Supported living comes under a variety of names so that, with small variations, schemes with titles like sheltered or very sheltered housing, assisted living, close care, housing with care, and extra care housing provide a fairly similar range of services. All of them are already or potentially competitors for at least a slice of residential care’s client base. Jef Smith explains.
Where does the concept of residential care as embodied in contemporary residential and nursing homes really come from? It is to British history that we need to look to understand why we currently interpret care in homes as we do. One of the major formative influences was the workhouse, the central institution of the dreaded Poor Law.
The English Poor Laws, a system of the state’s dealing with people regarded as needy through poverty, age, disability or — as they saw it — moral depravity, derived from late medieval practice, were codified in the 16th century, and were finally abolished only in 1948.
The other major influence on the way we conceive of homes has been the hospital. At first sight, hospitals look more benign than workhouses, but their influence on physical design has certainly been unhelpful to residential care. The nightingale ward, where privacy was sacrificed for ease of staff surveillance, has only gradually been phased out of the NHS; in social care we like to think we have more concern for human values, but within living memory there were homes where residents slept in dormitories or at least shared rooms with strangers, had little personal space, were obliged to use communal bathrooms and toilets without locks, and led lives in which independence and dignity were scarcely recognised.
There is, however, a third strand to residential care’s history; welfare and health have played out their parts in forming care, but housing also had a role. Here, surprising for some, the model is more positive. The housing consumer is viewed not as needy, sick, or pitiful, but simply as making a claim on the universal human requirement for shelter. The assessment of what is being asked for is less judgmental in tone, and the relationship between client and provider is more one of contractual partners reaching a mutually satisfactory agreement.
What is Supported Living?
It is this sort of imagery which forms the framework for supported living, a type of provision which has grown in volume over recent decades and which could conceivably eventually replace most of what we currently think of as residential care.
What all the types of supported living arrangements have in common is that their central objective is the provision of accommodation; that means they have a housing perspective rather than regarding their clients’ need for support as a defining characteristic. It follows that the unit each person occupies has its own front door; is not that the first requirement most of us would expect when we move into a house or flat of our own? Privacy therefore is a presumption not, as it often feels in residential home settings, a right to be painfully won back from a regime which assumes communality as its starting point.
A supported living building, which characteristically includes several separate units of occupation, may be purpose-built or may have been adapted for its current purpose. It may in fact comprise a series of buildings, linked perhaps to form a campus or a village or something recognisable as a community. The terms used derive from a range of settlement types, but the principle is always of a grouping of clearly independent units, with a shared purpose. This contrasts with the care home, a single institution, parts of which, the residents’ bedrooms, are regarded as at best semi-private.
This is not to say that there is no communal space in a supported living environment. Practice varies, but characteristically there will be sitting and entertainment areas where residents meet each other, and cafes or restaurants where they can take some or all meals according to individual arrangements. Again, the contrast with residential homes is encapsulated in the presumption that people spend most of their disposable time in their own units — pretty much like the rest of us — and use the communal areas only when they specifically want them — to have a meal, to meet someone by arrangement, or simply to be in an environment also casually frequented by others.
Residential care staff are getting better at acknowledging that a proportion of their residents may like to spend time and even take meals in their own rooms, but for some homes ending the practice of more or less automatically herding residents into lounges and dining rooms at set hours has been a long and painful process. For this change in attitude to occur of course individual rooms have had to become larger, be appropriately furnished, and be comfortable enough in the daytime to be acceptable for a wider range of uses than just for sleeping in. Homes are getting there but it is taking time.
Another element which has depended on both shifts in relationships and improvements to the physical layout of homes has been the growth of en suite facilities. Having access to your own toilet, washing and showering facilities has immensely added to the dignity of living in a home, even if specialist bathing facilities for people with severe disabilities still have to be shared. Some establishments cannot realistically be converted to incorporate all of these improvements and, less forgivably, some management are still to be persuaded of the overwhelming importance of respect for privacy in modern care. Supported living of course does not have to make this leap; in fact, its automatic incorporation of private bathrooms into residents’ accommodation laid out a path that residential homes have followed, in some instances reluctantly.
There is one more advantage sheltered housing schemes enjoy, which is the choice they offer between tenancies and outright purchase. Many older people needing care, whether individuals or couples, do not want to give up their place in the property market. To be able to buy a unit in an extra care housing block or campus, usually on a leasehold basis, represents a trading up in support and a trading down in the size of their investment, a double attraction when compared with the enforced decision to sell whatever they own to enter a home. Alternatively, people who prefer an arrangement which avoids their tying up capital have the option of entering an agreement providing much firmer tenancy rights than are generally available under notoriously variable residential home contracts.
Personal Care and Support
At this point of the discussion advocates of traditional residential care tend to point out that only a home can guarantee the level of care which many of today’s highly vulnerable older people need. Supported housing’s answer to this objection has been to make domiciliary care readily available, provided not by the company controlling the accommodation but by home care agencies operating independently by arrangement with individual residents. The number and frequency of hours of service can be adjusted according to each person’s needs and varied over time if and when the need changes.
There is of course neither the watchful 24-hour cover which some homes provide nor constant daytime supervision, but alarm systems, telemonitoring and the like, it is argued, offer a realistic alternative, with immeasurable gains in privacy and independence. Though housing schemes are not Care Quality Commission regulated, the home care providers do of course have to be registered, that inspection providing some assurance of quality.
It is unlikely that extra care housing or equivalent schemes will altogether replace traditional residential care homes, and homes with nursing in particular can make a good case for continuing to look after the most sickly and dependent of older people, particularly perhaps those in the late stages of dementia. Nevertheless, supported living clearly has the capacity to eat into what, with the sharp decline in local authorities’ funding, has become a shrinking market. Some providers, originating either in care or housing, have spotted the trend and cannily now have a foot in both camps. Sheltered and supported housing has led the way in enhancing independence, and some homes, even within their institutional constraints, have taken the message and adjusted their plan and practice accordingly.
Technological advances, demography, rising user expectations and economics, therefore, are conspiring to make supported living a certain area for growth. The same cannot be said for residential care, and certainly not if it fails to achieve radical change.
Last reviewed 3 May 2016