Despite the drizzle the Range Rovers were as sparkling and new as though they were still in a showroom. This was clearly an affluent street in Wimbledon, lined, beyond the cars, by well-appointed Victorian villas. One of them stood out. It had a big front driveway evidently adapted from two houses being knocked into one. The banner outside announced it was Queen’s Court, one of the Barchester group of care homes.
My visit there was to give me insight into how the care home sector is providing compassionate and personalised care to a range of people both privately and publically funded and satisfying a variety of care needs. Being ushered in to the sitting room I was immediately struck by the high standard of welcome, friendliness and customer care. Arguably not difficult to achieve for a scheduled visitor in an unpressurised environment. I was soon impressed that this standard was not reserved for guests from the Department of Health but was evident for everyone, residents and visitors alike. And to think it was unpressurised underestimated the high levels of activity discreetly hidden around the building.
Clean, tidy and well decorated (although a bit dated perhaps) this care home faced the not unusual challenges of being home to 43 residents but at the same time being a clinical environment for those needing nursing care.
Mrs Matthews[i] was the first resident to settle in the sitting room mid-morning. Her preference, which was obviously observed and respected by the staff, was to have a leisurely start to her morning, abluting in her en suite facilities with help from a care assistant and having breakfast in her room. But her coffee was taken in the sitting room so she could do a crossword whilst looking out onto the world passing by in the street. Her speed at progressing into the sitting room was enviable given she was pushing a wheelie Zimmer frame across carpet. Again, it’s a challenge to get the balance right between a carpeted residence and a shiny lino floor fit for a clinical area. My hosts and I had an interesting conversation about that and they had gone to great lengths to risk assess this issue and record their judgments and decisions. A straightforward observation about Mrs Matthews and her Zimmer frame was clearly a big deal and a pile of paperwork.
Trying not to intrude on the residents in their rooms was difficult for the inquiring nurse in me, but the dependency of the residents was evident. Those requiring continuous oxygen and those needing frequent pressure relief and those needing help with the toilet were obvious demands on the staff. And meeting the registered nurse was a joy. When I first arrived Fernando was tied up administering medicines. This took him a considerable time, but his care and diligence in doing this well was obvious. He was remarkable in his attitude to older people and evidently really loved his work. But even more remarkable for me was his autonomy. His judgements, his clinical decision-making were his alone. Of course there are others in the team to contribute to discussions about evaluating and modifying care but on this shift he was the only accountable registrant. That’s not to say they were short staffed that day, the home consistently meets its own exacting staffing requirements and national standards. Exemplified by Fernando, I saw the importance and authority of nursing played out in a lone practitioner on whom some very vulnerable people were wholly reliant for their fundamental and some very complex and challenging care. This style of nursing was the antithesis of most of my acute hospital experience where teams were heavily populated by registrants and, if a doctor wasn’t within arms-length, then one could be easily summoned whenever needed at any time of the day or night. I was full of admiration for Fernando, and those many, many thousands like him, who carry this responsibility for highly personalised care with absolute professionalism and dedication.
Similar commitment and enthusiasm was obvious from Mervyn the head chef. Quite clearly he had infectious passion for producing nutritious and attractive food day in day out. His creativity was unending and there were two things striking about him. The first was his desire to treat all the residents the same despite their range of nutritional needs. Naturally he understood that some people needed soft or pureed food to help them swallow, but his vision was to make them feel they were eating the same as everyone else, not to stand out and be discriminated against. He achieved this by making the special diets available for everyone, beautifully presented to high calibre restaurant standard, so that it was a normal choice. And secondly, this inspired and inspiring young man was a product of Barchester’s own chefs’ academy. His early talent had been spotted and nurtured and he, by his own admission, had achieved way beyond his expectations. So much so that he won Barchester Chef of the Year Award in 2007 and was National Care Home Chef runner up in 2008. Having done so well, he was now taking pleasure in nurturing the next talented generation. And not only was Mervyn a great character, he was also an outstanding reminder that compassionate care isn’t just about nursing, he demonstrated it amply through his creative cooking.
The second Barchester home I visited was Worplesdon View Care Home near Guildford – a beautiful new building in a beautiful setting. And again the quality of the food was a prominent feature in the life of its residents. I was treated to lunch by another highly creative team (the carved fruits were amazing) led by Andy and enjoyed a high standard of cooking, the same high standard enjoyed by the residents on a daily basis. This home was much bigger with 78 rooms with a large number of residents needing nursing care. With so many needing sophisticated nursing and medical care the relationship between the nurses and the local GPs was strong. It had built up relatively quickly and because of the demands of those needing this degree of care Lynda, the home manager, organised for the GPs to have a dedicated room in the home. This was used for rapid consultations and with IT links back to the surgery they could do everything electronically, including prescribing, on site. A superbly innovative approach which is efficient and effective for the residents and the clinicians.
I was also struck by the comprehensive notes some of the care assistants were keeping to record their care earlier on their shift. I was privileged to have a look at Mrs Rosenberg’s notes. She was well into her 90s with her son, who was next of kin and in his 70s, living in America. The notes were extraordinarily comprehensive. They were well ordered in a way that I could understand her social needs and was able to get a very strong picture of her nursing needs. Never having met her before I was confident I could have cared for her to meet the requirements of her care plan whilst also satisfying her likes and dislikes. Of course I should have expected nothing less, but my flawed preconceptions led me to think that clinical record keeping in such a facility might be more superficial. Mrs Rosenberg’s notes also reminded me that she was likely to need end of life care at the home. Her wishes were recorded in exact detail including essentials about her religious requirements, when to contact her son in Florida (noting the time difference) and which undertakers were instructed to conduct her funeral. On a more cheerful note, the other reason Mrs Rosenberg has stuck in my mind is because she was Resident of the Day. This initiative is like giving someone a second birthday with a bit of focussed attention and pampering. They can have their own choice of food (not from the set menu), their room spring cleaned and anything else they might want, well almost. It’s a delightful and important idea which residents, families and staff seem to enjoy in equal measure.
But this type of care is not without its challenges. I saw a charming but vulnerable lady of 102 start to cry simply because she suddenly felt alone and deserted. “Where’s Grace?” she asked us. Her care assistant had just left her to make her a much wanted cup of tea, but she had, for that moment, forgotten that that was why Grace had disappeared. She was quickly reassured, but the pain of that instant for her was profound – and for us who saw it. It’s impossible to predict and guard against such moments but the nurses and care assistants rise to the challenge. How much easier it would have been to restrain the lady with dementia who repeatedly used the soft furnishings as her toilet. She wasn’t strictly speaking incontinent, she knew her bladder was full but was convinced the nearest arm chair or sofa was the toilet. Often she was stopped in time and helped to the toilet, but not always. We discussed her care, short of one to one care it seemed difficult to come up with an alternative strategy and, since one to one care distressed and antagonised her, the compromise was discreet watchfulness. That’s not easy to achieve on a floor of people all with dementia with their own exacting and very personal needs. Despite her confusion there was an eager readiness to deal with the consequences quickly and as inconspicuously as possible. The furnishings were cleaned and cushions replaced with no resultant tell-tale smell.
Giving care of this sort takes very special people. And I met many at these two homes. Nursing is a challenge in any setting. I don’t suppose any of us came into the profession expecting it to be an easy job, but neither had I anticipated, from the sanitised security of my hospital experience, that nursing in the care and residential sector would be so complex and indeed arduous – and those who do it deserve our professional respect and gratitude.
David Foster is the Deputy Director of Nursing and Midwifery Advisor at the Department of Health
[i] All residents’ names have been changed.