The care-home classification: part deux

The other week in The care-home classification: part one,  I attempted to classify the variety of care homes that populate our fair and green land.

That classification was in respect to its function. However in terms of experience , I also mentioned that such care homes can easily be ranked in terms of suitability, appearance and functional ability to offer the care they aim to deliver. I also commented that this system via wise Dr Legend is comparable to the football league.

From conference to premiership, I have seen them all, and no doubt will continue to see and experience them. However what is paramount is the patient experience of these places, as hopefully what will become clear is that this is the true variable that actually counts.

In terms of the conference league, this is where unfortunately you just do not want to be. This is not a dig at the actual conference league clubs in football, but in terms of this metaphor, to be in such a place generally means minimal care.

A particular example is one care home where your entrance way greets you directly into the main lounge room where alcohol befuddled patients sit in high back arm-chairs, heads drooping with the occasional snail-trail of saliva dripping down on their top, most likely from being knocked out by the stale stench of cigarettes, alcohol and possibly urine. The staff appear eventually like the stunted zombies of a George Romero film, only to shuffle you and a patient into a nearby room for an obligatory examination. The resulting consultation, met with plenty of statements such as  ‘I don’t know’ or ‘I have been away so will get the manager’ or best yet ‘how am i meant to know that?’. Eventually the patient’s care will be managed (more often or not you are actually called because the new shift team has failed to read earlier reports, finding something that has been ongoing and advised upon, but wanting to punctuate their own mark on the fact that something  will be done), and you leave a management plan with the hope that it might be followed before your next inevitable visit. Let me be clear these care homes are unsafe, unsanitary and unwanted.

I must point out the above home has undergone major changes since initial visits and no longer at this level, more a promotion to league 2.

League 2 care homes show more effort, with more caring staff as the key reason. However the aesthetics remain the same, and unfortunately so does the odour. This means you have good, well-meaning staff working unfortunately in an unappealing site. The emphasis being well-meaning, this does not necessarily mean that they are good at what they do, but at least the effort is there, and they will keep on trying, much to the benefit of the patients they care for.

One such place I visited recently though visually deterrent enough by the putrid brown wall paper, is packed full of driven staff who know their residents well enough to recognise subtle changes in them and alert the practice I worked at, regularly. The problem being this was on a daily basis, such as ‘bowels have now moved’, ‘she has eaten half her meal today’ etc. This fits with the law of everything, as in if they tell us of everything, then occasionally something is wrong and at least we know about it (sensitivity over specificity).  While this over-referral is more an issue with how the practice handles the home, at least the 3 strokes and 2 bowel cancers we picked up in the past 4 months were dealt with faster than most of our normal non-care-home patients.

Promoting up from league 2 we have League 1. Here things start to look better, reasonable rooms, a communal area with likely a flat screen TV, radio, pretty pictures on the wall, like a Travelodge really. The staff however seem to have had some form of sleep/social interaction with the human populace. Additionally they will have accurate records of the patients, kept well in reach for need, and have legible records of care and medications. The reason why they don’t however make it to the championship is that some staff just brings them down, so here exist staff you trust, and the staff you don’t. This is a rather personal option as invariably some doctors get on better with some staff than others, but just like in primary and secondary care, the team works better if you trust the other members than if you don’t.

From my experience most dementia care homes live in this category, as though the decor maybe nice, here particularly is where the quality of the staff dictates the true quality of the care delivered. This reminds me of a private care home with nursing cover that fit this description to a tee. Though aesthetically they were on par with various premier hotels, the staff knowledge was so variable that some days you would leave confident the patient would be looked after, others gnashing your teeth at the frustrating magpie that has just needlessly made your life and the patient’s experience more frustrating. All this and the patients were paying enough to finance most of next-years university students through a medical degree!

Jumping up now we have the Championship league. Each of these care homes will have nice pleasing accommodation, like most 3 star hotels, group activities, day outings for patients, relative-related events, and staff that wear clean, pressed uniforms, and know their job. Most importantly they know their patients. In all honesty, most good care homes sit here, as you will always exist the variability of time, staff and residents that change the environment, but on the whole, these places work well, and generally have a good relationship with the practice too.

But such an award to this league is not just placed on care-homes in the nursing/residential group but in other environments. An example would actually be a warden patient I look after called Irie Knitting. She is a tough as old boots retired seamstress who lives on her own, has horrendous COPD which she actually manages very well on her own, as well as diabetes which invariably leads to leg ulcers. Despite this she is resolute that she can manage on her own, and continues to prove that she can, with the help of our local district nurse team; but is safe in the knowledge that if she has a problem, she can call her warden who will pop over to help, on top of his daily visit and if not, he will call for the right person (invariably me for some mystical reason).

Our final league is that pinnacle upon high, the Premiership. I will be honest few places make it to this level. While aesthetically many will claim to boast such abilities, invariably they tend to have less than well-meaning and competent staff. In truth to exist in the Premiership like in football, it is not about the grounds, but about the staff. Here they excel beyond imagining and make for a truly humbling patient experience.

One particular home that comes to mind, though more in terms of the decor had a more League 1 feel, however the staff worked tirelessly for their patients, keeping the soiled patients clean, relatives happy and managing to relay information back to the clinicians better than the 4x400m American Olympic relay team of 2008. A particular example would be where this home managed the lovely Mrs Batty Temporarily, who evidently went thorough a psychotic episode while being a resident. However rather than the reflex action to send her to hospital, a combination of amazing nursing, excellent family members and communication; meant she was stable within a short space of time, still in the home where she chose to reside, and conversing the third time I saw her like the eloquent woman she was, compared with the profanity spewing, Evangelic saviour of the world she had been when I first met her.

When looking at care homes there are various different types. I like working with them (aside from when they have called me out for the 4th time that when I really don’t need to visit). And just as there are various models of care homes, there are various models of working with them. In a later post I plan on exploring this aspect of primary care, though it wont be next week just before someone shouts at me for suggesting such a thing.

Nope next week, we take a look at something much more dark and sinister. A simple concept that will make Dr Who run for his TARDIS, make Hercules weak at the knees, and Superman beg for his kryptonite……. OSCEs.

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