Knowing and understanding the person


Quality statements 1 and 2

Quality statements 1 and 2 are about knowing and understanding older people as unique individuals and supporting them to develop and maintain their personal identity. They should be able to take part in activities that are meaningful to them and also be able to stay connected to the world.

Statement 1 says:

Older people in care homes are offered opportunities during their day to participate in meaningful activity that promotes their health and mental wellbeing.

Read quality statement 1

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Why is this an area for quality improvement?

Activity helps to sustain both physical and mental health, so it is important that older people living in care homes are able to maintain interests and have opportunities to develop new ones. The challenges of providing good care for older people with complex needs in care home settings, as well as the culture of the care home, can result in staff prioritising practical tasks above supporting people to take part in meaningful activities. Risk management can also be an issue, with staff not feeling empowered to support people if there is an element of risk involved in activities.

How can care homes improve quality of care?

Understand that activity doesn’t have to be organised

Activity doesn’t have to mean organised activity. It is a myth that the Care Quality Commission (CQC) expects there to be an activities programme and that delivering such a programme is the responsibility of 1 person – the activity coordinator. Activities coordinators play an important role, but ensuring that people can spend their time doing things that are meaningful to them is the responsibility of all staff.

Encourage people to be involved in daily activity

Care homes can greatly improve levels of activity for the people living there by ensuring that they have opportunities throughout the day to take part in the daily life of the home. To achieve this, staff need to know that engaging with people living in the home and encouraging activity is central to their caring role. SCIE’s film Excellence in residential settings – older people demonstrates the success of this approach in a care home. Meaningful activity can include routine personal care tasks, such as getting dressed and brushing teeth. If older people are encouraged to carry out these tasks for themselves, rather than have others do them on their behalf, it will contribute to their sense of wellbeing.

Offer a range of activities

Organised activities contribute to the sense of community in a home, but they aren’t for everyone. Some people prefer activities that they can pursue on their own, such as reading or listening to the radio. Other people prefer group activities, but a group activity that is enjoyable and meaningful to one person may be of no interest to another. People need a range of activities to choose from and support to maintain existing interests. The College of Occupational Therapy’s Living well through activity in care homes toolkit has plenty of ideas for building meaningful activity into the daily life of a care home and Staying involved and active from the Alzheimer’s Society provides tips on how to involve people with dementia in activities.

Understand risk

Some activities involve an element of risk and care home staff may be concerned about health and safety regulations and organisational policy. However, older people need the freedom to choose to take some risk if they want to. Care staff should feel confident about supporting people to take risks and know how to manage and monitor risk. Independence, choice and risk: a guide to best practice in supported decision making from the Department of Health provides advice on this subject.

... empower and authorise the staff to take risks, to actually do things that are out of the ordinary
Ian Turner

Chair, Registered Nursing Homes Association


Case studies

Case study: Football memories

John (not his real name) had difficulty taking part in activity other than walking in the secure gardens of his care home. His attention span was limited and his concentration appeared to be quite poor. Staff tried to engage him in games of bingo or cards when playing with people living in the home, but he would quickly get bored and walk away.

John’s short-term memory was impaired; his wife thought his memory was now focused at some point in the 1970s. A member of staff spoke to his wife about what was important to him during this time and she mentioned he was passionate about football. The member of staff printed out some names and pictures of football players from the 1960s and 1970s and created a game for him to match the names to faces. John engaged well in this game, it held his concentration and contributed to a friendship between John and another resident, who came over to join in with a common interest.

Following this success, a variety of other games with different sporting heroes have been devised, and John is much more settled around others. He has formed some good friendships and has a particularly good relationship with the member of staff who created the game.

This case study was supplied by the College of Occupational Therapists and is based on the observation of a member.

Case study: Supporting choice and managing the risks

Emily, 97, lives in a care home. She walks with two walking sticks, which affects her ability to carry out some activities of daily living. Emily gets up very early; members of staff help her wash and dress, then offer her tea. When she lived with her family, she would get up herself and then sit in the kitchen drinking cups of tea until the rest of the family got up.

Soon after arriving in her new home, Emily insisted on going into the dining room in the mornings and making her own tea. Staff were concerned that Emily was at great risk of falling or of scalding herself. The dining room is unsupervised at this time as staff are busy in residents’ room. They cannot lock the dining room, as other residents like to go in and out.

Emily could not understand why there was a risk, as she has always made her own tea. Making her own tea helped her feel at home in her new environment. Care home staff reviewed Emily’s care plan with her, explaining their concerns, and found a way for Emily to make her morning tea, minimising the risks. Emily accepted shared responsibility for any risks and, with her family, agreed that the home would leave out on a table in the dining room all that she needed to make her tea in the mornings.

This small task meant a huge amount to Emily. This was recognised; consequently, her wishes were supported and staff did not need to worry about her walking round the dining room unaided.

This case study was taken from Independence, choice and risk: a guide to best practice in supported decision making. May 2007

Statement 2 says:

Older people in care homes are enabled to maintain and develop their personal identity.

Read quality statement 2

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Why is this an area for quality improvement?

When an older person moves into a care home it can be difficult for them to adjust and to maintain a sense of identity. They may have experienced many losses and their transition into the home means adapting to a new way of life. They need a supportive environment where they have opportunities to continue their own interests and where other people take an interest in every aspect of their lives. They also need to feel that they are able to make decisions for themselves and that they can maintain existing relationships as well as make new connections. The challenges and competing demands on staff in a busy care home may make it difficult for them to respond to individual needs and aspirations. People living and working in care homes can often feel caught up in a rigid routine and this can hamper how they relate to one another as human beings. If people are not able to preserve their own sense of self and make a contribution to their new community, it will have a detrimental effect on their wellbeing.

How can care homes improve quality of care?

Build a picture of the person

Enabling an older person to maintain and develop their identity starts from the very first contact with them. It is vital to build a picture of the person and to get to know their needs and preferences. Care staff should understand the importance of seeing the person as an individual, talking to them and finding out about their life, so that they feel a sense of belonging in their new community. The people in SCIE’s film Older people and quality of life: better life in residential care ask to be 'seen as how we see ourselves' and their experiences show how much can be achieved and enjoyed with the support of committed care staff. Developing a personal profile (by using Getting to know you from SCIE or This is me from the Alzheimer’s Society, for example) or taking part in life story work (such as in Daughter and carer a film from the Life Story Network), can help with this process. SCIE’s film Personalisation for older people: residential care is also useful.

Support decision making

Being able to make decisions about how to live your life contributes to good mental wellbeing. Sometimes people need support to make bigger decisions, but they can still make decisions about everyday matters such as what to wear and where to sit for meals. The Choice and control section of SCIE’s 'Dignity in care' guide provides advice on supporting people to make decisions. The Making decisions in a person's best interests section of SCIE’s Dementia Gateway has information on decision-making for people who no longer have capacity.

Create a community

Strong personal relationships are also important for good mental wellbeing. This includes relationships with the staff at the care home, with other people living there and with family and friends. People need relationships that make them feel that they are part of the care home community and the wider community. Creating communities (PDF) from My Home Life has advice for care homes on building a community in the home and making strong connections with the local community.

Help people learn new skills

Our personal identities continue to develop throughout our lives. By learning new skills, older people can feel a sense of achievement and personal progress. Enhancing informal adult learning for older people in care settings, a video from the National Institute of Adult Continuing Education, shows some people who live in a care home learning new skills, such as playing musical instruments, learning Welsh and using a computer.

People need to be understood as individuals. We need to understand their personal history, what makes them tick, what they remember, what makes them happy, what makes them sad…to make people understand that they still matter and that they are recognised and treated as individuals who can still contribute to society.
Laura Bale

Matron and Director of Care, Royal Hospital Chelsea.


Case study

Case study: Home decorating

Des has dementia and is a resident at Ashley House Care Home. He was seen as a problem by staff because of his angry and challenging behaviour. He was on antipsychotic medication, but this had little effect on his behaviour and it was beginning to look as if he would not be able to stay at the home. Des often tried to move the furniture into the middle of a room; he would strip his bed and cover up the television with a sheet.

Des was, in fact, preparing to decorate. He had worked as a painter and decorator and was now repeating the actions that he had performed so regularly during his working life. Rather than trying to put a stop to these activities, the care home recognised that Des’s work was central to his identity and they encouraged him to continue. Only now Des was given paint brushes, a roller and a paint tin filled with water so that he could decorate without causing any disruption. Des became much calmer and was able to come off the antipsychotic medication.

This case study was taken from SCIE’s film: Minimising the use of restraint in care homes for older people: creative approaches.