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It’s all about the individual

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Caring for people with dementia requires a highly individualised approach that may be hard to get to grips with. Nic Paton looks at the delivery of the most effective patient-centred care.

Visiting a relative with dementia in a care home can be unsettling at the best of times. So how would you feel if you found them unwashed, in their pyjamas, digging in the care home garden?
For Sheena Wyllie, programme development manager for the Memory Lane initiative at Barchester Care Homes, this would not be a reason to get angry or accuse staff of neglect.
‘It may be exactly what that person needs to be doing at that particular time,’ she says. ‘It is not about getting them all up at 6am and giving them breakfast. It is not about bending them to our will.’
This is Barchester’s approach in its Memory Lane homes, which use various techniques to ensure residents with dementia ‘do more than just exist’. These include memory boxes (with a glass cover containing memorabilia from a resident’s life), adapted crockery such as insulated plates to keep food warm, sensory gardens and walkways that are uncluttered and well lit. Meetings and social gatherings are organised for families and friends, while activity coordinators are employed to create programmes including gardening, baking, outings, pet care and gentle exercise.
Four years after being rolled out, this initiative is in place in around half of Barchester’s 160 care homes.
But attitudes to dementia care are changing slowly. As recently as July this year, the National Audit Office said that given the steep rise in cases of dementia, the condition is still too often given a low priority by health and social services. The office drew comparisons with attitudes towards people with cancer in the 1950s.
Graham Stokes, head of mental health at Bupa, says accommodation and equipment have improved dramatically in the last decade. Bupa’s Braemount Nursing Home in Paisley, Scotland, uses techniques like bright lighting and white walls to help people see where they are going, and coloured plates to draw their attention to food. But this is just one example and there has been a lag around how far person-centred care has been made a reality.
Merevale House in Atherton, Warwickshire, is taking person-centred care one step further by specialising in providing small-scale domestic living for people with dementia. Dr Stokes describes it as ‘person-centred care plus – when you walk in it doesn’t seem like an institution, it feels soothing. It’s hard to pinpoint what they do – there’s an overarching atmosphere of calm’.
Residents play football, go to the zoo, cinema, bowling or even shopping. Workshops on living with dementia are aimed primarily at carers. Doll and soft-toy therapies are used to promote well-being – this alone is seen to have significantly reduced aggression, agitation and wandering among residents while also increasing the interaction between residents, relatives and staff.
Both Ms Wyllie and Anne Fretwell, owner and manager of Merevale House, want their homes to feel more ‘home-like’, while giving specialised care and promoting self-esteem and independence. Their emphasis on small-scale living means that instead of 30 people gathering in one area, it is more usual to find groups of five or six people dotted around the house.
As with all innovations, it is vital to gather evidence that the approach works. Ms Wyllie says: ‘We have some quite robust audit tools. There is an environmental audit and we have just started to pilot an audit tool similar to Dementia Care Mapping, which is due to be completed by next May.
‘The tool is watching and mapping what is happening for these people, ranging from neutral to positive or malignant – although that never happens.’
‘There are a lot of people who are not prepared to change, even over things such as uniforms, or the staff not eating with the residents,’ Ms Fretwell says.
But the results at Merevale House and in the Barchester homes speak for themselves and explain why these pioneering homes are determined to go beyond what Ms Wyllie calls the ‘clean, safe, dry, warehousing’ approach.
‘We have seen a reduction in accidents reported and a reduction in falls. We have fewer reports of people not eating. There are also fewer reports of staff being challenged,’ says Ms Wyllie.
She adds: ‘There may be more mess, but that’s because instead of the rummage boxes being kept neat and tidy, they are being used and people are engaging with things.’
Patient-centred care means looking at individuals and what they need. Ms Wyllie adds: ‘It is about helping people who live with dementia so they are seen as more than just a challenge or a problem.’

MY HOME LIFE

My Home Life is a major research and development project to improve the quality of life of older people in care homes. It sets out eight themes, the second of which is maintaining identity. A sense of identity is linked to self-esteem and quality of life in old age. In care homes poor health, cognitive decline, lack of privacy and institutional routines can undermine residents’ sense of identity.

My Home Life recommends:
• Ensure the same member of staff works consistently with residents so they can get to know each other and more tailored care can be provided;
• Biographical or reminiscence activities – these give a powerful boost to residents’ sense of identity and help staff and residents get to know each other;
• Find out what ambitions residents have, and explore how to make them happen;
• Get the community involved – in one home, community education workers met residents to discuss their interests and give classes;
• Allow residents to contribute to the home and the community, for example by helping new residents or working with schools;
• Residents must be able to choose how they dress, what possessions they keep with them and be allowed to control their personal space;
• Establish a forum so residents and relatives can suggest improvements that matter to them.
Resources on My Home Life’s eight themes are being rolled out to care homes across the UK. More on this and the other themes can be found at www.myhomelife.org.uk.

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