Sweden is twice the size of the UK, with a population the size of London. Care homes in Sweden are mostly owned and managed through local government structures and fees are subsidised by the State.
The care home I visited, Harakarrsgarden in Akarp, a leafy suburb comprising 8,000 people with enviable infrastructure. Harakarrsgarden is a 34-bed home for people with dementia. It is separated into four units and each resident has their own apartment with small kitchenette, sitting area and bedroom. The rooms all have overhead track hoists and easy-opening bathroom doors. All bedrooms are individual and personalised. There is a courtyard garden with hens, rabbits, a pond with ducks and fish, plus plenty of small sitting areas in the shade.
Staffing and staff development
Harakarrsgarden is run by the manager, Eva, with nursing assistants known as ‘under nurses’. The under nurses whom I re-named ‘wonder nurses’, due to their emphasis on quality of life and their enhanced education, are neither registered nurses nor care assistants. In training for their role, they can undergo a three-year further education course with different placements. Alternatively, they can undertake 40-week online training with practice learning on the job.
Under nurses change their roles as the day progresses. Firstly, they are assisting with activities of daily living and care, then they may become activity assistants or dining assistants. They also act as a key contact for the resident and their family.
The care home has very little turnover of staff and I was interested in their continuous development and whether this was a contributing factor in their retention. The emphasis in the home is on the caring culture and how much fun it is to live in the workplace. This means that staff need ongoing support and a sense of pride in their job.
It is important that staff have flexible ways of working to enable them to deliver spontaneous activity in the daily flow of the day. This is creatively enabled with the use of life story work and approaches have been developed that have been designed to lift mood and alter energy levels amongst residents. The manager is keen to be seen out and about on the floors, encouraging and reinforcing positive approaches to care and support through modelling or coaching.
Staff appraisals focus on staff development and the support the company can give them, as well as feedback on any improvements the company can make. There is no minimum wage.
Due to recent changes to nursing there is only one nurse to 70 residents in the region. They are stationed in regional offices and work in district formation. The care home manager admitted that she was is not happy with this as it affects the continuity of nursing care on site.
The daily organisation of care
The manager empowers her staff to be spontaneous and creative in how they build relationships with residents. The manager ensures that there is a higher ratio of staff on duty in the afternoons. This is the time she wants them to use their initiative to help residents enjoy their day, build relationships and make sure residents are able to get outside every day.
Mealtimes offer a graded service to accommodate different needs; these can be met in separate environments. There is a pub/restaurant service on open days for relatives to join and eat together.
There are additional day care spaces for up to seven local community members with dementia. They arrive by subsidised transport and are supported by an under nurse. Adopting a community-building approach, the manager works closely with the activity co-ordinator to integrate these local residents into the home’s community.
Although there is only one activity co-ordinator for the home, all staff stay with a group of residents and work together as a community supporting the activities in the morning. The under nurses work independently on a one-to-one basis, using their creativity in the afternoon, reporting to the manager who encourages her staff to be person-centred and use life stories. The under nurses participate in and support group activity. This enables them to really get to know the resident as a person, which the manager explained is an important part of their role enrichment. It also builds relationships and residents are more likely to be treasured rather than managed.
Caroline, the activity co-ordinator, is also an experienced under nurse. Her role is to both co-ordinate the activities within the home and deliver some. She regularly links up with the nursing home next door for inter-home activities. The formal activities are delivered between 8am and 4pm. Spontaneous daily activity also occurs, led by the other under nurses with whom she has a good working relationship.
The range of activities include singing together, weekly community church activities with a coffee morning (run by volunteers), a library visit with short story readings, slide shows and films. Some residents also enjoy Bingo and residents select the prizes weekly. Baking and flower craft is popular alongside the multi-sensory themed activities. Discussions include history and traditions, and there are exercise sessions too. Outings include fishing trips, with cold beer, shrimps and meat, and a range of cultural excursions. The home also has a London cab to take residents out on trips in small groups.
There are also drama and dressing-up sessions plus sensory boxes. The garden is full of things to see and do with several shaded sitting and walking areas.
One-to-one activities include individualised music with personalised earphones to suit different tastes, outdoor walks, bike rides and an indoor sensory relaxation chair.
The use of the arts is evident in the home with murals and themed displays. Corridors are wide and generous, broken up with the themed displays and an old sweet shop.
Community building and sharing best practice
The care home offers respite services for one week each month to help eligible carers. This is common practice in Sweden.
There are formal relatives’ meetings with the manager, activity co-ordinators and contact person twice a year, any other meetings are informal. There is a weekly review meeting with the multi-disciplinary team, including a physiotherapist, occupational therapist and specialist nurse. There is no boundary to the discussions and ideas are facilitated in an open environment, focusing on the quality of the care experience. There is also a domiciliary agency attached to the care home.
There is an annual two-day holiday for some residents where staff share a room with a resident and a family member. The manager said that her staff are committed to this and that it is life-changing for them.
Life in a Swedish care home
There are a number of points that can be drawn from the care home I visited for consideration by UK care providers. There is a learning environment led by the manager who models and supports her staff. Staff are encouraged to be creative with structures, including time and job profiles to reflect their flexible roles. Daily activity is everybody’s business and built into the flexible job functions. There is a strong emphasis on education for nurse assistant roles as the primary workforce and the nursing role is seen as important. Although it is not organised to deliver the optimal health and wellbeing outcomes. Use of the arts is encouraged in the indoor and outdoor environment and forms part of the community building.
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