"The Third Age" Dundee University Report

"The Third Age" is a study by Dundee University into the future needs of the elderly in Scotland, commissioned by Balhousie Care Group.

View the report highlights, read it below or click here to download it (PDF - 220Kb).

A Vision for High Quality Residential Care for Older People in Scotland

Report for the Balhousie Care Group, April 2008

Professor Jennifer Harris, Dr. Norman Alm, Mr. Dharmadeo Luchoomun, University of Dundee

Contents

1. Executive summary
    
2. Background
   1. Brief for the report and questions to be addressed
   2. Demographic and cultural trends
       
3. Good practice guidelines
   1. Examples of good practice from the 'coal face' in Balhousie Homes
   2. What features make Balhousie care currently distinctive from other providers?
   3. How can life in a care home be more like life in the community?
   4. What ‘small things’ would turn good quality care into excellent quality care?
       
4. A vision for innovative and high quality care for Balhousie Homes, addressing the following questions:
   1. How can staff and residents be engaged in producing high quality care?
   2. How can local people be more involved in residents’ lives?
   3. How can cost efficiency be combined with raising quality standards?
   4. How can moving to a care home be made a ‘positive choice’?

Back to top

Executive Summary

This is a report commissioned by Balhousie Care Group from Prof Jennifer Harris and Dr Norman Alm of Dundee University to offer them ideas about achieving excellent residential care for older people.

The population profile of Scotland, the UK and many countries in the world is shifting towards a new balance, with a rapidly increasing number of older people. The number of people with dementia inevitably is following this trend.

The emphasis on community care means that older people who do enter residential care will tend to be more frail, and more in need of specialist care, than in the past. At the same time potential residents and their families are becoming more discerning as recipients of this care, and rightly are demanding the highest quality.

Balhousie Homes emphasises care based on small living units within each Home, delivered by staff who are proud of their professional approach. The Homes aspire, largely successfully, to be friendly and with a homely atmosphere.

In order to set a standard for excellent care in this field, we recommend that Balhousie give consideration to a number of suggestions. We recognise that these suggestions may represent the 'ideal', but we believe that they can be developed over time.

Care should be personalised and individualised as far as possible, with choice being offered over décor of rooms and food. The residential/nursing home divide should be replaced by having a continuum of care available at the same Home, so that disruptive moves would not be necessary. Formal and regular links with the wider community should be created and maintained, so that each Home feels 'permeable' to the outside world. Each Home should have a Residents Committee. A weekly rota of appropriate planned activities should be available. New approaches which should be considered are the use of volunteers to help with activities, and the creation of a lively computer corner at each Home. The philosophy underlying all this should be that aging is inevitable but that the Third Age can also be a positive time for all of us.

Back to top

Background to the report

Brief and questions to be addressed

Balhousie Care Group requested a report that would help them to plan their future provision by highlighting good current practice in the care of older people and provide ideas for future quality improvements.

Project Aims

• To identify what features make Balhousie Care Homes distinct in the care of older people market.
  
• To investigate what other Scottish providers say about their service and their unique selling points.
• To identify examples of excellent practice in care of older people from the UK and abroad.
• To provide ideas for innovative approaches for producing high quality residential care for older people.

This report combines the experience of the Consultants, the most obvious features and aspirations for care provision by Balhousie and a number of other providers, and ideas for improvement which the Consultants have developed through their interaction with this field. It is our hope that some of these ideas will be helpful to Balhousie in their pursuit of an improved service for their residents and their families.

Demographic and cultrual trends

Demographic changes in Scotland and around the world are dramatic. The proportion of older people in our populations is increasing rapidly. The number of people of pensionable age is projected to rise by 25 per cent to nearly 1.2 million in 2027. (Without allowing for the change in the female pension age from 60 to 65 between 2010 and 2020, the number of people over pensionable age would have increased by 45 per cent between 2002 and 2027.) The number of elderly people of 75 and over is projected to rise by 61 per cent to 585,234 in 2027, and the sex structure of the elderly population over 75 years old is projected to change from 35 per cent male in 2002 to 42 per cent male in 2027.

Table 1 - Care Homes by Sector, Places and Residents, September 2005

	Local Authority / NHS	Private	Voluntary	Total
Number of Care Homes	186	638	145	969
Number of Places	5,741	28,034	4,416	38,191
Number of Residents	4,960	24,824	3,932	33,716
Places per Home	31	44	30	39
Occupied Places	4,979	24,829	3,931	33,739
Vacant Places	574	2,762	385	3,721
Unavailable Places	188	443	101	732
Occupancy Rate	90.0	90.1	91.3	90.3

In most countries of the world, the trend is away from extended families all living in the same place, where care for frail elders and relatives with dementia can be shared among a number of people and the presence and continued participation of elderly relatives, as much as possible, can be integrated into the activities around them, with some support. The trend is towards care for elderly people with high dependency needs to be provided by a professional facility which looks after a number of people. The objective for this care must be to retain as much as possible of the desirable features of the family support system, and to try to find innovative ways to add advantages to living in care.

Features which are important for all elders in this position, and in particular those with dementia include:

1. Retaining a sense of personhood and self-worth
2. Retaining as much autonomy as possible
3. Enjoying a wide range of social connections
4. Feeling useful
5. Having opportunities for entertainment and enjoyment

In Scotland and in many countries of the world older people are beginning to form a significant proportion of the population, and increasingly will be demanding high quality support from outside their families to enable them to pursue the lifestyles they have come to expect.

Governments (both Scottish and UK) are concerned that older people receive care that conforms to standards of best practice and provision. To this end, the National Service Framework for Long Term Conditions and the Scottish equivalent have been established. One of the authors of this report was instrumental in the development of the former and continues to research best practice in these areas. One of the key messages of the NSFLTC is that service users want to be listened to by professionals and want their experience to be valued and respected. They also want to be more involved in managing their condition.

These research findings demonstrate that the future care home residents and their families are likely to be well informed, articulate and knowledgeable concerning standards of care. It is also evident that people increasingly demand access to services that can support them without removing their independence and individuality.

The policy context and background is also rapidly changing, with direct payments and personalised budgets set to become the norm for older people. This combined with the long-standing commitment to Community Care will lead to older people staying in their own homes for longer, with increasing levels of frailty catered for by social work and health care community services. The move to personalised budgets and the widespread acclaim they have attracted especially compared to criticism of traditional social work and health care services can be seen within the context of the higher standards of the new generation of older consumers, and also gives pointers to the key features of quality service that will be required. The key features allowed within personalised
budgets and direct payments that do not figure in traditional services are choice, control and flexibility. It is important to recognise that these elements will also be important for the development of high quality residential and nursing care and that these will be increasingly demanded by the residents of care homes in the future.

The demographic changes leading to an ageing population are resulting in a dramatic increase in the incidence and hence the social and economic cost of dementia:

Dementia costs Scotland £1.4 billion and the number of people suffering from the condition will almost double in the next 25 years, experts have warned. A report by the Alzheimer's Society stimates that the number of Scots with dementia will rise from 58,000 to 102,000 by 2131…. Jim Jackson, chief executive of the charity, said: "Our population is ageing. By 2031 there will be 75% more people with dementia in Scotland."

In the future care will be provided at home for the majority of older people for longer than has been the case in the past, and domiciliary services will cope with long term conditions as they arise in the older people they serve. This will result in older people being enabled to retain their independence for longer.

What does this mean for Balhousie Care Homes Group and for other care home providers?

• Customers are likely to enter residential care at a later stage than they are currently doing, with more advanced impairments and conditions.
• There may be less time in residential care and a need to move to the provision of nursing care more swiftly than we see at present.
• Customers will wish to see increased flexibility from care home providers so that they will be involved in making only one move into care. This means developing care homes that can cater flexibly for increases in care needs.
• Care provision for customers with dementia will increasingly form a large part of the market. Innovative care for this group will be valued and will position good providers of this care at the forefront of the market.
• Customers will be increasingly discerning concerning levels of care and will value provision that is consistently high. This means giving residents opportunities to continue to pursue their social, community and leisure interests and to maintain as much independence as possible for as long as possible.
• Relatives and carers of older people will increasingly be discerning. They will expect to see innovative, personalised, high quality care that puts their relative first and enables them to feel that they are in the best possible place.

Back to top

Good practice guidelines

Examples of good practice from the 'coal face' in Balhousie homes

Size of unit
At Balhousie Homes, the living units are all of about eight people, sharing a common lounge. This creates a manageable and comfortable group size, even in a larger home. Each group has its own lounge area, or where residents are more able and mobile, a selection of lounges with different 'personalities'.

Homely environment
There is an obvious and commendable attention to detail in architecture and décor at all the homes we visited (e.g. placement of residents' windows at one Home all face the front courtyard, attractive traditional and modern prints on walls).

Professional staff
A proactive approach is taken to induction, probation, and feedback for new staff. Staff are pleasant, helpful and smartly attired. Balhousie senior staff are active in professional organisations and wider community groups.

Friendly atmosphere
All residents are known by name and personality to all staff. Some Homes organise a weekly detailed activities schedule and it is planned to make this the standard at all the homes.

What features make Balhousie Care currently distinctive?

The personal touch
The personal touch is emphasised. This is evidenced in the hands-on management style from the top down in the organisation. Each home manager is encouraged to put their personal stamp on the culture of the home.

Size of the living units
Balhousie Homes are small enough so it is possible for all staff to know all residents by name and personality.

Genuine concern with getting care right
Balhousie have a proactive approach to meeting government standards and being ahead of the game. Managers at all levels invite views from outside about the care regime at Balhousie homes.

Training for the future
There is an obvious emphasis on staff training and development. Staff are encouraged and supported to study for qualifications which will help them in their own careers, and help the home they are working in.

How can life in a care home be more like life in the community?

This begs the question of what people miss the most when they live in care homes as opposed to living at home (with or without support).

The best research of older people’s views on this is clear. People want to preserve choice, control and flexibility over food, surroundings, privacy and levels of support, socialising opportunities, and being heard by service providers.

Studies have consistently shown that these features are the hallmarks of quality service.

Providing residents with choice, control and flexibility takes ingenuity and creativity in service provision, but is by no means impossible. The most important aspect of this process is willingness to listen and a can-do attitude, especially from the Officer in Charge.

When it comes to living at home, rather than in a Home, the ability to personalise one’s environment is an important feature. For a person who lives outside in the community, choice of décor and furniture is a matter of expressing one’s personality and an important part of one’s identity. With a little imagination it should be possible for new entrants to a Balhousie Home to be offered a
choice of décor, perhaps using paint colour cards and sample curtain fabrics from a high quality range. Carpets are probably less important, although individual rugs that match the chosen curtain could be sourced and chosen at the same time. In addition, residents could be consulted when the time comes to revamp the common lounges and hallways on choice of colour schemes.

In terms of activity, any event or activity that increases stimulation and encourages dialogue between residents should be considered. An example of such a possible activity is indoor gardening. Many older people enjoy gardening, although as they become older, heavy work such as digging and wheelbarrowing, and even being out in the Scottish climate when the weather is poor, become difficult. Indoor gardening provides a creative solution that is not high cost and can be something that residents and staff undertake together. Therapeutic gardening has been shown to lower blood pressure and increase stimulation in care home residents. Not only this, plants increase the levels of oxygen in the environment which is good for resident health, whilst looking beautiful and sometimes providing pleasant scents. The cost of setting up such a project could be very modest.

In all Homes, residents have access to TV (and also in their own rooms of course). However, how much use is made of DVD players to provide activities such a ‘film nights’? Copyright issues for showing films at the homes would have to be investigated, but something like this would make an excellent activity. Residents could take a lead in deciding on the films to be shown. Films are
relaxing and pleasurable and watching them is a social activity that will have been enjoyed by most residents in former years.

By increasing the choice residents have, it is usually the case that the amount of control they feel they can exercise is simultaneously increased. Residents of Care Homes quickly become used to being part of a large group of people who all do certain things at certain times, although this is not always desirable. Some residents become ‘institutionalised’ and fear to ask for things they want as they don’t want to cause an upset or increase staff workload. In this regard, it is important to take small steps to making resident choice and control a priority, so that residents feel it would not be an imposition to state their views. Older people in care homes can quickly feel that they have little control over their environment. On the one hand, this is a relief as perhaps they have been
struggling to care for themselves in the community, but in many respects this is ‘all or nothing’ when entering a care home. This is why it is very important that opportunities to increase continual resident choice and control are explored at every available opportunity. This should not be a one-off assessment at entry, after all, everyone changes their view on what they like and dislike over time. An on-going system of individual review that had an eye to increasing opportunities for residents to directly control and influence their environment would ensure that choice and control were maximised.

Another important factor in making a Care Home like home is to explore ideas that make it more 'permeable' to the wider community. This could include exploring avenues for making Balhousie Care Homes more visible in the local community (by attending local groups and encouraging residents to participate in them). Another idea would be to consider offering facilities in the Care Home as a regular venue for community groups. This may have added benefits in involving the residents since the transportation issues would be circumvented. Another idea would be to host occasional well-publicised one-off community events such as a visiting speaker, ceilidh / Burns Night / barn dance, or a dramatic presentation / concert. The more these are not associated with aging the better, e.g. the concert could be a folk / pop concert, and the speakers could be talking about a wide range of topics.

Visibility to the local community is important, not just for commercial reasons. It is worth taking the time to find creative ways in which the Balhousie name can reach out into the local communities. It is also important that volunteers have a chance to establish contact with the residents in the Homes. Given appropriate vetting and oversight, there are ample benefits to be gained from establishing a programme of volunteer support for Home residents.

What ‘small things’ would turn good quality care into excellent quality care?

Most Care Homes set out to provide a good quality service to residents and to give them individualised attention. They wish residents to be happy in the Homes. However, the reality of any provision that is organised for a large number of people is that individual wishes can get subsumed within the organisational directives of staff rotas and institutional routines.

The outcomes of interviews conducted with residents’ families highlighted the following positive aspects of Balhousie Care Home features in their view:

• Infrastructural features, for example: room comfort, cleanliness and tidiness
• Care-related features, for example: staff are kind, caring, warm and approachable; provision of high standard care; prompt response to call from residents; good communication between staff and residents; competent and expert senior staff; the home has a good reputation
• Socialising aspects, for example: recreational and group activities; it is a relaxing place

Flexibility is arguably the hardest element to realise in Care Home provision. Flexibility implies maximum choice and control and should be an aspiration for all good Care Home providers. However, producing maximum flexibility is not easy within a system that must ensure the welfare of the whole group within realistic budgetary limits. Even given these restraints, it should be possible to introduce improvements which maximise flexibility without ignoring the budget.

Take for example the issue of food and when it can/should be consumed. In one’s own home, there is access to food on demand. Admittedly, most people do stick to set meal times, but at weekends and holidays, meals are missed or sandwiched together (e.g. ‘brunch’) or change time (from evening meal to Sunday roast dinner). In the outside world, people choose when and whether to eat and are not ruled by the clock. Having said this, many older people develop a liking for regular meal times. Therefore, making a Home like home implies that the flexibility of food on demand be incorporated somehow into the structure.

Many people keep a fruit dish and eat from this over the course of the day. Such an innovation in all Balhousie Homes might prove popular, would cost little and looks attractive. Fresh flowers or plants provide another way of creating a pleasing, homely and welcoming environment.

Maximising ‘personhood’ (especially for people with dementia) is important. It is easy to lose one’s sense of identity in a crowd. Creative and imaginative ways of providing support can be found that maximise personhood. A very important way is for care staff to make time regularly to simply sit down and chat with residents. There is an important management role here, which is to ensure that
staff see this sort of activity as an important part of their job, and that they are recognised and praised for doing it. Without this backing, it can be too easy for staff to feel that they must be busy at visible tasks at all times. This is an example of a small change in the culture of a Home which can have profound results.

Presenting a positive and upbeat view of the Home to visitors, staff, and residents can be facilitated by paying attention to the Reception Area of each home. If there is no such area, the visitor's first impression is one of slight confusion on their part and a lack of focus and welcome. A prominent display of material 'about us' in a reception area makes a positive and confident statement. This could take the form of a display of photos, or a more high-tech version, a large screen with a rolling display on it. Such a display should avoid ‘corporate’ material and instead emphasise the individual, with material highlighting residents, staff, activities, and favourite poems or photos.

Each home should have daily planned activities, which of course residents can opt out of if they like. This could be a weekly rota, so there would be some predictability and planning would be easier. The point is to have a default situation where an activity is taking place and which residents can choose to take part in or not. Such a programme of activities is easier to produce if regular
volunteer help is available.

Computer technology offers ways to open up the world for older people, particularly those who are not as mobile as they would like to be. The current generation of older people has mainly not experienced using computers in their working lives and has a lack of confidence in attempting to use them. Extensive work by Dundee University and other academics has established that it is
possible to encourage older people to use computers, and that once they have overcome their initial reluctance and lack of confidence they often become enthusiastic and regular users of email, the internet, and other facilities appropriate to their interests. We recommend that every Balhousie Home set up a state of the art computer corner and provide the encouragement and support
needed to make this a regularly available activity of the Home.

One problem new staff have is getting to know residents quickly as people, particularly if they have dementia. Something which would help here would be a short multimedia profile for each resident which staff can access in five minutes via a touch screen display. Contents could be photos from the past, a map showing where they lived, photos representing their work, hobbies, interests, or a favourite poem, picture or famous person. Families would need to be involved in setting this up, but this in itself could be a very positive activity for them to do in cooperation with staff at the Home.

Back to top

A vision for innovative and high quality care for Balhousie Homes, addressing the following questions:

How can staff and residents be engaged in producing high quality care?

High quality care means different things to different people. To residents, security, food and pleasant, clean surroundings may have priority. For relatives, safety, kindness and individualised care may be paramount. Producing this consistently day after day takes dedicated staff and attention to detail.

High staff morale is of central importance in providing consistently good care. High morale will be a product of:

• Perception in the outside world that Balhousie is a doing a good job
• Staff members' own perception that they are doing a good job
• Being recognised for the good work they do
• Knowing that poor quality work is not acceptable and measures will always be taken to ensure quality is maintained
• Enjoying the work
• Having fun at work as well as performing necessary routines
• Residents who are enjoying their lives to the full

As far as possible the running of Balhousie homes should be a partnership involving staff, residents, and families.

Staff and residents can work together in the production of high quality care. An important aid to this would be to establish a lively and thriving Residents Committee at each Home. Of course there will be individual differences in the degree to which each resident wishes to and is able to take an active part, but the existence of such a committee would in itself be a worthwhile and interesting
activity for the Home, and the ideas and insights it produces will be helpful in moving beyond a passive view of care.

Balhousie has shown a willingness to invest in producing high quality surroundings for residents. Taking bold decisions in the areas of choice, control and flexibility will help to create an environment in which it is natural for residents to influence the running of their Care Home.

How can local people be more intrinsically involved in residents’ lives?

Every opportunity should be taken to involve residents in the lives of others in their community and vice versa. This report has suggested that volunteers could make a helpful addition to life in the Homes. Although their use would need to organised carefully, to take into account current legislation on vetting, and the need for appropriate activities, direction and supervision, other countries use
volunteers in these settings with considerable success. Volunteers can add value to Homes because they have live connections to the world of work and the community. A fresh face and a new perspective can be very beneficial to residents, particularly from someone who has the freedom to be there simply to interact with residents. Volunteers can be usefully employed to assist in craft
activities, trips, and anywhere where there is a need for extra unskilled assistance. Volunteers can also be a great source of local information and can assist staff to find out about local events that residents can join in.

The local council often keeps lists of volunteering agencies and there are schemes run on the internet (for example there is one run by the BBC at their website). Local charities such as the Rotary Club and Round Table are a good source of volunteers, as are Church organisations such as the Women’s Institute.

Every opportunity should be taken to obtain positive local publicity about each Home. This will keep the Homes from becoming 'invisible' and will emphasise the outward-looking philosophy that Balhousie aspires to. Each time there is publicity will also provide an opportunity to emphasise that the local community is welcome to talk with staff about making use of facilities at the Home. Staff
should be encouraged to become involved in local activities that draw positive publicity for the Home. If it is possible to identify a suitable celebrity with a mature yet upbeat image who would be willing to be associated with Balhousie's programme and approach this would be very helpful for getting Balhousie's message across to a wider public.

How can cost efficiency be combined with raising the quality standards?

Raising quality standards often means incurring some extra cost but it is not always the case that it must. Some of the suggestions above involve working differently but without significant additional resources. Having a Residents' Committee, staff chatting regularly with residents, and having an activities rota will not make a significant call on funds.

Having volunteers to help with activity sessions may seem like a good deal of work at first, in setting up a rota and contacting all the organisations to be involved. However, a good scheme will eventually develop its own momentum. Participating organisations can be encouraged to ‘self-replace’ should individual members need to move on. Such a scheme requires only a relatively small amount of time invested and could reap large dividends for residents in terms of quality of life.

Many staff at Balhousie are undertaking study courses at College towards NVQ qualification. As part of their studies, staff could be encouraged to undertake projects to develop the ideas contained in this report. There would be minimal costs in doing this and both the organisation and staff, as well as residents, stand to benefit.

How can moving to a care home be made a ‘positive choice’?

Many residents will enter a care home from a situation where they have struggled for some time to manage in the community. However, care home entry does not need to be a disconnection from all the stimulation of the world. Ideally, it should mean that the stress and worry of looking after oneself is removed and that the resident has the time to concentrate on more fulfilling activities. Getting this balance right in an increasingly discerning generation of older people is going to be a major challenge.

High quality care that removes stress and worry and at the same time incorporates the quality care features we have identified is likely to make moving to a Care Home more of a positive choice. A move to a Care Home would be more of a positive choice where there is a good balance of privacy and socialising under the control of the resident, plenty of interesting activities and more opportunities for desired community links and involvement than the person had when living on their own. In situations where choice, control and flexibility are maximised, residents could ideally have the best of both worlds. They could feel they are ‘at home’ whilst having the assurance that the support they need is always available.

It is worth considering moving away from the current residential home / nursing home distinction to a continuum of support model, available on the same site. There can still be separate wings for the more intensive care if necessary, but care and other staff could move between wings (and residents too where possible and appropriate). This is flexibility in perhaps its most ambitious form,
where the entire care regime can be altered to suit the resident, as their needs increase, without the requirement for a potentially disruptive move away from familiar staff and surroundings.

But, to grasp the nettle, how could moving into residential care ever be considered a positive life choice? Even if the move were into a 5-star hotel in a beautiful location, most of us would see this as wonderful for a break away from the routine, but would eventually welcome a return home. Some experts in aging have called for a reappraisal of the life stages. If we are to spend up to a third of our lives in a state that leaves work and child-rearing behind, what are we to do with this time? Surely not spend it in the equivalent of being on holiday, however enjoyable that may seem on first offer. Another way to look at the human life span is to call this time a Third Age, after Childhood, and Adulthood, and age with its own characteristics and opportunities. It can be a time for consolidation, reflection, sharing of perspectives with younger generations, and opportunities for creative expression when freed from the daily concerns of work and family. Excellent residential provision for older people in the future could aspire to embrace some of the spirit of optimism and adventure that lies behind the Third Age idea. Whatever plans this resulted in would need to be culturally appropriate and welcomed by residents and families, but we would recommend that this forward-looking and positive approach to aging be at the least a guiding principle of good residential care for older people.

Jennifer Harris, Norman Alm and Dharmadeo Luchoomun
14 April 2008

Back to top