Health
Nursing home or minefield? Print E-mail
Written by Marion Shoard, 2009   
Finding the right residential care can be a positive and agreeable experience, but you must ask all the right questions at the start, says Marion Shoard.

As we all live longer, more and more of us are having to choose a nursing home for ourselves, elderly partners, relatives or friends. We need to know not only how to do it, but also to be sure that we, or our loved ones, will be well cared for. So how do we choose?

Basic information about the differences between the thousands of nursing homes in England and Wales is provided free of charge by the national agencies that regulate and inspect them - the Commission for Social Care Inspection (to be replaced by the Care Quality Commission later this year) and the Care and Social Services Inspectorate Wales.

Not only do they provide lists of homes categorised by geographical area and type: they also publish the reports of the inspections carried out by their own inspectors. It is very well worthwhile reading these reports carefully before you visit a home that looks promising, since they can inform your questioning.

You can also obtain from the Commission or the Inspectorate the legal framework within which homes operate - the care homes regulations and the national minimum standards.

These provide invaluable information about what to expect. Also, Age Concern, Counsel and Care, Help the Aged and the Relatives and Residents Association (which specialises in supporting older people in care homes and their relatives) provide useful general information about homes as well as telephone helplines.

Many nursing home residents pay their own bills, with some help from the state (through the state retirement pension, for instance). Another group of residents have their bills paid by the social services department of their local council, because their savings are less than £13,500 in England, or £19,000 in Wales.

A much smaller number of other residents are funded by their health authority because their medical and nursing needs render them eligible for special funding called NHS Continuing Healthcare.

If you fall into the second or third category, you should be aware that you have choice about which home you go to. Local councils must allow residents to choose their home, whether it lies within or far from the local authority's area, so long as the home meets basic criteria.

This requirement for choice does not apply to health authorities, but if you are granted NHS Continuing Healthcare you should expect to be given a choice, and you are free to ask the authority to fund your place in a different nursing home from those offered.

Some prospective residents who will cover their own fees decide off their own bat to go and live in a nursing home, relying largely on tips from friends and guidance from the care homes they visit (which are usually private businesses and are thus trying to attract another customer). Such people are very vulnerable to selecting unwisely.

Expert advice might reveal that they do not need to be in a nursing home at all, but would be fine in a residential home (where fees are lower) or in their own home, with appropriate equipment and help. One-to-one expert advice is available from the social services department of local authorities.

Councils must carry out a community care assessment, free of charge, to anybody who might need help, regardless of their income, if asked to do so.

Once you know that the help you need can best be provided in a nursing home, it is then all too easy to plump for a home falling into the highest grading without asking many questions.

The Commission for Social Care Inspection (but not its equivalent in Wales) has been placing homes in one of four categories, from 'excellent' through to 'poor'. But although the inspections on which these gradings are based are useful, they are limited: inspectors rarely visit at night and they may not inspect frequently.

Also, nursing homes tend to see a very high turnover of staff, so key staff may have moved on since the last inspection.

It is worth concentrating on two basic areas when selecting a nursing home. The first revolves around the medical and nursing care of residents, the second the sort of daily life they live.

You will get an initial idea of how the home approaches these twin areas on your first interview with the manager of a home and the tour of the premises on which they take you.

Quality of care

You are probably contemplating a move to a nursing home because you have one or more ongoing medical conditions, such as Parkinson's disease, après-stroke, osteoarthritis, severe sight impairment or dementia.

Does the home have the expertise and sufficient, trained staff to look after the nursing and care aspects of your condition? Before you visit, find out how your condition should ideally be treated, so that you can ask intelligent questions.

Good sources of information are the voluntary organisations that help people with such conditions (the Stroke Association, the Parkinson's Disease Society, the Macular Disease Society, the Alzheimer's Society and the like) and the detailed guidance for professionals issued by the National Institute for Health and Clinical Excellence (NICE). For instance, if you have a pressure sore, study the NICE guidance (available free by post or on the Internet) on how it should be managed and treated.

To complement what it can offer, a nursing home should have established easy access to NHS professionals outside, from physiotherapists and continence nurse advisers to opticians, audiologists and chiropodists, whose services should be provided for free.

Dental care can be difficult to obtain, as the NHS community dental teams that visit people in their own homes are often thin on the ground. So ask how dental care is obtained. If not through the NHS, how and at what sort of cost?

It is usually best to keep your own GP, if you can. The practice will have built up a relationship with you over the years and should know your medical history well.

Nursing home residents have just the same right to choose their own GP as anybody else. If the home tries to persuade you to change to a GP practice with which it has a special association, only do so if you are convinced it will give you better care.

The home should be doing whatever it can to stop further health problems arising. Infections and falls are a particular danger. How does the home seek to prevent the spread of coughs and colds (potentially very dangerous for frail, elderly people) and MRSA, for example?

Several residents may have MRSA, which is a wound infection. How is this handled? The residents in question should be enabled to live a normal life but steps taken to prevent cross-transmission, in particular through keeping the wound well covered.

What does the home do to minimise the risk of falls? For example, are there enough grab rails? Do you see residents with mobility aids using them properly or are they shuffling around with inadequate equipment and footwear? Are all parts of the complex that residents use well lit? (Older people need a lot more light than younger people to see as well.)

Daily life

Nursing homes draw a sense of what they should look and feel like from two main models. One is the hospital, the other is the domestic home.

Nobody wishes to live full-time in something resembling a hospital. But just how does a care home manager seek to create a real sense of home in a nursing home? Would you find this nursing home homely? And would it enable you to live as happy and fulfilled a life as possible?

If you are assessing a home on behalf of somebody else, think carefully about their particular tastes. You might be impressed by the matching décor in the lobby, but if your mother is moving from an unmodernised, small, terraced house, then an open-plan, purpose-built nursing home might leave her feeling disorientated and unhappy.

Would the other residents provide congenial company and, ideally, kindred spirits? Are there plenty of activities on offer that she would find interesting or entertaining? Expect at least one organised activity every day, such as crafts, exercise or singing. Is every assistance given to enable residents to participate fully?

One crucial area that is difficult to assess on the initial tour with the manager is the extent to which staff have the time, skill and motivation to help residents live the sort of life they would like to live.

A good way of assessing this is to ask if you could return some time and simply sit and watch what goes on around you, on your own, for a couple of hours. Observe whether residents are treated with respect and warmth by staff. What do residents do all day?

Are staff prepared to speak slowly and clearly and write things down for those who are hard of hearing? How are residents helped to move around? Techniques for moving residents should vary according to their disabilities, but you ought to be able to judge whether people are being moved with consideration and skill.

Try to sit and watch several times, at different times of day and on different days of the week.  Try to include an activities session and a mealtime. Does the food look tasty and nutritious? Are portions adequate? Are seconds offered? Is any necessary help given with consuming food?

If you are looking at a home on behalf of somebody who has some degree of dementia, the approach of staff is of overwhelming importance. People with dementia often feel frightened and very insecure.

Often they do not understand where they are or indeed who they are, even if that information is conveyed to them many times. They lose their cognitive and language skills, but not their emotions, and thus their ability to feel pleasure and pain.

Those who look after them must be patient and genuinely willing to enter into the mental universe of the person with dementia, to meet them where they are.

If you see care assistants chatting across a person with dementia as if they simply were not present, if you see care assistants neglecting even to talk to somebody with dementia, then that home is unsuitable for such people.

Staffing

Find out about the numbers and types of staff and their qualifications. Expect at least half of the home's care staff to have achieved the basic qualification of National Vocational Qualification (NVQ) level 2.

Find out how often the home employs agency staff, as these will not be able to provide continuity of care. Try to meet all the staff who would be involved in your life in the home, including the night staff and anybody the home proposes as your 'key worker'. Could the cook cope with any special requirements or preferences you have?

Visiting

Is the home conveniently sited for visitors? When they visit, what would they do? Where could they talk to you in private? If your partner is to visit frequently and for long periods, where would such visits take place? Look to see how visitors are welcomed (or not). What would young children do if they should visit? Do care staff have the time and inclination to give residents any help they need to get into the grounds?

The bedroom

On the tour, the manager should show you the room they are offering; the contract between resident and home should specify which room is to be occupied. Do you like the feel of the room? Does the room afford a space apart from the bed area in which visiting could take place? Is there a pleasant view?

Is there an individual temperature control? Can you have your own telephone? Is there sufficient space for any furniture, equipment, pictures and other memorabilia you wish to bring? Is the bedroom quiet? How could you summon help, day or night, from any part of the room or ensuite bathroom? (Don't rely only on fixed devices that you might not be able to reach in the event of a fall: expect a pendant alarm worn round the neck.)

If your relative has dementia, what provision is made by means of sensor systems, alarms and checking by staff to ensure they are all right? If you are hard of hearing, how will you be alerted in the event of a fire - perhaps by a flashing light or a vibrating structure under your pillow?

The contract

Do not consider entering the home on a permanent basis without having signed a contract: if you do, and problems arise, like an uncalled-for hike in the fees, or a proposal to move you to another bedroom, or suggestion that you share, you will have little comeback. So before you sign the contract with the home, scrutinise it carefully.

Contracts vary a good deal, and you should seek amendments if necessary. Examine carefully the grounds in the contract on which the home could ask you to leave.

If you go into a home with your partner, try to make sure that the contract covers the provision of a specific double room and that you cannot be split up or moved out of it without your consent. The Office of Fair Trading has published guidance on unfair clauses.

If the contract is between your local authority or health authority and the home, make sure you are given a copy so that you know what to expect the home to do. If appropriate, suggest amendments and/or ask for written clarifications.

A trial period

Finally, a trial stay is a good idea. You could see whether you could stay in the home for a trial period to get a real feel for the place, day and night; the national minimum standards expect homes to allow this facility. Only after that would you have to make a final commitment.

While scare stories about care homes abound in the media - and some do leave much to be desired - many are very agreeable places in which to live. Some people find they spend some of the happiest times of their lives in a nursing home and wish that they had moved in sooner.

Useful contacts

Marion Shoard is the author of A Survival Guide to Later Life (2004), which is available through Amazon. Her new book, A Comprehensive Guide to Later Life, will be published next year. Further details can be found on her website www.marionshoard.co.uk
 
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