Life in the home

The principles which should govern life within the home focus on the importance of promoting residents' independence through enabling them to make their own decisions, fostering their individuality, sustaining family and community contacts and ensuring that they are satisfied with the quality of life and care in the home.

4.1.1 Control and independence

Quality of life for individuals will be enhanced if they are able to have control over what happens to them. There is a danger that living in a group means people lose control over their own lives because they are all treated alike and have little privacy or opportunity to be regarded as individuals. It is obvious that in some cases the degree of dependency experienced by many of the residents will preclude any possibility of extensive independence. However, the spirit of the principles of control and independence should govern the care provided to all residents.

Rules and routines

The imposition of rules and routines often leads to an erosion of residents' independence. They should therefore be kept to a minimum and employed only to promote rehabilitation (with the agreement of the resident), fulfil statutory requirements, prevent undue disturbance to other residents or ensure acceptable standards of safety and hygiene.

Risk-taking

Responsible risk-taking should be regarded as part of the normal expression of people's independence. After appropriate assessment of risk, they should not be discouraged or unduly restrained from undertaking certain activities solely for fear of the consequences, for example that they may hurt themselves. Excessive paternalism and concern for safety may lead to infringement of personal rights. Those who are competent to judge the risk themselves should be free to make their own decisions so long as they do not threaten the safety and lifestyle of others. Managers should distinguish between behaviour which endangers or seriously inconveniences others and that which involves only the individual concerned. The latter, such as bathing unassisted, or going out unaccompanied, should be restricted only if the resident is not capable of making an informed decision for which he or she can be responsible or if it runs counter to an existing agreed therapy or treatment programme. Managers will need to recognise the demands which getting the balance right place on junior staff and provide support and training to assist them.

4.1.2 Individuality

A home where staff recognise the individuality of each of its residents is likely to be a good home. From this recognition is likely to flow a style of management which enables residents to make decisions for themselves, choose the way in which they spend their time, build friendships with whom they wish, and find satisfaction in living in the home environment.

Ways of maintaining individuality

Ensuring that residents have their own private space, with plenty of reminders about their identity for people with dementia, is an essential part of maintaining their individuality. Single rooms, places to withdraw to from busy, active communal areas, opportunities to prepare food and drink for themselves, and choice over when they get up and go to bed will all contribute to the process.

A resident's earlier life

It is easy to underestimate and undervalue the qualities, experiences and talents of people in care. Residents' willingness to share their past experiences, interests and life histories with their companions will help create their individual identity for fellow residents and staff. A reciprocal regard for family and friends and an encouragement of their involvement with the continued care of the resident and in the life of the group (with the residents' agreement) will reinforce the esteem in which residents are held.

Culture, background and ethnicity

The principle of valuing individual identity means that anyone, from any background, should be treated as unique. As people grow older, their earlier associations and allegiances will remain important (and often become more so). People moving into residential care are likely to want to go into homes which reflect their particular ethnic, religious, educational, occupational or social backgrounds. Where this has not been possible, and they are living in a mixed setting, their particular needs, be they cultural, religious, language or any other, should be recognised and accommodated. Wherever possible, the staff complement should reflect the cultural and ethnic mix of residents in the home.

4.1.3 Satisfaction with the quality of daily life

A key measure of the quality of life in a home will be the degree to which residents are satisfied in their daily lives. This will relate to:

• the activities of daily life;
• the quality of food and the way in which it is served;
• opportunities, for those who wish, to engage in social and leisure activities;
• quality of care;
• choice in daily routines;
• the skills and attitudes of staff, managers and volunteers.

Residents should be able to look forward positively to the day, and days, ahead. The regular testing of residents' views about the quality of the service they receive should be part of the management process. For people with dementia this may be done by using techniques such as 'dementia care mapping' which involves careful observation of individuals over a specific period of time and assessment of their interaction and reactions. Managers should also be receptive to the ideas and suggestions that residents, their family, friends and advocates might make to improve the general quality of life in the home. Many relatives and friends are sometimes fearful of appearing critical lest it rebound on their relative. They are also often very grateful for the care given and feel guilty they can no longer provide this at home, so they do not want to criticise. Therefore a home has to generate a positive and easy welcome for ideas if it wishes to hear them. Openness and receptivity should be seen as a mark of good management and procedures should be established for enabling this.

Domestic routines are necessary for the smooth running of a home and are part of the normal rhythm of most people's days in any setting. They need to take account of individual needs and preferences. As far as possible, routines should be agreed with residents and carried out in a friendly and flexible way.

Examples of flexibility:

• changing the time of a regular bath so that the care assistant can take the resident for a shopping trip;
• a resident having a meal at a later time in the afternoon (instead of the meal at lunchtime) so that he or she can go to an education class in the morning;
• raising plants in the corner of the conservatory because there is no greenhouse;
• a resident with dementia who has always worked a night shift being able to sleep all day and be active at night.

Examples of unacceptable practice:

• early rising for the convenience of staff; routinely arranging chairs around the edge of the room and leaving the television on with no one watching;
• serving the same meal with no choice to everyone at the same time;
• serving the last meal of the day to suit the cook's working hours;
• adhering to rigid bath routines.

4.2.1 Getting up and going to bed

One measure of a flexible approach to daily life is the extent to which residents are able to choose when they get up and when they go to bed. It should always be their choice and never be fixed to fit into a routine dictated by staff rotas. Some people with dementia lose their sense of night and day. In these cases, assistance may include reviewing medication, the provision of highly visible clocks and orientation to daylight and darkness.

4.2.2 Mealtimes and food

Food and mealtimes are of great social importance in the lives of all people. This applies to the residential setting as much as anywhere else. Being separated from the sights, smells and noise of cooking food is seen by some as a deprivation. Involvement in the process of preparing food is regarded by others as an essential part of life, although it can be a welcome relief that meals are provided. The degree to which people are directly involved in preparing and serving food and participating fully in mealtimes will depend on their abilities and legal restrictions but where possible the emphasis should be on willing participation (as long as this does not mean residents are standing in for staff.

The following points should be observed:

• people should have the opportunity, if they wish and if they are able, to prepare snacks and drinks for themselves. This might mean kettles in rooms (if this has been assessed as an acceptable risk) or small kitchen facilities near or in their own accommodation;
• residents, according to their capacities, should have the opportunity to be involved in menu planning, preparation, laying tables, clearing away and washing up. Staff should make great efforts to find out individual preferences for types of food and style of preparation, particularly where residents are less able to do things for themselves;
• residents should have regular opportunities to talk to the cook(s) and catering staff about the sort of food they like and to comment on the meals they are given;
• assistance with eating food should be given individually and discreetly and with care and sensitivity. Staff should sit with the person they are assisting. Residents should always have a choice of food so that they can avoid the type of food which they find difficult to handle (for example, peas) or, for people who find mealtimes too stressful, buffet-style meals might be an alternative. If people wish to eat in private in their own rooms they should be enabled to do so. Care should be taken by staff to enable residents to make their views known if another resident's messy eating habits cause distress to others;
• food preferences based on ethnic, religious and ethical observances should be respected. Storage and preparation facilities may be required, and staff may need to be trained in how to prepare some sorts of food and to find out what residents want.
• food should be nutritious, well-balanced and appealing. Great efforts should be made to ensure that food is offered which residents take pleasure in eating;
• the serving of food should be seen as part of the social life of the home. Preplated food as a general way of serving meals is unacceptable because it denies this. Plastic tableware should not be used. Care should be taken to ensure that food offered to an individual resident is attractive even though it has to be appropriately prepared to meet the physical capacity of the individual. Food should only be liquidised if absolutely necessary and care should be taken to present it attractively (for example, by keeping different types and colours of food separate);
• dining rooms should not have the appearance of institutional canteens. Furniture and furnishings should be domestic in style. Chairs should be of a comfortable height with sturdy arms (but which can be pulled right up to the table) to assist those who have difficulty in getting up from sitting. Residents should be able to choose how mealtimes are organised and how dining tables are arranged. Choice of sitting at tables alone or with one or two or several other people should be possible. Regimentation at mealtimes all people being required to sit down to the meal at the same time should be avoided unless it is the clear wish of residents to do so;
• dining rooms should be non-smoking although smoking areas may be designated elsewhere as long as this is in line with the home's overall smoking policy;
• expert advice from dieticians can be sought and followed with regard to nutritional requirements. Special diets specified on medical grounds must be adhered to;
• the handling, storage, preparation and serving of food must comply with all official requirements.

4.2.3 Activities

The therapeutic benefits derived from being physically and mentally active are well known and all homes must provide stimulation of this sort for their residents. The range of opportunities available in the home for people to pursue leisure and intellectual activities should reflect the diversity of its residents and their social and cultural interests and intellectual and physical capacities. It is important for staff to remember that just because people have become infirm and just because they have reached old age, it does not mean that they all have the same likes and dislikes. Not everyone wants to sit and watch television (or the same programme on television); not everyone likes playing bingo or having singsongs. Scope for choice and variety should be made available. Residents confined to bed should as far as possible also have the opportunity for social interaction and intellectual stimulation.

• in many cases, involvement with the local community will provide welcome social activity for residents. Children from schools may wish to visit and in some cases entertain residents. Carol singing at Christmas is a good example although contact should not be restricted to festival times. Local voluntary organisations may wish to establish a continuing relationship with the home which residents may welcome. Residents should always be consulted before any arrangements with outside organisations are established;
• residents may wish to maintain their religious links once they have come into care. The home should positively foster such links with religious and spiritual bodies of all faiths and denominations as appropriate. They may be a source of comfort and reassurance to residents. The wishes of individual residents not to have links of any sort with religious bodies should be respected. Religious belief should not be assumed;
• staff should be sensitive to the changing needs of residents. Over time, some people may wish to withdraw from activities that previously they were closely involved in. These changing attitudes should be picked up and acted upon.

General examples of daily activities:

• gatherings in the home, coffee and tea groups;
• exercise classes, movement to music, dancing;
• books, newspapers (including large-print and audiotape);
• indoor and outdoor gardening (with modifications for disabled people);
• craft activities;
• intellectual activity education classes, quizzes, life history and reminiscence work;
• alternative therapies (aromatherapy, snoezelen room);
• swimming, walking;
• active games (carpet bowls, quoits);
• pets (individuals', the home's, visiting);
• religious worship;
• intergenerational activities (with local schools);
• shopping trips, outings;
• fundraising, social events, local community activities.

For some people, the ability to participate will be limited by restricted movement, deafness, visual impairment or memory loss. When individual residents have a clear wish to participate in certain activities, every effort should be made to help them overcome or compensate for these restrictions by providing personal assistance or aids and adaptations.

In everyday life, many families and friends enjoy doing things together and additional pleasure can be generated for residents and their visitors if opportunities for their involvement exist within the home and on outings. Visiting often increases when people feel that they are coming in to join in an activity or to assist residents.

4.2.4 The needs of people with dementia

An organised day is particularly helpful for people with dementia. It stimulates them and builds on the abilities they still retain. The table opposite lists the sorts of activities which may be possible and sets out the benefits to be derived.

4.2.5 Special occasions

A person's sense of identity is partly linked to his or her appearance. Clothes may be an important part of this. All residents should wear their own identifiable clothes and the staff should take care to ensure that clothes do not go astray or get damaged by careless handling. The practice of supplying clothes from a communal pool is never acceptable. Residents (and family and friends) should be advised about the suitability of fabrics for laundering when planning to purchase new clothes. Staff should be ready to assist in making arrangements to purchase new clothes. The following points need to be observed:

• all personal belongings of residents should be treated with care;
• clothes should be labelled discreetly with name tags to ensure they do not get lost during laundering;
• clothes should be kept fresh and clean. Residents should be able to get involved in washing and hanging out laundry, ironing and mending if they wish, as long as this complies with the law and regulations;
• opportunities for handwashing and ironing should be available and staff should check regularly whether clothes need mending. Clothes should be drycleaned if necessary. If additional charges are made for all or some of these services, this should be made clear in the terms and conditions of residence;
• where residents have difficulty in dressing, for example because of arthritis or rheumatism, it may be necessary to choose clothes which are easy to put on or have simple fastenings. Clothes which are easy to remove may help people who suffer from incontinence. Occupational therapists can offer advice. There may also be benefits in using thermal or other special fabrics.

Many residents will need assistance with personal care washing, dressing, eating, going to the toilet and getting about (either walking or in a wheelchair) in order to be able to participate in the social life of the home. Any tasks associated with providing care of this sort should be undertaken with due regard to the privacy and dignity of the individual.

In particular:

• attention should be paid to ensuring such things as catheters and colostomy bags are not exposed;
• special care should be taken of dentures, spectacles and hearing aids;
• residents should choose when they are washed or bathed and they should be assisted in doing as much for themselves as they wish. While encouragement to bath regularly should be given, rigid bath routines should be avoided.

It is important to take account of individual preferences in the way in which people are addressed. A person is entitled to be called whatever he or she wishes whether it be, for example, Mrs Brown, Alice Brown or Alice. Names and special names are not only labels of identity, they are personal possessions to be handled in the manner their owners choose. It is reasonable to wish to be addressed in different ways by different people. Even when people invite fellow residents to use their first or special names, they may still prefer strangers or members of staff to use a more formal mode of address.

Staff should never use terms of address which patronise residents or make them seem like children. They should not discuss residents' persona! matters in the hearing of other residents. They should not talk to each other over the head of a resident as if he or she were an inanimate object.

Residents should have opportunities for emotional, physical and sexual expression and for intimate and personal relationships within and outside the home as they wish. Sensitivity will always be required to prevent possible exploitation of vulnerable individuals. The ability to manage relationships and to assume personal responsibility may fluctuate over time. Nevertheless residents will continue to have the same needs as other people for expressive behaviour and physical human contact and these needs should be respected.

Many older people value contact with pets and will have had pets living with them until the time of moving into the home. The following points should be taken into account:

• homes should make clear in their information brochures whether or not pets can be brought with residents when they come to live in the home;
• it is important to recognise the therapeutic benefits of pets (for some people) in deciding what policy will operate in the home;
• if individual residents are not able to have their own pets it may be possible for the home to keep pets which belong to the home as a whole or to have them visit;
• there are national and local schemes which can arrange for visiting pets.

Having access to transport will improve the quality of many residents' lives. Some homes may be able to run their own minibus. Other options may be:

• borrowing or hiring an adapted minibus;
• dial-a-ride schemes;
• car schemes (hospital transport);
• volunteers' end staff cars;
• taxis;
• local buses (with agreements to stop outside the home);
• electric outdoor wheelchairs or battery cars (for loan to residents).

Anyone driving a vehicle should have the necessary qualifications and all formal requirements must be met (insurance, minibus regulations, driver training and certification, seatbelts, wheelchair clamps). Any signwriting on vehicles should be discreet and not draw attention to the residents unnecessarily or in a stigmatising way.

The way in which staff, relatives, friends and other supporters are involved with residents on a day-to-day basis will affect residents' well-being and sense of satisfaction.

4.9.1 Staff

Staff have a responsibility to be alert to the needs of residents. They should be ready to talk and listen to them during the course of the day and especially at night. Some residents may find it hard to express their true feelings about how they are and what they want to do. Staff may be best placed to discover some of these things while going about their general duties. They should be sympathetic and sensitive to the residents to enable them to express their feelings.

A normal and natural part of daily conversation for staff should be to talk about what residents would like to do or have, about ideas for doing different things, or changes they would like made.

Management should ensure that opportunities are built into the staff routine so that time can be devoted to doing things with individual residents or to talking to them (especially about things which might be worrying them). The trust and friendship of a key worker or other staff member is particularly important. The value of such time is demonstrated by residents often saying they appreciate their bath because it is the only time they receive individual attention from a staff member; likewise staff report that this is when residents often talk most about personal matters. Bathtime should not be the only occasion for this.

4.9.2 Relatives and friends

Relatives and friends have an important role to play within homes. They should be encouraged to participate in the daily life of the home as long as the resident wants them to. This might involve sharing meals, doing shopping, washing hair, reading and other social activities. Some homes may wish to draw up agreements or contracts with relatives and friends, setting out what each party might be expected to do or provide. Having relatives actively involved in the home is likely to act as a check on possible intrusive behaviour by staff.

While the benefits of involving relatives and friends are usually clear, it should also be recognised that relationships between them and the resident may not always be harmonious. Staff should be careful not to make unwarranted value judgements but always be ready to support the resident in whatever way is appropriate should the resident so wish.

4.9.3 The role of advocates

Many people living in homes have no relatives or friends to take an interest in them or provide advice and support in matters affecting their daily lives. Volunteer advocates should be welcomed by the home to provide support to residents if residents so wish. There are different sorts of advocates from those who provide a steady source of support and friendship to those who act on behalf of people who 'lack capacity' (a legal term). Local advocacy groups have been set up in many areas and can give information to residents and home managers and staff about what they can offer.

4.9.4 The role of volunteers

Volunteers from the local community may wish to become involved in the life of the home and may be suited to act in a 'befriending' role as well as undertaking more social and communal activities (for example, leading reminiscence work or exercise classes). Where residents want this, then it should be encouraged. Care should be taken, however, that residents do not feel their private space (their home) has been 'invaded' by outsiders although many residents will greatly value continuing links with the local community. Volunteers should not be used as unpaid staff. It may be helpful for the home to provide leaflets for potential volunteers setting out their roles and responsibilities when they are helping in the home.

The other key role volunteers play in homes and other organisations in the voluntary sector is that of trustees taking overall legal responsibility for the policy and standards of the establishments under their governance. Under both charity and company law such trusteeship is central in ensuring good practice.

Residents need to be kept informed about what is happening in the home if they are to be able to participate fully. Staff should ensure that they keep residents informed directly. Additionally, in some larger establishments, noticeboards and news-sheets may be useful ways of ensuring that residents know what is going on in the home. Reliance on non-personal means of communication should not be a substitute for direct communication between staff and residents as part of normal social interaction.

It is important that residents (and their family and friends) have an opportunity to have a say in how the home is organised and run. Residents' groups, relatives' groups, groups of friends, are all ways of facilitating this. However, if formal residents' meetings are held, they may well fail in some cases because they are seen as artificial exercises. Informal, natural, day-to-day conversations, for example over meals, at coffee time or on social occasions, may be more productive. Nevertheless, formal meetings and regular gatherings of residents can be held to discuss issues of importance. Staff and managers should be aware of, and compensate for, the difficulty some people may have in hearing what is said or in participating in large meetings. The existence of a formal residents' meeting may be regarded by inspectors as an indicator of residents' involvement.