In a roundtable sponsored by Blueleaf, our panel of industry leaders discusses what the future of dementia care will look like in terms of design and the environment, care models, workforce, technology and innovation, and funding
Mala Agarwal, MD, Athena Care Homes
Liz Wardell, head of dementia, Signature Senior Lifestyle
Sanjeev Kanoria, chairman, Advinia Healthcare
Joyce Clutton, senior interior designer, blueleaf
Tony Stein, CEO, Healthcare Management Solutions
DESIGN AND THE ENVIRONMENT
LIZ WARDELL (LW): Unless you are end of life, my opinion is that everyone should be enabled, particularly people living with dementia. So many people who have that disease say if you do everything for us, we’ll forget to do it. Things like signage and the gimmicky mock pubs and mock murals, they are just not in my opinion necessary. They are treating people like infants rather than enabling people in real things. There were so many Singer sewing machines in our buildings and half our people didn’t use them. You should do a risk assessment and get a proper sewing machine and use it with them or enable them to do it.
Mala Agarwal (MA): I think there are many misconceptions about what a facility actually requires, which leads to a lot of copycat behaviour. In reality, we should be looking at care homes and ensuring they are bespoke to the residents – whether they are living with dementia or other conditions. Your care home may look very different to others, but if you can prove that the outcome is positive, the CQC will see that when they visit. I know when I walk into one of my homes, whether it has a positive feel to it.
Joyce Clutton (JC): It is trying to help create innovation that works. We have meetings with care home managers about what it is we are looking at. It’s about getting everyone involved so it doesn’t become this self-focused ‘I am doing this for the sake of design’ approach. If you get the care home resident involved they might say ‘we are going to put this into our plan and actually make this a task that we do so this room gets used because sometimes the staff don’t know how to use it and it gets forgotten about’. If it’s a piece of technology, get everyone involved as a team.
Sanjeev Kanoria (SK): Murals are not a waste of money in dementia care. They really do help in outcomes. We have woodland themed areas in some of our homes with trees and bird calls and they calm the residents down. People living with dementia forget things and become very anxious and don’t trust the people around them. I am not sure about the benefits of sensory rooms but we find our cinema rooms and hairdressing salons very useful.
Tony Stein (TS): It’s interesting you said you are finding murals useful because you are judging them by their outcomes. You may find that murals are simply stimulating people’s interest and distracting them from the circular thinking that occurs in their minds, whereas there are other places where a different approach, such as calming music or a comfortable environment, might work better. The problem with care homes is that by their nature they are going to be institutional rather than reflect normal domestic living arrangements, so how do you make them more homely and familiar?
TECHNOLOGY & INNOVATION
TS: When we learn how to monitor outcomes that will determine what we do and how we do it and in terms of staffing, who we staff it with and how we document that and what technology we use. We won’t get there unless we invest huge amounts into how we manage and assess outcomes. What about putting a wearable watch band or strap onto a resident that measures some of their physical signs? People complain that’s intrusive and brings problems of consent. If we can move towards something like that it ticks a lot of boxes. We need to be a little bit flexible. You can monitor people’s health remotely and concentrate more on their emotional well-being. Instead of spending part of your time monitoring their physical health, spend more time on their psychological well-being. If we could have a strap on device that indicates when someone is dehydrated or when they have had a fall or when their pulse is racing, we can monitor that automatically and the staff can forget that and just concentrate on making sure all the residents are happy.
SK: We are coming to that era because people are getting used to wearing technology. We are wearing Apple watches and getting used to being measured. We have been trialling robots in our homes for the past five years. Initially, we were a little apprehensive as to how the residents would take them on board but it has been absolutely fantastic. It has taken us about five years to design the software. It has been designed to embrace three cultures – Western, Asian and Japanese – and is dementia competent. The Institute of Social and Public Health, the University of Bedfordshire and the Japanese government have done a lot of work on the software and the technology was put together at the University of Genoa. The interaction with residents is absolutely astonishing. It’s about the ability of the robot to recognise behavioural changes.
CHP: Have you seen any negative reactions to the robots?
SK: None at all.
LW: I heard Wendy Mitchell say at the Doncaster Dementia Conference last year how dependent she was on Alexa and she had not used an app before she had dementia. The point she made was how do we get people who are living with dementia involved in the research from the beginning? We can gain so much insight from people actually living with the disease.
LW: My personal view is that the care home per se is still very institutionalised for all the reasons we’ve been talking about. That’s a hard nut to crack in terms of orientation, culture, staffing, funding, etc. Realistically anything is going to cost money, even people in the community are going to have to have support. When there are specific dementia villages, then the argument is going to be ‘are we stigmatising these people?’ None of us would want to be in an institution.
MA: I think it’s always about talking to each individual and asking what they want. People inevitably want safety and security. Sometimes they just want to be left alone. So we should ask the question: ‘What does that environment look like?’ And whether that’s a village, staying in your own home or residing in a care home, it will differ for everyone.
TS: We are in great danger of trying to find one size fits all. It’s going to be a mixed economy of solutions. We are working with Stirling University on a new project in Pitcrocknie near Alyth in Scotland. A gentleman came to see me a year and a half ago and said: “We have a nine hole golf course and a club house and we want to build a dementia village.” I said: “Don’t do it.” I can’t personally conscience the idea of ‘ghettoising’ people with conditions whatever they might be. They have now built housing for families, individuals, a crèche facility, some light industrial units and a care home specifically designed around dementia. It’s a village and not a care village or a dementia village. There’s a play area within site of the home so that people within the home can see the kids playing. That’s the kind of mixed economy solution we ought to be going for. In Florida, where they are world leaders in retirement villages, they are paying the price because they are now 30 or 40 years into them and when people were moving in they were all playing golf and getting together for social events. Now they are all 90 and the place is dead. It’s God’s waiting room. Nobody wants to move in. There’s no life and no activity. It’s just become a ghetto. We need to avoid that.
SK: I have seen in Germany how they have integrated some of the dementia care homes into a shopping centre. Residents can walk out into the shopping centre wearing their tracker bands and all the shopkeepers know them. They were free to roam around and it was very healing for them. The shopping centre was designed as a circular path that came back to the care home.
JC: I think that’s where the funding and the design is going to have to step up. A lot of design briefs we hear are for homes with safe amenities but that are also able to bring the community in from the surrounding area so that the residents feel part of the community. A lot of people are doing cafes that are open to the outside. Sometimes they can look a bit like a Harvester. Expectations for design are growing all the time. It’s about creating areas that are going to draw the public in.
MA: We’ve recently done some work with Neil Eastwood about the way we recruit and what our workforce ratios look like. In the past we’ve taken out adverts with Indeed, but we’ve found that more than 70% of our workforce are referrals or people who have previously worked as unpaid carers. We are now changing our way of recruiting. For instance, we asked our managers to identify three of their best staff members, and with Neil we analysed how they were recruited and what we needed to do in future to improve our practices.
LW: Signature has just started using the Judgement Index. It’s quite insightful. We have all been through it. It shows the two sides of your being – your work ethic and your personality. You can overanalyse everything but I think there needs to be something far more scientific about recruiting the right people. We all know it is hard to recruit and there is a high turnover.
TS: I am a big fan of Neil. He has done some research and found that the best people who have come into the care industry are those who are introduced and those who have had previous exposure in their lives of caring for people. As the population is ageing more and more people are being exposed to their elderly relatives with care needs. Do you think we are going to have a bigger pool to fish in because of this?
MA: Traditionally, the onus of looking after a loved one has always fallen on the family. I am not sure that new generations are as able or willing to take on such a big responsibility.
TS: I am not necessarily saying they will have taken responsibility for it but they may have had exposure to it.
MA: If that’s the case, there is light at the end of the tunnel. My mum has been unwell over the last year and all three of my children have actively helped look after her.
LW: It would be nice to know that’s true, however, on the other hand the extended family has declined over the decades. Even if you do have a frail family member you are not necessarily going to have exposure to them if you live far away.
LW: There is not going to be one funding model. I think there will be a variety of models that ultimately will need to be funded for them to be effective. I know the Alzheimer’s Society are going hell for leather to get the funding that David Cameron promised. We need more money in a variety of models because the disease is so complex.
MA: If we consider dementia 10 years ago compared to where we are now, a lot more research is being done. But as Liz said, I think we will be looking at a variety of models which are bespoke to the individual.
SK: Technology will have a big role in keeping people in their homes. I think it will only be people who are harming themselves or have medical conditions who will be looked after in an institutional setting. I think this will be more and more in a village type setting where people’s psychological and mental well-being is looked after where people are allowed to venture out and interact with other people.
TS: I think the sad reality is the NHS is so big and so well entrenched in the national psyche that it’s become the sacred cow that nobody can touch because there is such an outcry even if what is being proposed is perfectly reasonable. The only sensible solution to care in general is to combine the health and care budgets as one so then decisions can be made for the individual rather than the institution. In Manchester, where they have tried to combine the NHS and social care, people are despairing of the fact that it doesn’t really work. You try to take two huge institutions and mash them together to work as one and it will never happen. The question is how do you fix that? You can go one way and privatise the healthcare market because I tell you now the private sector would fix it. Simple commercial pressure drives change in the private sector in a way that it never will in the NHS. I don’t genuinely believe that would be a good solution, however, because I am a big fan of having a socially funded safety net. So the answer is I don’t know but in the mean time somebody has to get a grip of providing some hypothecated funding to local authorities that will help provide a bridge to where we end up. One of my big campaigns is properly funded social care. I think people who have worked and contributed taxes all their lives should expect to be properly looked after in their old age. If you are rich you can look after yourself. Someone needs to look out for the working class guy who can’t afford their care. We can’t let them slip by the wayside.
A word from the sponsor:
Thank you to CHP for hosting our roundtable discussion about ‘The Future of Dementia Care’. At Blueleaf, we’re in business to create compassionate, sustainable care for every future generation, and this means listening to experts and creating discussions like this one to keep us one step ahead. Visit: www.blueleafcare.com