Quality of care special report – Putting the past into the present

Person first… dementia second

Kate Emery put a slightly unusual item at the top of her to-do list when she took over as manager at Gallions View Nursing Home: history lessons for her staff.

“When I first observed the staff here, I realised they had nothing in common with the residents,” she explains. “Obviously there was the age gap, but it was also the fact that some didn’t know the history or the life events of some our residents.

‘These are people who have had a life and their experiences are really interesting. You just have to take five minutes to talk to them’

“So we did history lessons. In our dementia community, for example, we’ve got a Bomber Command navigator from World War II, but the staff didn’t understand what his life had been. So we explained what he would have gone through, how many colleagues he probably lost. The staff then took an interest in the individuals, and that’s the key thing - they have to get to know the individuals.”

Or, to use an oft-discussed phrase, to deliver person-centred care. Back in 1995, when writing a paper on looking after those with dementia, Professor Graham Stokes drew on the example of a care home which was confident it was taking just such an approach. Staff were completely mystified, therefore, as to why one woman appeared to be deliberately incontinent.

“They said they had this very, very difficult woman who would never use the lavatories,” recalls Professor Stokes. “She would walk to a toilet in the home, not use it, walk out, and be found wet. Yet her daughters were saying this wasn’t her mother: she had always cared about cleanliness.

“What the staff didn’t know was that this woman had always had an ingrained distaste of public, communal toilets. She had cared about cleanliness to the point that she couldn’t share a public lavatory, and that’s what the staff were expecting her to do because they didn’t know about her aversion.”

It was a story on which Professor Stokes based his paper. He titled it Person First… dementia second and, since 2010, the term has been used to sum up Bupa’s approach to caring for those with dementia. When they join Bupa Care Homes, all staff receive training based on the ethos.

“The training gets people in to the shoes of our residents with dementia, and of their families,” reports Lorna Rose, area director at Bupa Care Homes. “Everything is aimed at getting to know our residents with dementia, so that we are able to look after them well.”

Sometimes that may mean the simplest changes. “If I go in to a resident’s room and I find a pack of incontinence pads on the top of a chest of drawers, I’ll ask my staff to step in to the room and ask them what they see,” says Ms Tart. “I ask them what they are telling me about the lady in that room by leaving the pads out - that she is incontinent. I point out how undignified that is, just because the pads haven’t been put away. At Bupa, quality is helping our staff to understand an individual, to empathise with that individual.”

Making every experience special

Allan Birch-Murphy didn’t have the most auspicious start to his career in care. “To be quite honest with you, I thought I would last about an hour,” he remembers with a laugh. Part of the problem was his fear of dentures. “My nerves were shot and the first lady I went in to, she went: ‘Oh, good morning, dear. Do me a favour: just wash those’ and she handed me her false teeth!”

It was extreme exposure therapy, and it did the trick: three years later, Mr Birch-Murphy is still working in the care sector. He says a big part of the reason is the opportunity he has to discover what good quality care means for each of his residents.

For one resident, it was making it possible for her to attend her daughter’s wedding though she wasn’t able to travel: truly person-centred care which saw Mr Birch-Murphy recognised with a staff award.

“I thought there had to be something I could do,” he explains now. “So I phoned the church and asked if they had a webcam. I was expecting them to say no, but they said yes, and so on the day of the wedding I brought my computer in and put it on a little table I’d dressed up.

“And then I turned the computer on and I said: ‘See, it’s the church where your granddaughter’s getting married. You can watch the wedding!’ Well, the look on her face! The award was lovely, but it wasn’t as nice as seeing her face when she realised she could watch the wedding.”

He says he is continually encouraged by his colleagues to deliver this sort of high-quality, highly individualised care. “The house manager and the other office staff, including the area managers, have been so, so supportive,” he continues. “You can come up with ideas and they will talk them through with you and do their best to implement them.”

According to Angela Zuraw, regional manager for Bupa’s care homes in Merseyside, encouraging frontline staff to get involved in defining quality is a crucial part of the company’s approach.

‘I always envisioned care homes as being people in chairs. But no, these people have had a life’

“We always want frontline staff to come forward with ideas because they might be really important to us providing better quality of care,” she says. “Our managers visit the units every day, but our carers are with the residents all the time and so it’s really important that their input is valued.”

Mr Birch-Murphy now trains other carers and says he is trying hard to pass on his approach. “When I train people, I keep bringing it back to remembering that we’re looking after a person, and how special that person is,” he explains.

“I always envisioned care homes being people sitting in chairs, fed and put to bed,” he continues. “But, no, these are people who have had a life, and their life experiences are really interesting. You just have to take five minutes to talk to them.”

Making Every Moment Count

Melanie Abram is not a fan of the word ‘activity’. “We all do things in our day to day lives, but at no point does anyone say: ‘I’m doing an activity this weekend’,” points out the manager of Arran View Care Home.

“I may walk the dog, I may go out to lunch and see my friends, I may go to the pictures, but I don’t ever talk about doing an activity.”

That is why she believes the word should be eliminated from the vocabulary of care homes. “The word ‘activity’ makes people think of it as an add-on, and not an integral part of what we do.” Instead, she suggests, the emphasis should be placed on making each moment of a person’s life count.

It is an approach now enshrined in a document produced by the Scottish government and Care Inspectorate, and shaped by staff from Bupa. “We wanted to develop a resource for staff that really put the person at the centre of everything we did,” explains Ms Abram.

“It was about thinking about the things a person does from the moment they get up to the moment they go to bed, and life as being the interactions throughout that day,” explains Ray Ainsworth, another Bupa home manager who worked on the project. “It is those interactions which keep people in wellbeing.”

“I think Ray and I really felt that we did influence a lot of the decisions within the document,” continues Ms Abram.

Today, all those working in care in Scotland receive a copy of the pocket-sized Making Every Moment Count leaflet. At Bupa, that means literally everyone - whether they are directly involved in frontline care or not. This is a crucial aspect of delivering high-quality services, Ms Abram argues.

“People are still aligned to the job roles they have,” she says. “So it’s trying to say to the housekeepers, for example: you’re not just cleaning the unit, you’re cleaning the person’s home and you can add such a lot of quality to this person’s life by just small things you do, whether that you don’t touch the ornaments because the person doesn’t want them touched, or you put things back exactly where they belong.

“It’s a cultural shift, and the important thing about Making Every Moment Count is that it doesn’t cost anything. It is just about true person-centred care.”