Living with dementia in care homes – not just ‘commissioning services’

An organic transformative cultural change towards a sense of ‘working together’ will drive the development of care home services which are driven ultimately by the people who need them.

The population of residents in care and nursing homes can often too have diverse and complex cognitive and behavioural needs. The mental health of residents, such as depression, can often be totally ignored, however remains amenable to treatment from psychological therapy. And yet care can be fragmented and poorly co-ordinated. Critical to this is understanding people’s individual backgrounds, or life stories, and, it is of course a workforce planning issue that staff of all grades including student nurses are fully trained in such approaches.

Poor co-ordination of care between different care environments can be distressing for all involved, not least NHS patients and carers, and can unfortunately lead to a breakdown of trust and compassion. The NHS is currently aiming for a whole system, sustainable model of integrated care. For example, multidisciplinary ‘vanguards’ have been established linking GPs to community beds, i.e. care homes, aiming for personalised care plans, improving person experience and avoiding hospital admissions where desirable.

“In-reach” services mean that a patient might be now cared for at home, enhanced by improvements in telecare and other technology innovations. Looking for high quality outcomes, rather than merely commissioning for services, arguably has become very important, with care homes well placed to become ‘community hubs’, priming reablement or rehabilitation after secondary care, or offering support for carers in the community. Reablement is being increasingly viewed as an opportunity allowing independent outcomes-focused living in the short and long term.

Care homes have come under recent scrutiny, not only in terms of high profile regulatory issues, but also in a shift in emphasis from minimal compliance to high quality outcomes from regulators. There has also been a greater focus on the need for anti-discriminatory language, the need to acknowledge the social care and nursing perspectives, and the desire to improve wellbeing and quality of care. But ensuring quality of care needs close partnership with private and voluntary sectors, in the context of trenchant local financial pressures. Austerity can never be an excuse for cutting back from less visible caring needs, such as mouth care, which requires expertise and full attention.

It is all too easy to use the term ‘person centred care’ as the solution to all quality of life and quality of care concerns, but it is now fully acknowledged that meaningful activity and occupation, high value staffing, and protection against “risky threats” such as neglect and abuse are all essential in delivering good care homes. People living with dementia tend to have specialist needs, such as co-morbidities such as frailty, often experiencing loneliness after the point of diagnosis, and this necessitates co-commissioning approach.

Tragically, too, there is a shortfall in quality and quality of research in care homes. Previously, it had become a default option for some to call people with dementia as having challenging behaviours, and yet we do need better research in synthesising perspectives of residents themselves, relatives and staff. Existential issues, such as religiosity or spirituality, might exist in residents, and it must surely be ethical for care providers to identify these issues accurately. End of life care requires in a care homes requires a complete understanding of residents’ life experiences in ‘accepting’ being in a care home, and is inevitably a delicate balancing act involving the views of ‘significant others’. Finally, we need to have much greater definition on what can cause the problems in residential care; such as poor physical environments, polypharmacy, poor mobility, falls, and infections. But we further must take a balanced approach with authentic leadership.

With recent devolution of other responsibility to local areas, such as in housing or transport, but one which emphasises looking for outcomes rather than commissioning services, hopefully residential care will be characterised in England by autonomy and a rich diversity. It seems sensible for us to take stock about where we want a joined up approach involving care homes to head, even if it is the case that most of us would not want to start from here.