Maintaining health and wellbeing


Quality statements 3, 4 and 5

Quality statements 3, 4 and 5 are about keeping the whole person well, and what care staff need to know and do to help this happen.

Statement 3 says:

Older people in care homes have the symptoms and signs of mental health conditions recognised and recorded as part of their care plan.

Read quality statement 3

Jump to the case study

Why is this an area for quality improvement?

Mental health conditions are very common in older people who live in care homes, but often they are not recognised, diagnosed or treated. This can be because care staff have little knowledge of the symptoms and signs of mental illness and don’t refer people for specialist help, or because declining mental health is regarded as a normal part of the ageing process. Early recognition, diagnosis and treatment can prevent an older person from developing more serious and long-term mental health problems. Ageing with good mental health can make a key difference in ensuring that life is enjoyable and fulfilling.

Many people living in care homes have dementia. Their symptoms will change over time, but all symptoms should be monitored carefully because the person may develop additional mental health difficulties, particularly depression or anxiety, that can be treated.

Moving into a care home can be a very stressful time for an older person, and can lead to a deterioration in mental health and the need for specialist mental health care. Care staff have many demands on their time, but recording information about changes in symptoms in a care plan is always a priority. Without this information it is difficult for a GP or mental health specialist to make a diagnosis.

How can care homes improve quality of care?

Train staff to recognise the signs of mental health problems

Care home managers need to ensure that all staff have training in recognising the symptoms and signs of mental health problems in older people. The Common core principles to support good mental health and wellbeing in adult social care, published by Skills for Care, provides a basis for a general understanding of promoting good mental health and recognising signs of poor mental health among everyone receiving care and support. The Let’s Respect toolkit for care homes from the Life Story Network helps care home staff to recognise when older people need support for mental health difficulties and understand how to support them. The Age UK factsheet on the causes and effect of depression in older people and the Depression and anxiety information from the Alzheimer’s Society provide information about recognising and treating depression and anxiety in people with dementia.

Recognise that moving to a care home is stressful

Many older people find moving to a care home stressful and it takes time before they adapt to their new life. Others find it difficult to cope and may need extra support to maintain good mental health. Recognising symptoms in a new resident may be more challenging for staff because they do not know the person. Working closely with family and friends will help. The Managing transitions bulletin from My Home Life gives advice on helping older people to settle in to a care home.

Record and communicate information with confidence

Care staff need to be clear about how they should record information about symptoms of mental ill-health on a care plan and should be able to recognise when to refer a person to a GP. Staff also need to be confident about communicating accurate information about symptoms to a GP. The Workforce development, standards and regulation – developing trained, confident care workers section of SCIE’s 'GP services for older people: a guide for care home mangers' has information about staff training in this area.


Case study

Case study: Mental health concerns

Alice (not her real name) had lived alone for many years following the death of her husband. Her family eventually realised that she had been neglecting herself for some time, living in poor conditions and eating very little. She no longer wanted to live alone, so they arranged for her to move into a care home. Although the move was her own choice, Alice found it hard to settle in. She became withdrawn, wanting to stay in her room most of the time, and said very little. She was reluctant to eat, found it difficult to sleep, and the skin on her hands began to look red and raw.

Staff in the care home became concerned about Alice, and felt that it was more than just the transition to living somewhere new. They monitored her weight and skin condition carefully, and sought advice from the GP and community psychiatric nurse. They also shared their concerns with her family, and took time to build a supportive relationship with Alice, sitting quietly with her listening to the music she loved. The home had strong links with the specialist mental health services, and after further discussion with the community psychiatric nurse, an assessment with a consultant psychogeriatrician was arranged. Alice was found to be depressed, with high levels of anxiety. She had begun washing her hands very frequently in response to her anxieties, which was causing the skin problems.

With medication and support from the care staff and her family, Alice’s condition started to improve. Staff continued to seek advice from the community psychiatric nurse when necessary, and ensured her medication was regularly reviewed.

This case study was supplied by a social worker in older people’s services.

Statement 4 says:

Older people in care homes who have specific needs arising from sensory impairment have these recognised and recorded as part of their care plan.

Read quality statement 4

Jump to the case studies

Why is this an area for quality improvement?

Most older people will be affected by some degree of sensory loss, but because loss is often progressive it can go unnoticed for some time. This can lead to poor communication, lack of confidence and isolation, and have a negative impact on mental wellbeing. Sometimes the symptoms of sensory loss can be mistaken for the symptoms of dementia so people don’t get the help they need for their sight or hearing loss.

Good support from care home staff can make a big difference to people with sensory loss. If staff are aware of the early symptoms of sight and hearing loss, they will be able to identify and refer people who need specialist help. Some people will just need glasses or a hearing aid to enable them to communicate successfully. Others have a higher degree of sensory impairment and find it more difficult to communicate so need extra support from staff. If a person’s support needs are recorded on a care plan, all staff are able to access the information and understand how they can help. Information about a person’s needs for hearing aids, glasses and other sensory aids should also be recorded, including details about maintenance.

How can care homes improve quality of care?

Understand the needs of people with sensory loss

Care homes can ensure that older people with sensory loss are well supported by providing training and support for staff. Staff should understand the needs of people with sensory loss and learn good communication skills. A world of silence – the case for tackling hearing loss in care homes from Action on Hearing Loss provides recommendations for care homes on how they can manage hearing loss effectively. Quality of life for residents with sight loss from My Home Life, in partnership with the Thomas Pocklington Trust, has advice on supporting people with sight loss. The Seeing me booklet from Sense explains the particular needs of older people with dual sensory loss. The Dementia and sensory loss section of SCIE’s Dementia Gateway will be of interest to those working with people with dementia.

Ensure people have regular sight and hearing tests

It is important that older people have regular sight and hearing tests, whether or not they have shown any symptoms of sight or hearing loss. They can be tested at the care home at no charge. Tests can be arranged through a GP or NHS audiologist or optician.

Be aware of the aids and equipment people use

Staff should be aware of day-to-day problems that can cause distress to older people, such as misplaced or faulty hearing aids or misplaced or dirty spectacles. These problems are easily solved, but can quickly affect mental wellbeing if not dealt with. Staff should also be aware of any special equipment that people use, such as low vision aids, and make sure that these are available when needed.

Pay attention to the design, layout and lighting of the home

For people with sight loss, the design and layout of the care home is important. Simple changes, such as removing waste bins or rugs that could be a hazard, can make the home safer. Good lighting also plays a part in creating a suitable environment. Lighting and design advice from the Thomas Pocklington Trust explains how simple changes can make a big difference to people with sight loss.


Case studies

Case study: Deaf awareness

Marlborough Court care home in Market Harborough has recently been awarded Deaf-Aware Care: a care quality mark for older deaf people developed by the Royal Association for Deaf People (RAD), Sonus and Care England. By meeting the requirements of the of the quality mark, care providers can ensure that their services are accessible to older deaf people.

To achieve the award, care providers are assessed against 4 standards:

  • accessibility
  • engaging with older deaf people
  • British Sign Language/English interpreters
  • recruitment.

In preparation for assessment for the quality mark, Marlborough Court amended policies and procedures to ensure that they took the needs of deaf people into account, and updated the care planning process so that specialist support needs could be easily recorded. They also made changes to their recruitment procedures so that deaf people are encouraged to apply. Some existing staff will be trained in British Sign Language (BSL). Many deaf people have BSL as their first or preferred language, so communicating can be difficult if none of the staff have signing skills.

The changes made by the care home mean that they are fully prepared to support deaf people, who won’t feel that they are being treated differently from other people living in the care home. This includes leisure activities. For example, on film night subtitles are provided on all films; deaf people don’t have to request that they are turned on.

The number of older deaf people is rising and very few of those who move into residential care will choose to live in specialist care homes, so there will be an increasing number of deaf people in mainstream care homes. The quality mark helps providers to achieve a high standard of care for their deaf people living in care homes.

Leslie and his wife Betty communicate in BSL. When Betty had a stroke they moved into a residential care home that didn’t provide support for deaf people. Leslie says “when you cannot communicate with anybody because nobody uses or understands sign language or what it is like to be deaf, believe me that is hell. Living in a care home would be so much easier if there were other deaf residents and if the staff were more deaf aware”.

Case study from the Royal Association for Deaf People.

Case study: Sailing trips

Steve (not his real name) has macular degeneration plus dementia. When he moved to Vista's New Wycliffe Home for the Blind he rarely showed any facial expression. He had difficulty dressing and there seemed little that he could do by himself. Staff recognised that he liked to walk so, to try help him regain some independence they showed him the rails in the garden and walked round with him many times until he was confident enough to walk in the garden by himself.

Still looking for things to stimulate Steve, the manager thought he might like to go on the one of the regular sailing trips the home arranges. When asked if he would like to go, Steve said he would. When they got to the lake the volunteers helped Steve orientate himself by encouraging him to feel the water, which he loved. There are hoists to assist people in and out of the boats. The volunteers talked him through every step and he was not anxious at all.

Once sailing, Steve started to beam with pleasure. He did not stop smiling all day.

Case study from the Thomas Pocklington Trust.

Statement 5 says:

Older people in care homes have the symptoms and signs of physical problems recognised and recorded as part of their care plan.

Read quality statement 5

Jump to the case study

Why is this an area for quality improvement?

The majority of older people living in care homes have some degree of physical ill health. Physical health problems can cause discomfort and affect activities of daily living, participation in social activities and independence, and therefore mental wellbeing. Many older people living in care homes have complex health needs so recognising new symptoms may not be straightforward, particularly if staff do not know a person well and are not familiar with their general state of health.

Recognising the symptoms of physical illness in people with dementia is particularly challenging because they may not be able to communicate that they are feeling pain or discomfort. People with learning disabilities may also be unable to tell staff that they are experiencing symptoms of ill health. People at the end of life may have unnecessary pain and discomfort if their symptoms are not recognised and treated.

How can care homes improve quality of care?

Give staff the skills they need to recognise changes in symptoms

Good management of existing conditions and prompt recognition, diagnosis and treatment of new health problems is vital. Care staff need training so that they are confident in recognising the symptoms of ill health in older people and can identify when a person needs to see a GP. Although older people may tell staff about their symptoms, often they don’t and staff need to recognise symptoms through their own observation. If staff have had the chance to get to know a person and are aware of their general state of health, they are more likely to recognise changes. Good communication skills enable staff to get an accurate idea of symptoms more quickly. The Communication section of SCIE’s ‘Dignity in care’ guide supports staff development in communication skills.

Communicate with people who cannot speak

People with dementia who can no longer express themselves through language will need extra support. The Communicating with a person with dementia section of SCIE’s Dementia Gateway has advice on communicating with people who have lost the ability to speak. Meeting the health needs of people with learning disabilities from the Royal College of Nursing includes advice on communication.

Assess pain

The assessment of pain in older people from the Royal College of Physicians explains how to recognise pain in older people through observation. The pain management section of SCIE’s ‘Dignity in care’ guide is also useful.

Talk with family and friends

Talking with the family and friends of an older person will help with recognising symptoms because they are likely to have a good knowledge of the person’s general health. The Managers' responsibilities and the NHS reforms – actions as a result of listening to residents and relatives section of SCIE’s ‘GP services for older people: a guide for care home managers’ provides further information of the role of family and friends in an older person’s healthcare.

Accurately record any changes in health

Changes in a person’s health should be accurately recorded on their care plan. If this does not happen, it is difficult for staff to share important information about a person’s state of health. GPs and other healthcare professionals may not be able to make an accurate diagnosis without a full picture of a person’s recent health problems. SCIE’s GP services for older people: a guide for care home managers also includes a section on record keeping.

Understand how to respond to changes in symptoms at the end of life

People at the end of life may experience new symptoms or existing symptoms may become worse. Changes should not be ignored because a person at the end of their life should feel as little pain and discomfort as possible and it may be possible to provide relief from the symptoms. The End of life care e-learning course from e learning for Healthcare covers symptom management at end of life. End of life care, a SCIE TV film, focuses on good end-of-life care for people with dementia.


Case study

Case study: Person-centred end-of-life care

Moreton Hill Care Centre in Gloucestershire was keen to make sure it was providing good end-of-life care for everyone living in the home, including people with dementia. Using the Gold Standards Framework, they developed a person-centred approach to end-of-life care, ensuring they considered the full range of needs of both the person and their family. Care staff understand how important it is to look for and record any change in the physical health of each resident. Knowing each person well helps them to achieve this, because they can easily see very small changes even when the person is unable to communicate well. The home uses a traffic light system to ensure all staff recognise and understand when people are near to or at the end of their life, and their care is adjusted accordingly.

Advance care planning is an important feature at Moreton Hill. Staff work with the person and their family to ensure they have a full record of how the person wants to be cared for and supported at the end of their life. This means staff can feel confident they are meeting the person’s wishes even if they become unable to communicate. The home also understands that particular skills are needed to support people at the end of their life, and staff receive training in areas such as pain management. They take a multidisciplinary approach, working closely with the GP and discussing changes needed to medication to ensure people have the right pain relief and remain comfortable and calm.

Mairead Smart was a resident at Moreton Hill. The staff knew her well and recognised when she had reached the final stage of her life (the red light stage of their traffic light system). Mairead had expressed her wishes for her end of life care in an advance care plan. She wanted her family, including her grandchildren, to be near her in the final weeks of her life. Mairead had lost the ability to communicate with other people, but she was still able to recognise her grandson Joe’s voice. Her smile of delight when she heard him talking as he played near her bed showed how important it was to her that her wishes were followed. Marion, Mairead’s daughter, spent a lot of time with her mother and worked closely with the staff to make sure that Mairead’s final weeks were comfortable and that her care was provided according to her wishes in her advance care plan. Mairead died peacefully on 17 January 2011.

This case study is taken from SCIE’s Social Care TV film End of life care.