Last reviewed 23 May 2014
Asking what the ideal size is for a care home poses an impossible question, to which the only answer can be “it all depends”, says Jef Smith.
There is a clear division between those who argue that small homes are homely, intimate and the best available substitute for the supportive relationships of a natural family, and proponents of the counter case that only large establishments can offer the range of expertise and facilities that some residents need.
Clearly both types can be run profitably, the efficiencies of slim management and a shallow hierarchy sometimes compensating for the much-heralded economies of scale. However, laying aside commercial considerations and concentrating exclusively on the quality of care, what determines whether a home works better with 20 residents or 100?
To assess the case for expansiveness, I recently visited Peterborough and spent a day at Eagle Wood, a newly-opened, 105-place nursing home, or “neurological care centre” as its owners PJ Care describe it. It has attracted praise from regulators and commissioners, as well as winning many awards.
Jan Flawn, the company’s co-founder, who came to the role from a background of senior nursing posts and several years in the upper reaches of the Department of Health, still chairs its board and is a regular presence in the home, though she is progressively handing over day-to-day responsibility to her son, Neil Russell.
PJ Care operates two other, much smaller, homes in nearby Milton Keynes but it is this large complex that most successfully embodies the breadth of Flawn’s ambitious vision.
On first sight, Eagle Wood does indeed look large, leaving it open to the charge of repeating the sins of huge and long-discredited mental health institutions. The citation for its shortlisting for a recent architectural prize reads, “The apparent scale of the building has been reduced by using a subtle pallet of materials, articulated roof heights and varying window styles.”
All of that is true, but the size of the building can still be overwhelming for a first-time visitor. The expansive and expensive-looking reception area would do justice to a purpose-built general hospital. It even incorporates the remains of a Roman well found on the site, along with several showcases containing recovered ancient artefacts that were accidentally dropped, simply discarded or — the version Eagle Wood managers, for obvious reasons, prefer — offered up to the gods of healing.
The grandeur continues through a generously proportioned third-floor boardroom, a whole suite of training areas (which can be combined into a single space for major events), comfortable overnight accommodation for visiting relatives, and state-of-the-art kitchen, laundry and other services. The therapeutic facilities are on a similar scale, including a hydrotherapy pool, gym, training kitchen, and sensory stimulation room.
I became totally disoriented when being shown around the building, though in fairness the complicated route we took was not one that would ever be followed by a service user. No wonder that the local social services questioned the size of Eagle Wood when first presented with the plans. It was, in due course, won round, convinced that the variety of expertise available would offer some very damaged people services that would be difficult to provide in any environment outside a hospital.
Division into units
The chief argument Flawn, Russell and the other managers I met use to counter the accusation of intimidating scale is the home’s division into five, physically distinct units, each embodying a separate “care model” appropriate to its user group.
The units cater respectively for complex care, neurological rehabilitation, progressive neurological conditions, early-onset dementia, and young learning disability: a mixture therefore of short and long-term residents.
Each unit is physically self-contained, even to the extent of having its own secure outdoor area — those upstairs consisting of attractive balconies and an elevated enclosed courtyard. The gardens are thoughtfully adapted to the special needs of their users with, for example, a rectangular pathway for restless dementia sufferers to pace or wander safely, easy access for anyone with mobility problems, and aromatic and tactile plants throughout.
Many residents regularly visit the communal therapeutic services, conveniently on site as opposed to an ambulance or minibus drive away, but most of their time is spent within their own units, so that day-to-day living remains relatively intimate.
Within the units, in the words of the home’s brochure, “Small groups of large bedrooms open directly onto flexible, multi-purpose, communal areas, with an emphasis on light and open spaces, creating smaller living areas within a larger setting.”
The capacious individual bedrooms make for convenient delivery of complex nursing and therapeutic procedures, and also offer residents the opportunity to spread out and express themselves. Careful thought has been given to the needs of different groups; in the dementia unit, for example, there is the option for the en-suite toilet, washing and shower area to remain doorless, an arrangement some residents find reassuring.
It is the communal areas in the units that provide the most surprises, however. Each has a nursing station situated just off centre for ease of observation, but the size and irregularity of the remaining spaces mean that people can be eating a meal at one end or chatting quietly in a corner, not at all disturbed by fellow residents playing table tennis or even indulging in noisy, attention-seeking behaviour in another part of the room. Size, in short, has been elegantly domesticated.
Catering is centralised for the whole building, which means that one never has the classic homely experience of smelling onions being fried — a loss many would regard as a distinct advantage. It also provides for high standards of preparation and presentation, close attention to a variety of special diets, and valuable purchasing and production economies.
Each unit has its own mini-kitchen where main meals are served and snacks can be prepared, very much on a personal scale. The culture of modern eating and drinking, I had to remind myself, is extremely diverse; the model of a happy family regularly sitting down to dinner at a communal table is no longer one most households would recognise, so here, again, individual preference very properly trumps regimentation.
Although Flawn often refers to Eagle Wood as a family, she was nearer the mark, in my view, when she used the less conventional term “bubble” — the building as a whole acting as an outer skin containing many more, or less, autonomously functioning elements. It is a system in which, as one of the residents tellingly put it, “each segment is its own entity”. Is this also how staff view their working environment, I wondered, and how does that, in turn, reflect on the service user experience? Here, the evidence leads in slightly different directions.
Each applicant for a nursing or care post is interviewed on the unit of their choice, and the majority of his or her subsequent work time will be spent with that group. This provides the necessary continuity of a named nurse for each resident and — somewhat less easy to achieve given the disruption of shifts, holidays and turnover — a key worker system.
At times of pressure, however, units borrow staff from each other, a better option than hiring in agency workers, and anyone wishing to enhance their experience or gain promotion by switching units is facilitated to do so, if feasible. Service users therefore probably experience as high a degree of continuity of staffing care as they would in a smaller home: a critical test in my view.
Working in a very big home offers staff one other major advantage: quite sophisticated training can be provided on site. This is an attraction that both Ginny Smith, general manager for quality and compliance, and Paul Trim, who leads the care team on the complex care unit, valued highly from their different perspectives.
Smith spoke to me, for example, about the training available on end-of-life care, while Trim described the process of helping staff learn to strike the delicate balance between ensuring users’ safety and promoting independence. Both felt that Eagle Wood’s scale and reach enhanced staff job satisfaction while not in any way compromising care.
The claim PJ Care makes for Eagle Wood in its literature that “all of the downsides of traditional care homes have been removed” is surely a bit ambitious, however you define “traditional”. Nevertheless, the record is impressive. As I strolled around and ate lunch I chatted with a number of residents, their views being the ultimate test of the home’s success. None of those with whom I spoke had dementia or a severe learning disability but I am left with a slight doubt as to whether the Eagle Wood model is ideal for these clients.
The learning disability unit was a late addition to the plan, added at the specific request of local commissioners when the building was actually going up and, on reflection, there is room to doubt the wisdom of that frankly opportunistic decision. The facility is certainly popular with residents’ families, who see it as a place where the whole range of their loved one’s complex needs can be addressed, but current best practice would suggest that such clients do best in a setting that offers a rather more familial lifestyle in closer contact with the wider community.
Success for residents
There is, however, absolutely no denying Eagle Wood’s success with residents, who can look forward to a more independent future whatever the scale of their current problems.
I spoke at some length with Jules Corry, who suffered massive head and body injuries in a car accident and has been in the home since July 2013. He will be going home to his wife as soon as the necessary, and inevitably complex, domiciliary care package can be agreed with his local authority.
Jules is full of praise for Eagle Wood. For him, the scale of the complex with its wide range of therapeutic facilities is perfectly countered by the relative intimacy of the unit, and a small staff group who are closely familiar with his care plan. Having passed through several hospitals since his accident, Jules is a seasoned critic of health and social care.
“This is what rehabilitation is about,” he said: “caring and understanding the space to rebuild yourself.”