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Under one roof

I have found myself thinking more about the question of mix in the disability/needs profiles of people in residential care and maybe in other settings too.

When I became involved with mental health services for older people there was a considerable contribution to the long-term care of those most damaged by dementia and similar conditions by the NHS. There were beds within mental hospitals and geriatric hospitals. Their use within a comprehensive service which ranged over care of people at home, in acute hospital settings, in mental health and geriatric medicine wards and day hospitals and care homes (almost exclusively Local Authority run Part 3 Homes) was key to the success of a service which could respond to need as it arose – and confirm a reliable support through to the end of life, even for the most damaged. Indeed every element of such a comprehensive service was essential to its adequate function.

Part 3 Homes were a new world to me – called to see a resident in distress or the source of worry to the staff - I would need to spend a lot of time getting to understand who they were, how they came to be here and what might be the cause of the decompensation which brought them now to attention. Extra time because the sources of information available when seeing someone in their own home were usually lacking – the state and content of the house, a husband, wife, daughter or son, a long-term or caring neighbour. They might be around somewhere, but not immediately to hand and requiring a bit of detective work to get hold of them. But one way or another we would fathom it out and make a guess on what might be done to improve matters for everyone – Try it out – and follow up to see if it was working – adjusting accordingly.

But out of the corners of both eyes I could see that there were many other residents who were impaired/damaged and requiring a great deal of help and understanding – decompensation might occur at any time.

I was very fortunate in being able to research the world of Part 3 with David Wilkin, Beverley Hughes and others. They taught me and the wider world a great deal about the characteristics of residents and staff of Part 3 Homes – and the dynamics of life within the homes.

David Wilkin, Beverley Hughes and David Jolley. Quality of care in institutions. Chapter 8 pages 103-118 in Recent Advances in Psycho-geriatrics. Edited by Tom Arie. Churchill Livingstone 1985.

Given that the most damaged and disturbed were cared for in NHS Long-stay beds, Part 3 Homes, with a balance of a few independent sector residential homes and nursing homes, provided for everyone else who could not be supported in their own homes. There was no segregation into specialist homes. Every part 3 Home housed a mix of fairly able and much less able people – dementia being the most important factor in determining dependency and potential disturbance. Within this mixed population there was opportunity – inescapable – for residents of differing strengths and weaknesses to interact. Ninety percent of resident time was spent immersed in the social environment determined by other residents. Staff were occasional players – at dressing, bathing, mealtimes and occupational therapy sessions. While staff might generate activities, engagement and attention, over all much more was determined by what other residents were contributing.

We felt that there were great advantages in the mix of abilities and needs – This could be lost if the concentration of disability and disturbance went beyond 20 percent.

Changes which have occurred since that time have removed long-stay beds for the NHS, giving almost all long-term care into the independent sector, denying the possibility of day hospital care. The integrated comprehensive services which we had constructed during the 1970s and early 1980s have been dismantled. The key consideration of the potential of residents to make positive contributions to the milieu of homes has all-but been lost. This puts huge pressure on staff-resident interactions. As we reflected last week, staff are now less often drawn from the immediate locality and this goes for residents too. The salve of mutual respect and shared culture has been pushed aside and replaced by one of strangers caring for strangers.

It may not have felt like Paradise, but something good has been lost

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