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Transforming lives
The Butterfly model and best practice in dementia care

Care home providers are continually seeking the ultimate guide on how to provide the very best in dementia care. Huge investments are being made in dementia care awareness training and there are many different perspectives available on what good dementia care really looks, sounds and feels like. Here, Sally Knocker explores some of the best practice the Royal Masonic Benevolent Institution has been implementing alongside Dementia Care Matters.

Dementia Care Matters, a leading dementia care culture change organisation, has been developing its model of dementia care over the last 20 years. The Butterfly Household® model places a strong emphasis on emotional intelligence as a core competency, more so than formal qualifications or previous care experience. Key aspects of the model include:

  • Developing small household living for people with dementia in a family-like environment.
  • Removing institutional features such as uniforms, medicine trolleys, and rigid task-based routines.
  • Enabling greater freedom for people to do more for themselves and feel less restricted.
  • ‘Being with’ more than ‘doing things for’ people – eg. staff sharing the day as friends and eating together.
  • Connecting with, and occupying, people in ways which are woven into all parts of the daily life of the household and involve all members of the team, including housekeepers, maintenance and catering staff.

Investing in culture change

However, to achieve what can be radical changes in working practices requires culture change. Working together with Dementia Care Matters, care home provider, Royal Masonic Benevolent Institution (RMBI) has implemented a culture change programme across its care homes in England and Wales. Managers and senior care staff undertook a one-year Person Centred Dementia Care course (PCDC) and some also completed in-house training. Following the culture change process, Dementia Care Matters undertook yearly, unannounced audits of all homes for people living with a dementia.

As part of this, the auditor assesses the homes on the Quality of Life accreditation award. This is assessed through these qualitative observations of a day in the care homes. The potential outcomes of these observed days range from a level 1: exceptional person-centred dementia care, to a level 10: crisis level of dementia care requiring legal action. A home must achieve between level 3 and level 1 in order to become a Butterfly Household®. To achieve a level 1, there must be over 70% of the day where the majority of people living in the home are experiencing positive social interactions and positive personal care.

Previous research conducted by the Dementia Care Matters team based on 700 audits, and prior to any culture change programmes taking place, show that in reality, over 70% of the day in a care home is focused around tasks rather than relationships.

While a significant number of homes following the Butterfly model have achieved the Quality of Life accreditation award, only 13 homes in the UK currently hold a level 1 status. In the last year, four RMBI homes have received level 1, and nine homes now hold the kitemark accolade.

Key ingredients for success

To achieve such shifts towards exceptional person-centred dementia care, there are a number of factors to consider.

Leadership matters

Significant support, direction and commitment from the management team at every level are critical for success. It allows managers to confidently follow the core ingredients of the model and, therefore, have a real chance of implementing a lasting change. Passion and heartfelt leadership is key to driving the changes.

Shared vision across the whole team

Managers and senior carers use a 50-point checklist to help carry out the necessary changes. However, far from a simple exercise, it requires good leadership and buy-in from the whole team. Some of the areas covered include removal of barriers and creating meaningful ways to occupy people.

Creating vibrant, homely and active environments

Butterfly Households® embrace the importance of colours and objects in the surrounding environment. Tables are engagingly laid at meals with opportunities for people to serve their own vegetables and pour their own tea. Dolls and soft toys provide comfort and companionship to some people and there are lots of books, magazines and pictures to pick up and look at. There is a strong focus on life story profiles, activities and occupations that relate to peoples’ past lives and interests. Staff are highly-skilled at creating a constant flow of activities from aqua painting, to fruit picking, and reminiscing with family photographs and sensory props for those further on in their dementia journey.   

Regularly observing the lived experience of people     

Even for the most advanced care operators, sustaining progress is a continuous challenge. Environmental changes such as staff turnover or a change in management can naturally have a significant impact on a care service. One of the skills adopted by RMBI staff to address such issues includes observational tools, where a staff member will sit and observe common practices from an unbiased point of view and this can bring about important learnings.

Acknowledging and addressing the obstacles to progress

Managers involved in the culture change process often describe the challenges faced by ‘old school staff’. Louise Corris, the home manager at The Tithebarn in Liverpool, described an era where, ‘good care meant a clean, tidy environment and was shown in routine and efficiency.’ Care home managers now have to make difficult and brave decisions about their staff on whether they are open to change and able to let go of strict task-based care routines.

Making it happen in reality

Debra Keeling, Deputy Director at RMBI, shared the realities of bringing about culture change in a care environment. ‘It would be nice to say that it has been a smooth journey with everybody immediately “getting it” but this wasn’t the case.

‘Changing a culture of task-based, medical care into a place of warmth and ultimately a home, has been difficult. Both time and sensitivity has been essential to implement any real, lasting change, especially one that would be embraced by all. We had to dig deep to find creative ways to communicate messages to reach every level, with some people living in the home being equally resistant to change.

‘Support groups were formed where people were able to share experiences and essentially develop ways of supporting one another by talking openly about dementia. Various meetings were also held to communicate changes as they took place, and discuss any concerns or questions.

‘Some staff were initially reluctant to change. They preferred to keep themselves busy changing beds, emptying water jugs and pushing trolleys rather than speak to management about things that could be done differently. But over time, the barriers started to come down and staff began to embrace their achievements. A basket of laundry was no longer seen as just a basket of laundry – it was an opportunity for physical exercise, reminiscence and a chance for people to interact. We now have environments that make sense to the people that live in them; a more adaptable and flexible, working environment, and most importantly, a management team who actively promote a person-centred approach.’

Cultural change and the future of dementia care

Adapting a lasting culture change across an entire workforce presents numerous challenges. However, living proof of the Butterfly Household® model can be seen in RMBI homes and the charity continues to work towards a more person-centred focus to care. Feedback from people living and working at the homes has been positive which has allowed for staff understanding and participation to grow, as well as creating an environment with more open communication.

As the demands for older peoples’ care continues to increase, so do the complexities around dementia care. Understanding the needs of each individual, and adapting care to each person’s specific needs, can help providers to strive towards achieving the highest quality of life for people living with a dementia.

Nurses and care workers often feel a sense of relief when they experience what it is like to work in an environment that creates a real feeling of family and friends, rather than a formal clinical environment. Home Manager, Michelle Bladen at Prince Edward Duke of Kent Court in Essex has received a number of comments during her time at the home which indicate that leadership and development is heading in a positive direction. She said, ‘An external voluntary sector worker was so impressed when she visited the home recently. She said that she would have stayed in nursing twenty more years if she had known she could have worked in a household like this.’

For details of the 50 Point checklist, visit www.dementiacarematters.com

Sally Knocker is Consultant Trainer at Dementia Care Matters. Email: Sally@dementiacarematters.com Twitter: @sallyknocker

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