In 2015, I concluded a study commissioned by the Abbeyfield Society to investigate the nature of spiritual life in its homes. One of the factors that distinguished this study was the decision to explore the responses and hence care of everyone in the community of the home, rather than to focus on the residents alone. Another was the extent of the study, with over 100 people interviewed during its course, in a variety of geographical locations and different settings, from supported housing to care homes.
The intention was to listen carefully to the voices of all involved and draw out common factors that appeared to lead to feelings of security, being known and valued, and being enabled to live life as fully as possible.
There is a current policy emphasis on helping older people to remain living in their ‘own’ home as long as possible, equating this with independence. However, being alone in a house that may no longer be suitable and with care possibly being delivered in short visits, risks the person not moving into a more suitable care setting until they reach a point of frailty. A move at this point may be so disruptive that wellbeing is severely compromised.
Family life in care settings
To help tackle this, there needs to be greater awareness amongst the wider public that it is possible for people to rebuild a version of ‘family life’ in a new home. This is especially so if it is a community where they feel rooted, their isolation is addressed, and their critical needs met.
Of course, there are challenges in meeting such apparently simple demands, but these are surmountable, and more than that, the financial and societal savings in providing what really matters to older people, as opposed to what others think they want, are potentially life-changing for us all as a society.
I discovered people primarily want a safe, secure environment that fosters good relationships, recognition and being valued as a unique person; enjoyable nourishing food in the company of others; and personal care relevant to the individual’s needs.
The model that favours such provision is that of the ‘family’.
Families range from the highly-supportive to the dysfunctional, but in their essence, they are based on interactions whereby members are known to one another, and provide a model for two-way relationships, rather than a one-way process of giving and receiving care. A shift from unidirectional care engenders respect and a way of treating people with compassion but without patronising them.
This observation arises from talking to staff and residents, and hearing from them about how they view their interactions. In their own words, these include comments about their homes such as, ‘It feels like a family – they’re supportive of one another’ (manager) and, ‘The family bond is part of the home’ (staff). In these descriptions, there is a recognition of mutual support. Managers may help staff through difficult times, but residents can also do this for one another and for care staff; the burden does not fall solely on managers to ‘carry’ everyone because they themselves can feel known and valued by the community of staff and residents.
There appears to be a constellation of factors that nurture relationships, and they need to work together to be effective in creating a favourable environment for wellbeing. Continuity is critical: it takes time for interpersonal trust and knowledge to develop. This demands a high level of staff retention, which in turn argues for investment in training, a living wage, and ways of recognising the value of individuals who are not interchangeable units. The assumption that it also demands scheduling-in more time for resident/staff interactions may not be valid: relationships can be built during the giving of care and the sharing of meals. Although, this does not apply in the same way where people with dementia are concerned, as there is a need for staff and residents to pause during tasks for full interaction.
Good nutrition, delivered through hot food cooked on the premises is transformative, and meals bring people together, providing a structure to life. Again, using actual words from the study this can be put into context, ‘They sit down together for meals, and it makes them like a family again’ (member of staff); ‘I love joining in with the meals’ (resident).
Feeling safe and secure is critical and associated with long-term, settled relationships and the knowledge that there is ‘someone there for them’. A sense of real security grows with time, as residents learn to build trust in staff, and is essential to an environment in which people can flourish.
It also became clear that the physical environment strongly influences feelings of dignity, security and belonging. No-one in the study wanted to be in a home that looked like a hospital or hotel, people wanted somewhere to belong.
Whilst only a few managers may be in a position to influence the design of a new-build, relatively small alterations can make a big difference. It is well-recognised that certain design features are essential in homes supporting people with dementia, such as avoiding dead-end corridors, having a variety of communal rooms and waymarking to minimise confusion. However, in residential homes that don’t support people with dementia, there are equally desirable features. These can include having at least two lounges, one without a TV (or at the last resort, dividing a large lounge); making sure chairs are grouped for easy conversation; having focal and talking points; and enabling residents to display their books, paintings and ornaments in communal areas if they wish.
Volunteers and trustees
Volunteers and trustees are also great assets to the manager, as they can take some burden off her/him and be with staff and residents, joining in conversation and discreetly monitoring. They can and should also join in the ‘family’ of the home, by offering to help out and taking part in outings and meals.
Role of managers
Managers of homes have several vital roles to play in creating the ‘relational home’ and in effect are the catalyst that brings it into being or ensures its continuation. Residents and staff talk about managers as the ‘hub’ or the ‘soul’ of the home. They can, in many respects, prioritise the factors that nurture relationships, although in others, such as wage levels, they may only be able to put a case to the owners or trustees.
Critically, managers can influence the atmosphere profoundly, in practical ways such as scheduling rotas to enable continuity of care; organising tea and cakes around a focal point such as a fire, rather than by a trolley service; ensuring lounges are not dominated by a TV; and by setting an example of listening and being there. This may mean reserving paperwork to be handled unobtrusively or seeking an assistant from amongst the volunteers to look after some of the routine administration. It will certainly mean knowing staff and residents well enough to be sensitive to changes in mood or signs of discord.
Benefits of relational care
The ‘returns on investment’ of this self-commitment and time are considerable. For the manager, a supportive and ‘bonded’ environment is invaluable; for example, in the study a resident commented, ‘We are aware how badly affected managers can be by a death and are concerned for them.’ Put simply, the manager is no longer alone in a controlling or isolated position but becomes part of a group endeavour with mutual care between staff, residents, volunteers and trustees.
For the organisation running the home, there are the benefits of improved health of residents, with lower demands on staff time, and reduced management stress, staff sickness and possible adverse care incidents. For the public purse, in particular the NHS and housing provision, there are benefits from better use of limited resources. Finally, for society as a whole, the value, wisdom and presence of older people can be optimised.
Jenny Kartupelis is co-author of Developing a Relational Model of Care for Older People: Creating environments for shared living (Woodward & Kartupelis, 2018, Jessica Kingsley Publishers).
Jenny Kartupelis MBE MPhil is an author and researcher involved in issues of spirituality, older people and interfaith; she is Director of Faith in Society Ltd, and Development Officer for the World Congress of Faiths. Email: firstname.lastname@example.org Twitter: @Jenny33K