
dementia are done because staff are not encouraged to invest time
in assisting them or to see the activity as a potentially therapeutic
use of time.
Staff can all benefit from an understanding of the way stress
impairs everyone. People function less well if they are stressed.
Providing an environment where stress factors such as noise are
diminished, ensuring that staff are not communicating their own
stress in their behaviour and helping in a natural and positive
way will all help people struggling to undertake their own physical
care. All physical care activities can be made more or less stressful
by staff. Being helped to the toilet can be an opportunity for
a friendly chat or it can be a stressful experience. Being lifted
into a bath on a hoist can be an opportunity for a personal reflection
and a shared song or it can be terrifying.
5.1 Introduction
5.2 Principles of care
5.3 The continuum of care
Administration of medication
5.5 Care plans
5.6 Care for people with dementia