Selecting a care home
Many people with dementia move into a care home once their dementia progresses to a certain stage. Some people with dementia have other illnesses or disabilities that make it difficult for them to remain at home. Some people may need to move from one care home into another. Good quality care that preserves dignity, treats people with respect and promotes independence can improve the lives of care home residents with dementia. Choosing the right care home is, therefore, very important but it can be difficult. This factsheet explains how to find a care home and looks at what high-quality care for people with dementia should include. It then lists some key things to think about when visiting different homes.
Different types of care home
Care homes provide either residential or nursing care. The type of home that the person requires will depend on their general health and care needs. Everyone with dementia is different. For some people with dementia the main problems that they experience will be dementia-related, whereas for other people with dementia their main problems may be caused by a different condition, such as a stroke.
Residential care homes provide help with personal care such as washing, dressing and eating. In some residential care homes staff have had specialist training in dementia care. Nursing homes provide personal care but also have a qualified nurse on duty 24 hours a day. Some homes that are registered for nursing care will accept people with personal care needs who may need nursing care in the future.
Finding care homes in your area
Lists of local care homes and inspection reports are available from the Care Quality Commission (CQC) in England, the Care and Social Services Inspectorate Wales (CSSIW) or the Regulation and Quality Improvement Authority (RQIA) in Northern Ireland. See 'Useful organisations' for contact details. However, not all care homes are suitable for people with dementia. A professional such as a doctor or social worker, or a voluntary organisation such as your local Alzheimer's Society or Age UK office, may be able to give advice on the type of home that may be suitable for someone with dementia.
Phone or write to a number of homes and ask about the level of care provided for people with dementia, the fees and the waiting list. Review any information they send you. It is important to visit the homes that seem promising.
Choosing a care home
Care homes may be arranged through the local authority but many people will arrange them independently. It is a good idea to visit several homes before making a choice. Make sure you spend enough time in each home to get a good idea of what it is like. Ask yourself the questions in the 'Things to think about when visiting care homes' section of this factsheet (see below).
If you are looking for a home on behalf of the person with dementia, you may want to make the first visit on your own and then, if you think a home may be suitable, visit again with the person. You can then see what their reactions are, and how they might settle in. You may be able to arrange a trial period - many homes require these anyway and they can be very useful.
Before making a final decision, you may want to look at a recent inspection report for the home. These often give a lot of detail on how the home operates. You could ask the home itself to give you a copy or they are available from the CQC (in England), the CSSIW (in Wales) or the RQIA (in Northern Ireland).
If the local authority is arranging the care home, and there is more than one suitable home to choose from, the person has the right to choose which home they would like to live in. A care home is suitable if it can meet the person's needs, meets the local authority's conditions of cost, and has a place available for the person. The care home must also be willing to sign a contract with the local authority. If the person with dementia cannot make decisions for themselves (that is, they have been assessed to lack the mental capacity to do it themselves), the local authority must speak to the person's guardian, someone who has lasting power of attorney (LPA) for personal welfare or someone who is closely involved with the person. If there is no guardian, LPA or carer involved, the person has a right to an independent mental capacity advocate to make sure that the choice of care home is in their best interest. (See factsheets 459, Mental Capacity Act 2005 and 472, Enduring power of attorney and lasting powers of attorney.)
Moving between care homes
It is sometimes necessary for a person with dementia who is already living in a care home to move to a different home. Such a move can be stressful and people may react in different ways. It is therefore important that the move is carried out with proper planning and preparation. If the local authority would like to move a person to a different care home they should first carry out an assessment that considers the possible impact of the move on the person.
The person should move during the day, accompanied by someone they know. An optimistic attitude about the move will encourage the person with dementia to see it as a positive change. It is also best to give the person with dementia as much choice and control as possible. For example, visit two homes and give the person a choice of which one to move to. If there is more than one bedroom available at the new home, try to choose one that is similar to the person's previous room. For example, choose a room with a similar layout or a room where the way to the bathroom is similar to before.
If the person is moving to a care home in a different local authority, disputes about which local authority is responsible for the person's funding can arise. This should not lead to any delay in the provision of care or accommodation, and until the dispute has been resolved one of the local authorities must accept responsibility.
Recognising high-quality care
This section looks at some important principles for caring for people with dementia in residential or nursing care home settings. The way that a care home approaches these can give you a good indication of whether they offer high-quality care.
A good care home will follow the principles of person-centred care. This approach aims to see the person with dementia as an individual, rather than focusing on their illness or on abilities they may have lost. Person-centred care takes into account each individual's unique qualities, abilities, interests, preferences and needs. Person-centred care also means treating residents with dignity and respect.
Care homes that follow the philosophy of person-centred care aim to bring out the best in the people with dementia who live there. Each home has its own written philosophy, or mission statement, based on this concept. This should influence every aspect of life in the home, and makes it possible to measure how well the home is living up to its standards at any time.
It is important that you ask managers quite specific questions in relation to their philosophy on person-centred care to get a real sense of whether they are putting the vision into practice. A good way of finding out about a manager's understanding of dementia, for example, might be to ask what approach they would take if a resident continually asked to go home or wanted their mother. A 'good' answer would be one that recognises the emotional needs of insecurity and loss and an attempt to respond to these needs.
Respecting the individual
Each person with dementia living in a care home should have his or her own individual care plan. The care plan should summarise how staff can encourage and maintain the unique strengths of the person with dementia while meeting his or her needs for support. This plan should be reviewed at regular intervals.
Staff at all levels should have received training in how to care for people with dementia. This will enable them to understand the difficulties in communication that a person with dementia may face, and to help them express their wishes and needs.
Personal dignity and privacy should be respected at all times. Individual cultural or religious beliefs should also be taken into account. For example, staff should address the person with dementia in the way the person prefers, whether by their first name or more formally. However advanced the state of the person's dementia, the person should be treated as an adult and with courtesy at all times.
People with dementia have the right to expect those caring for them to try to understand how they feel and to make time to offer support rather than ignoring or humouring them. Staff should chat to residents while they are helping them with physical tasks such as washing and dressing. One member of staff should have particular responsibility for the care of each person with dementia. This staff member should have a clear idea of that person's life history, routines and interests.
The right to choose
People don't lose their right to take part in decisions about their lives just because they have dementia, or because they have moved into a care home. They should be included in plans and decisions about their care, and helped and supported to make choices. Whether it is choosing food, clothes or activities, their likes and dislikes should be taken into account fully. If the person with dementia can do particular things for themselves, they should be encouraged to continue to do so.
According to the Mental Capacity Act in England and Wales (and the Department of Health, Social Services and Public Safety (DHSSPS) guidance and case law in Northern Ireland), all adults have the right to make decisions for themselves unless it can be shown that they are unable to make them. Everyone should be given appropriate help and support to make a decision. Any actions or decisions taken on behalf of someone who does not have the capacity to make decisions for themselves must be in their best interests. This legislation should underpin everything that health and social care professionals do when working with a person with dementia. (See factsheet 460, Mental Capacity Act 2005.)
A meaningful life
Care staff should show a sensitive approach to helping people with dementia maintain a good level of personal care and ensuring that they get enough to eat and drink.
Many care homes will have some structured group activities during the week which may or may not be of interest to the person with dementia. It is important that life does not centre around these activities. The starting point for leading a meaningful life will be ensuring that a person's preferred activities are integrated into the care plan. This might include details of favourite radio or television channels, where and when a person likes to go out or whether they like an alcoholic drink in the evening.
You may want to ask about the activities programme in the home, but it is also important to ask specific questions in relation to the person who is going to be living in the home, for example 'My mother likes to do her shopping on Saturdays - can she continue to do this?' or 'My father is a keen cricket fan, how might he be helped to keep up this interest if he lived here?' The answers to these questions will give you a good indicator of the home manager's willingness to respond to individual needs.
The care team should create opportunities for residents to spend time together and get to know each other through a wide variety of social opportunities.
People with dementia should also be encouraged to maintain relationships with people outside the care home. Just because a person has entered a care environment, this should not mean the end of many of the familiar routines which have helped shape their day.
The physical environment
The environment of the care home should be as comfortable and homely as possible. A smart hotel-style environment might impress you as a visitor initially, but remember that it is going to be a place to live. People with dementia often need to have things to stimulate their interest and so an overly tidy environment is not always helpful. A home with pictures and objects on tables, and with opportunities for residents to do household tasks such as dusting or folding towels, will give you an indication that residents are welcome to get involved in the community of the home.
Spaces should be clearly signed and laid out to minimise any of the confusion or distress that people with dementia may sometimes feel. Residents should also be able to spend meaningful time outdoors. Some residents with dementia who don't live on the ground floor might not have easy access to the outside, so extra requirements may be needed so that they can spend time outdoors. Regular exercise, fresh air and natural light are important for a person's well-being.
Staying in touch
There should always be a member of staff available to talk to the person with dementia, their friends or relatives about any worries they have. Staff, in turn, should be supported at all times by the care home manager. They should also see relatives and close friends as playing an important role in complementing the support and care offered by the home.
Things to think about when visiting care homes
Spend some time looking around and talking to the person in charge, as well as other staff and residents. Don't be afraid to ask questions. It may help to take a checklist of things you want to find out. You will have your own views on what is important, but the following suggestions may be useful.
First impressions are often an important clue as to how a home is run. For example:
- Are you greeted in a friendly way when you arrive?
- Is the atmosphere homely and welcoming?
- Is it clean and pleasantly decorated and furnished?
- Are there any unpleasant smells?
The best indication of a good home is that the residents appear happy and responsive, and that individuals are treated with dignity and respect:
- Do staff speak to residents in a way the residents like?
- Are residents involved in activities or chatting?
- Are they properly dressed and well groomed?
- Do they seem alert and interested?
- Do they talk to you as you walk around?
- Are they encouraged to do as much for themselves as they can - and if so, can you see any examples of this?
However pleasant the home itself may be, ask yourself:
- Will it be easy for visitors to get to the home?
- Are there facilities such as shops, a park or a pub within walking distance, for residents who enjoy going out?
- Is there much noise from traffic, or anything else?
If the person with dementia is likely to need equipment or adaptations:
- Are the corridors and toilets wide enough for a walking frame or wheelchair?
- Are there suitably adapted toilets and baths?
- Are there ramps or a lift?
- Can residents have a single room?
- Are residents encouraged to bring in some of their own furniture and possessions?
- Are the bedrooms bright and pleasant?
- Can residents go to their rooms when they wish to be alone?
- Can residents keep pets in their rooms, or in other areas of the home?
- Do staff respect people's right to privacy, and knock on bedroom doors?
- Is there somewhere for visitors to sit in the room?
- Is there adequate storage space?
Getting to the toilet in time can sometimes be a problem as dementia progresses:
- Are there enough toilets within easy reach of the bedrooms and living areas?
- Are staff trained to spot the signs when someone needs to go to the toilet?
- Are staff cheerful and tactful about helping residents use the toilet and changing them if they are incontinent?
- Are chairs arranged in groups to encourage socialising, rather than placed in a circle around the outside of the room?
- Is there a TV or radio left on when no one is watching or listening?
- Is there more than one room where residents can sit or where they can be quiet or see visitors?
- Are there smoking and non-smoking areas?
- Is there a garden where residents can walk safely?
- Are special diets catered for, and are residents' likes and dislikes taken into account?
- Is a choice of food offered at mealtimes? Can you see the current menu?
- Can residents eat in their rooms, or eat at different times, if they prefer?
- Are there facilities for making snacks if a resident feels peckish?
- Are staff trained to sensitively help people eat their food, if necessary?
- What happens if residents are unwell or need medication?
- Which doctors can residents see?
- Does the home have access to other services, such as community mental health teams, chiropodists, opticians and dentists?
- Can a relative stay overnight if a resident is unwell?
- What happens if residents need help with taking medication?
- Are changes in medication discussed with the family carers?
Make sure that there is good communication between relatives and the home, and that phone calls and visits are encouraged:
- Are visitors welcomed at any time?
- Are there quiet areas where relatives can spend time with residents?
- Are visitors encouraged to take residents out, or join them for a meal?
- Can visitors make a drink for themselves and the resident?
- Are children made to feel at home?
- Is information readily shared with families? How is this done?
- Are families supported to become involved in the life of the home - for example, is there a relatives group?
Residents should be stimulated without feeling stressed:
- Does the home provide personalised activities that are suitable and engaging for residents with dementia?
- Are there opportunities for residents to help staff with small tasks if they wish?
- Are activities available each day or are residents left to sit in front of the TV?
- Are trips and outings organised and special events celebrated?
- Are residents encouraged to take exercise?
- Are residents able to choose and listen to a variety of music when they feel like it?
Security and safety
- What safety and security measures are in place to keep residents safe?
- What measures are taken to reduce the risk of falls?
- What call systems are in place if the person needs help?
End of life care
- What options are available for end of life care?
- What support or care is given to family or other carers?
If the person with dementia comes from a different background or culture from most other residents, you might enquire about how their needs could be catered for in a sensitive way:
- Are staff interested in learning about the person's background and culture?
- Do staff show a respect for differences that might involve diet, clothing, hygiene practices or religious observances, for example?
- Do staff find out how residents wish to be addressed, and how they prefer to relate to other people?
- Do staff speak the resident's language?
It is important to note whether staff seem friendly and caring towards residents and whether they treat residents with respect:
- Do they have any training and experience in dementia care?
- Do they make time to sit and chat to residents, or talk to them while they are helping them with physical tasks such as washing and dressing?
- How do they learn about residents' backgrounds, habits and interests?
- Will the person with dementia have a member of staff particularly responsible for their care?
- Is there a member of staff who you can talk to about your own worries concerning the person with dementia? How can they be contacted?
Manager/head of home
A manager who is caring as well as efficient can make all the difference to a home:
- Does the manager have a friendly manner with staff and residents?
- Do they answer your questions openly and seem to understand your concerns?
- Do they have a knowledge of dementia and can they deal with difficulties that may arise in an understanding way?
- Is there a full assessment before a resident moves into the home?
- Does each resident have a care plan? How regularly are their needs reviewed?
- Is the family carer consulted about the care plan and about any proposed changes to it?
If the home is being arranged through the local authority, the local authority will have a contract with the home. You may want to see a copy.
If you are arranging a home independently, make sure you have a contract with the home or a statement in writing. Get advice from a solicitor or Citizens Advice Bureau (see 'Useful organisations') before signing any agreement. You need to be clear about:
- what is included in the weekly fee, what may be charged as 'extras' and how much notice is given if fees are raised
- what kind of care, and what services, residents can expect
- what happens if a resident's condition deteriorates - can they remain in the home and, if not, how are alternative arrangements made?
- how much notice has to be given on either side.
For details of Alzheimer's Society services in your area and information about a wide range of dementia-related topics, visit our website at alzheimers.org.uk
Provides information and advice for older people in the UK. Age UK has been created by the merger of Age Concern and Help the Aged.
Care and Social Services Inspectorate Wales (CSSIW)
Care Quality Commission (CQC)
Regulates, inspects and reviews all adult social care services in the public, private and voluntary sectors in England. Formerly the Commission for Social Care Inspection (CSCI).
Citizens Advice Bureau (CAB)
Your local CAB can provide information and advice in confidence or point you in the right direction. To find your nearest CAB look in the phone book, ask at your local library or look on the citizens advice website (above). Opening times vary.
Provides an information and advice service for older people, their families and carers, focusing on social care, welfare benefits and befriending services. This is integrated with local support, including one-to-one and group befriending schemes.
Elderly Accommodation Counsel
Charity that aims to help older people make informed choices about meeting their housing and care needs.
Commerical consultancy company offering independent expert advice on housing and care options for individuals and organisations.
Regulation and Quality Improvement Authority (RQIA)
Independent body responsible for monitoring and inspecting the availability and quality of health and social care services in Northern Ireland.
Relatives and Residents Association
Advises relatives and close friends of people in care homes on a range of topics, from how to get an assessment to what to do when problems occur in a home.
Last reviewed: March 2012
Last updated: January 2014
Next review due: March 2015
Reviewed by: Dr Barry Aveyard, Senior Lecturer Faculty of Health and Wellbeing, Sheffield Hallam University, Sheffield and Dr Ann Capewell, Consultant Physician, St Helens and Knowsley Teaching Hospitals NHS Trust, Merseyside