A Manifesto for Residential Care

The Residential Forum agrees with the Social Care Future vision:

“We all want to live in the place we call home with the people and things that we love, in communities where we look out for one another, doing the things that matter to us.”

1. Make living in residential care settings a positive choice
2. Build a culture of respect for each resident and their relatives
3. Personalise caring and support though co-production
4. Positive leadership at provider, professional and political levels
5. Reforming the commissioning of residential services
6. Resourcing residential care for a fair price and a fair wage
7. Regulating for better outcomes, safeguards and quality

Vision Statement and a strategy for its development

Principles of Good Residential Care

The Residential Forum believes that good residential care:

• makes a positive contribution to the lives of children, young people and adults of all ages, and to the spectrum of care in the community and family support;
• promotes and demonstrates a commitment to basic principles of individuality, dignity, human worth, choice, privacy and self-determination, and to maintaining people’s rights as citizens;
• ensures that residents, especially children and young people, have access to a full and valued education which equips them for life in society;
• recognises the continuing importance of family relationships to many residents and their families, the benefits of encouraging the maintenance of good liaison between service users, their relatives and care staff, and the need sometimes to protect the service user from undue family influence or pressure;
• understands the social nature of human beings, their need for companionship and a sense of belonging, and the benefits of being supported, valued and appreciated by other people and able to make a contribution to the social groups of which they are members;
• appreciates and responds to holistic assessment of the physical, emotional, spiritual and social needs of individuals and groups of residents, including their need, whenever possible, to maintain and develop contact with their relatives and friends;
• treats every resident, no matter how dependent or disabled, as capable of personal growth, and able to make an individual contribution to the life of the residential community and society at large;
• takes account of the fact that people come from a variety of backgrounds and circumstances, and live in residential establishments for a variety of reasons, not always of their own choosing;
• acknowledges that service users are entitled to high quality service, active involvement in decisions about how it is organised and delivered; and recognition for their contributions, direct and indirect, to its provision and funding;
• maximises the positive aspects of shared group living, including the benefits of comfort, security, a varied diet, physical and emotional care, intellectual opportunity, companionship, a decent environment, and access to facilities and activities;
• aims to minimise the adverse effects of routines geared to other people’s needs, threats to individuality from institutional regimes, the impact of some other residents behaviour, and restrictions on personal liberty in the interests of the group;
• recognises that some residents are anxious to move on to other settings with greater independence, whilst others feel they have had no alternative to residential care available to them, and need the space to grieve for what they have lost;
• takes account of the long-term needs of each resident, seeing their period of residence in the context of their lifetime, preparing those able to move on to be successful and independent after leaving residential care, and providing appropriate after-care support for them when they have left;
• provides a base from which some people can contribute to the wider community, opportunity for others to develop a wider range of interests, contacts and activities, and a source of support for those learning to lead more independent lives;
• seeks to be open to and part of the community in which it is located, to encourage the community to feel a sense of pride in its residential provision and commitment to its standards, and to enable the community to feel it has a share of the responsibility for the well-being of all residents.

Differing Expectations of Residential Care

People’s expectations of residential care are as diverse as their circumstances.

• For a significant number of children and young people, residential care is an alternative to living in their family home, either temporarily before they return home or move to another family setting, or as the preferred option on a longer- term basis.
• For some children and young people, and adults in some circumstances, who have been hurt or damaged by previous life experiences, residential care can offer a chance to recover.
• For some younger adults with physical, emotional or learning disabilities, residential care can offer wider opportunities than living in the family home and may be a step towards greater independence.
• Other people may be a risk to themselves or the community without the day-to-day support, supervision and guidance of an appropriate residential setting, or may be required to live in residential care as a result of a court order in criminal or family proceedings.
• People can use short periods in residential care to recover from trauma, cope with crisis, receive treatment for a mental health or substance abuse problem or effect some other positive change in their lives.
• Some older people with various form of physical and mental disability opt for residential care in preference to feeling a burden to relatives and neighbours, or coping alone with failing competence, loss of confidence, feelings of isolation and loneliness, growing anxiety, depression, or confusion.
• Others would rather not be in residential care, but accept it as inevitable, often come to value the companionship it offers, and resolve to make the best of it.
• Others again feel residential admission has been imposed against their will by lack of viable alternatives, breakdown of family and other support networks, withdrawal of NHS or social services support to stay at home, or pressure from relatives, neighbours, GPs or hospital staff.
• A further group may need considerable support to enable them to play an active part in a residential decision because they suffer from dementia, severe depression, severe learning disability or personality disorder.

Diversity of Residential Care

Solo living is on the increase with around third of households now singly occupied. Thus most people continue to live in a communal settings. Besides family households there are several formats for shared living – hotels, schools, college hall of residence, multi-occupied houses, retirement villages and religious communities. Within this spectrum, supported group living and residential care can take a variety of forms. These will be affected by factors like:

• the functions of the accommodation and the services it provides;
• the size and location of the residential accommodation;
• the type and nature of the building;
• the number of residents catered for;
• the extent to which support and care is organised in groups and/or communally provided.
• Whether the service (accommodation plus care) are required to register as providing ‘personal care’.

The diversity of residential care additionally stems from differences of purpose and objectives; differences in the make-up of the resident group and the staff team; and different styles and models of providing care in a residential setting. Within the broad spectrum of support and care there is a rich variety of provision.

Residential care may be provided on a variety of scales, ranging from an ordinary house for one, two, three or four people, accommodation for a single group of five to fifteen, or a home for anything between ten and thirty or thirty-five people, through to larger facilities for up to eighty or a hundred, a complex for several living groups, or a whole “village” with a number of different units on the same campus. There may at times be a need to balance “small is beautiful” philosophies, access for residents to a wide range of facilities, user choice and economies of scale.

Children and young people may receive their care in a residential home, a school, or a unit within the health service. At the same time, elderly residents of care homes often have health and social care requirements similar to those of people in nursing homes. They need to be assured of continuity of support as their requirements increase. Registration and inspection procedures must be adaptable to the needs and wants of residents, not rigidly bound by organisational divisions.

The Provision and Management of Residential Care

Providing good residential care poses a variety of challenges and requires high levels of expertise and creative ability from managers, staff and external supports. They need to be committed to enabling residents to take as much responsibility as possible for the planning and management of their own care. Managers should adopt a planned approach to meeting the needs and promoting the potential of individual residents, within a regime and culture which provides the right balance of security, stimulation and scope for independence.

In many group living homes, individual needs and group characteristics will change frequently and unpredictably, requiring a style of management and care which is warm, sensitive, flexible and creative. To give of their best, staff need a management framework which is resident-centred, sets high standards and clear expectations without being regimented or overly clinical, maximises the potential of staff and managers, and uses all the talents they have to offer for the well-being of residents.

Managers must be alert to the risks of abuse, misconduct and poor practice by some individuals and groups of staff; and active in identifying and tackling instances of low morale, inadequate training and high staff turnover.

Managers should be skilled at overcoming the inherent restrictions and risks of the residential setting, exploiting to the full all the human and physical resources it offers, and ensuring residents have access to the expertise of other agencies, including the health service, education, training, employment and leisure services.

They need to encourage the involvement of relatives and volunteers to widen the range of experience and interests available to residents, and maximise the contributions and opportunities offered by the community in which the home is located. In care homes for older people, where residents may be physically and mentally very frail and nearing the end of their lives, families and friends can make a major contribution to their care and well-being.

Resources and Standards in Residential Care

Residential care is not a cheap option. Because it caters for those with complex disabilities, a high degree of dependency, needs for intensive staff support and supervision, or for high levels of professional skill and expertise, it must be properly resourced to be safe and effective. This is not to say that residential care may not be the most economical way of providing proper support for some groups of people with extensive or complex needs. But care on the cheap will generally be bad care and will often do more harm than good.

Residential care requires adequate funding, and a clear framework of quality controls and quality assurance to ensure high standards of service and practice. Service providers have a responsibility to see that their residential services are well-managed, and staff at all levels properly equipped through training and development programmes for the task they must do. A framework of external regulation, registration and independent inspection is essential, including of individual practitioners and managers, if the public is to have confidence in the standards of care, conduct and practice competence provided.

Strategies for the Development of Residential Care

A strategic approach is required to the development of residential care if the vision is to be turned into reality. Priority areas for consideration and development, either directly as part of the Forum’s work programme, or through action by others promoted and monitored by the Forum includes:

Strategies for management and development of practice

• developing high-level skills in leadership, strategic management, innovation and continuous quality improvement; creating the means for service users to share responsibility for planning their own care, with relatives involved as appropriate, to participate in service evaluation, and to contribute to shaping the development and management of services;
• applying the key tenets of effective human resource management, including clear definitions of aims and tasks, systematic attention to professional development and staff appraisal, effective equal opportunities strategies, sound policies for recruitment, selection and deployment of staff, and managing the performance of individual staff teams and units;
• ensuring managers and practitioners have access to information on progress of users, service performance, policy and standards guidance, research findings and knowledge for practice.

Training and staff development strategies

• improving data collection, nationally and locally, for workforce analysis and planning;
• identifying and meeting the training needs of residential staff, senior staff in homes, external managers. inspection and registration teams, trustees, directors and volunteers;
• promoting systematic approaches to staff development, supervision, appraisal and career planning;
• involving service users and family carers in training and management development;
• strengthening the knowledge-base of education, training and practice supervision.

Strategies for standard-setting, inspection and quality assurance

• involving users, carers, staff and other stakeholders in defining outcomes and setting standards of service, competence and conduct;
• establishing effective systems for regulation and registration through the a workforce/professional regulator
• strengthening safeguards for children and adults in residential care, taking account of the lessons from safeguarding reviews and inquiries into organised and institutional abuse;
• encouraging managers to adopt positive attitudes to complaints procedures and consultation processes;
• promoting residents human and civil tights, including those in the UN Conventions on Human Rights and the Rights of the Child;
• developing inspection techniques and approaches which set clear national standards, empower residents and staff, identify service deficiencies and abuses, promote improvements in quality of life and standards of care, and enable prospective residents and the public to make informed judgements about the service provided in individual homes;
• promoting a strategic approach to quality control and quality assurance, drawing on information from internal and external management, staff, residents, carers, commissioners, placing agencies, inspectors, other agencies which visit or have contact with the home, neighbourhood leaders and the general public, together with periodic assessments of residents progress, staff morale and the achievement of the home’s objectives, to provide a dynamic for continuous quality improvement, and early detection and correction of defects.

Strategies for community integration

• learning and disseminating lessons from residential and group living settings which have achieved successful integration with their communities;
• identifying the factors which lead to residents, staff and services becoming isolated from their families and communities, and how such circumstances can be overcome and outside contacts encouraged;
• clarifying the service provision and support residential homes should expect from social services, health, education, employment and training, community services, voluntary agencies and religious organisations, and ways to secure these;
• developing routes for the residential home and its local community to support, communicate with, and serve each other.

Resource strategies

• developing models for assessing resource requirements and value-for-money approaches to the provision of effective, good quality residential accommodations with support and care;
• devising techniques for relating resource inputs to outcomes for residents, and for optimising the match between them;
• applying these models and techniques to national and local systems for allocating resources and monitoring their use;
• undertaking a systematic review of the contributions to resourcing residential care made by governments (national, devolved and/or integrated) in the UK (through the mechanisms applicable), the vital contributions from partner services in education, housing, environmental health, arts, leisure, transport, the NHS, charges to individual residents and their families, voluntary donations, business sponsorship, and community support in cash and kind; and evaluating the proper balance among these contributions;
• developing the means for residents and relatives to judge the benefits they receive from residential and group living services, in relation to what they pay for them directly and indirectly, and to make representations appropriately.