For much of the last century, older people’s services were a clinical backwater in Ireland. Life expectancy was low and the frail and vulnerable who could no longer live at home were often admitted to community hospitals/welfare homes or, if “senile”, to institutions where the goal was to manage behaviour that might otherwise be seen as undesirable. Support services tended to be technical and care was often delivered by poorly trained staff in inappropriately designed buildings.
Thankfully our understanding of ageing and of older peoples’ dependency needs has changed significantly over recent decades as has the need for staff training, architectural design and the ethos of long-stay care environments. However, there is still scope for improvement, especially in parts of the country where the legacy of asylums, workhouses and institutions remain. There are also lessons to be learned from Covid-19 and from observing what takes places in other countries whose history of population ageing is longer than Ireland’s.
Yesterday I visited my father-in-law who has recently moved into a newly built care home in a rural part of Sweden, about 90 minutes' drive from Stockholm. The care home is small-scale and domestic-like. It accommodates eight residents and is located in the very centre of a small country village. That village consists of a large supermarket, a takeaway outlet and a hairdresser who shares her salon with a podiatrist. On arrival, one gets the sense this care home is these people's home, and residents who live here remain fully integrated into the local community.
The facility has been built alongside an assisted living complex comprising 16 self-contained bungalows. Daily activities at the care home such as cards, bingo, music, exercise and so on, can also be used by residents from the assisted living complex. Bedrooms open out onto a furnished patio area, leading to a small car park; so watching visitors and staff come and go is a natural part of each resident’s everyday life. Here there is no ringing on doorbells, waiting on care staff to open up and then signing visitors books. Rather, entrance and exit is done either through the external door that leads directly into the resident’s bedroom, or through the main entrance, kept open, leading into the common residential area.
Economies of scale
For economies of scale, the main meal of the day is prepared and delivered by staff from the local school (in Sweden all schoolchildren receive free lunches so school meals are already being prepared). Each resident has their own fridge and sink where light snacks can also be prepared. Bedrooms are large (27sq m), complete with sizeable en suites (7sq m), each fitted with washing machines and tumble dryers. This reduces laundry costs and means there is less risk of clothes being mislaid, an ongoing problem in many nursing homes today.
Covid-19 cast the spotlight on Irish residential care facilities where, sadly, a disproportionate number of our older people died
On admission, each family is shown an empty room and asked to furnish and fit it with curtains, pictures, plants and other memorabilia. So residents are surrounded with their own personal belongings that tell their story and help to keep them connected to a familiar world. It is this familiarity and bringing “home” into the care home that makes the facility so appealing. In this municipality, the monthly cost for full-time care for the individual is €730. The breakdown here is: room rent (€208); meals (€302); health and social care (€205) and toiletries (€15). Obviously the municipality subsidises costs through local taxation.
Ireland has had a lengthy history of new nursing homes being built sometimes off the beaten track, where residents can become socially marooned, being removed from family friends and community. This may be because land is cheaper outside towns and cities, and civic society places little pressure on developers. There has also been a culture of designing some nursing homes, certainly the public ones, like hospitals, with wards rather than single rooms and long featureless corridors.
Report after report
Covid-19 cast the spotlight on Irish residential care facilities where, sadly, a disproportionate number of our older people died. During the first two waves, there was much discussion about the need to recalibrate congregate facilities and to develop small-scale, domestic-style dwellings that would promote safety and autonomy and enable residents to comply more easily with public health measures.
But what has happened since then? In my view little or nothing, despite the publication of report after report. Indeed, over the last two years, no scheme or initiative has been launched that might entice developers or nursing home proprietors to shift their focus. Ireland was already behind the posse for, in 1987, Denmark had suspended all institutional care for older people. A few years later (1992), Sweden replaced all models of nursing home with special housing for older people and, in the Netherlands, in 2010 the Dutch government introduced fully funded schemes for small-scale, domestic dwellings.
We need a range of different designs for the diversity of older Irish people who in the future will require support outside their home
The person and the environment are an inseparable unit; aesthetic features of the environment affect mood and quality of life and can hinder or promote autonomy. Many positive outcomes are gained from small-scale, domestic-style environments. Features such as cosy lighting, non-institutional floor finishing, carefully chosen personal furniture and creative fittings along with assistive technology can promote independence and reflect an unobtrusive regard for safety.
Ironically, the more disabled a person becomes the more significant the environment is for that person. And the need to belong and feel “at home” is magnified for an older person often facing increasing dependencies, disruptions and disappointments. Good environmental design is as vital to an older person’s care as staffing and the ethos of care.
Here in Ireland, we need a range of different designs for the diversity of older Irish people who in the future will require support outside their home. Increasingly, the physical environment, its size, scale and surroundings must become a much greater priority during the planning stages of all Irish long-term care facilities. This will require a change in mindset and ideology, significant economic incentives and, like in other countries, a major reform in healthcare policy.