Earlier this year the University of Bedfordshire and Care Quality Commission (CQC) published a report on alcohol policy and practice in care homes. Funded by the NIHR School for Social Care Research (NIHR SSCR), it was the first study of its kind in England and the first internationally to include input from residents, families, care staff and inspectors.
Based on interviews with more than 220 people, the consensus was that while people should be allowed to drink in care homes, there was also an ‘urgent need to improve the quality of care in relation to alcohol, particularly for people with alcohol dependence, including inreach from community alcohol services’.
Alcohol was considered to be a source of pleasure for people who may not have many others, and who may be struggling with ‘deteriorating physical function and cognition’. It helped to foster a sense of community and allowed people to maintain some continuity with their life before entering the care home, the report says. Policies varied across the care homes surveyed, however, with some imposing a blanket ban and others only giving the ‘appearance’ of allowing drinking – one inspector described a facility with its own ‘pub’, complete with bar stools, Velcro dart board and fake fire. The alcohol in the pub’s optics was also fake, however – coloured water that was ‘just for show’. At the other end of the spectrum was a care home with an open bar, and one with an unattended drinks trolley accessed by someone in recovery who was then admitted to hospital with alcohol poisoning.
Safety concerns
In some premises the residents’ own alcohol was taken away to be served by staff, with its use ‘routinely monitored and recorded,’ says the report. While policies like this were the result of concerns over health and safety – the potential effects of combining alcohol with medications or liability for negligence – they also ‘may conflict with a resident’s right to self-determination, privacy and to have care tailored to their preferences’, it states.
‘We were originally approached by CQC who said they were concerned that there was less than good practice around alcohol in care homes,’ says director of the substance misuse and ageing research team (SMART) at the University of Bedfordshire’s Tilda Goldberg Centre for Social Work and Social Care, Sarah Wadd. ‘Most care staff were doing what they thought was best, and even those who were really prohibitive were doing it for the right reasons. They’d just gone a little bit too far.’
Some homes prohibited people with limited mental capacity or a diagnosis of dementia from drinking, while others admitted residents without realising they were alcohol-dependent – with the attendant risks of withdrawal. Others simply refused to admit – or evicted – people with an alcohol dependency, with managers saying that caring for residents with alcohol issues was a ‘huge workload’ or ‘legal nightmare’.
It’s hard to gauge exactly how many people are being evicted for alcohol issues, Wadd explains. ‘We looked at CQC data on evictions, and it didn’t show up too much in there. But when we interviewed staff they often talked about people being evicted, so the two didn’t match up. The problem is that if people are evicted it’s really hard to get another care home to take them, so they end up getting stuck, and it’s obviously very traumatic to be evicted or moved from one home to another.
‘Most care home managers said they wouldn’t accept people who were dependent on alcohol, and in many cases that was right – for the other residents, staff and the individuals who are alcohol-dependent,’ she continues. ‘Most care homes are caring for very frail and vulnerable people. Often they have dementia, and would get distressed if they saw someone intoxicated because they just couldn’t make sense of that behaviour. The staff often didn’t have sufficient training, so it really isn’t great for people with complex needs related to their substance dependence to be in one of these mainstream care homes.’
Harm Reduction Model
While some homes tried to care for people with alcohol dependence using a harm reduction model – without requiring them to stop drinking as a precondition of care – other issues alongside lack of training are that CQC doesn’t include management of alcohol as a mandatory part of its inspections, and residents, families and staff ‘don’t always know what good care in relation to alcohol should look like in this setting’, the document says. It also points out the significant gap in specialist residential care places for people with alcohol dependence.
Aspinden in South-East London is one of the UK’s few ‘wet’ care homes. ‘They have a lot of these in other countries – particularly the Nordic countries – but in the UK there are very, very few,’ says Wadd. ‘One of the problems with not having enough specialist homes is that often people will get stuck in either hospital or a homeless hostel because they can’t find a home that will accept them.’ Families may also minimise their relatives’ use, she points out. ‘They won’t tell the care home that they’re drinking so much because they’re desperate to get them into a home, and then the person experiences withdrawal because the staff didn’t know they were physically dependent. We also saw cases of people being coerced into stopping drinking when they weren’t ready. No one else would take them and they couldn’t live at home anymore, so they had no choice, and that’s really a breach of their rights.’
When it comes to mainstream homes, if someone ‘doesn’t want to discuss or change their alcohol use, you should not try to force the issue,’ says guidance for care staff produced by the study’s authors. With the resident’s permission, however, staff can ask someone from the local alcohol service to visit, carry out an assessment, and provide talking therapy or arrange a detox if necessary, it says, adding that it’s also important that anyone who has stopped drinking is fully supported.
Stronger Links
What mainstream care homes should be doing is recording alcohol preferences in residents’ care plans along with a risk assessment, the guidance states. So should they also be fostering stronger links with their local alcohol services?
‘Yes, and to a certain that really wasn’t happening,’ says Wadd. ‘First, many of the people weren’t ready to reduce or stop drinking, and alcohol services often don’t want to work with a group who aren’t ready to change. Also a lot of the people we’re talking about had alcohol-related brain damage or other cognitive impairment, as is very common in older people, and drug and alcohol services are really not very good at working with that group yet – some are, but most aren’t.’
While silo working has long been an issue in both treatment services and the care sector, it doesn’t need to be, she states. ‘We know that people can work with those who have both cognitive impairment and alcohol dependence. It takes a little bit of skill, but sometimes it seems people are being rejected from services when there’s no reason why people shouldn’t be able to work with both. We can never remove risks altogether, but what we would say is that they can be minimised. It takes a specific skill set to work with this population, and we did detect some stigma among staff who hadn’t necessarily chosen to work with this group. Some people with alcohol dependence can be cared for perfectly well within a mainstream care home, but for others with complex needs there need to be more of these specialist homes.’
The university has now applied for funding to look at the issues in more depth – as well as talking to people with alcohol dependence about their experience of being cared for in mainstream homes, it will also include drug use as the cohort of people with substance problems grows ever-older. ‘People in care homes have told us this is increasingly an issue,’ she says. ‘And it’s obviously going to become more and more of one.’ DDN
Alcohol management in care homes: A good practice guide for care staff at https://www.beds.ac.uk/media/q1obc4nf/care-home-guide-for-staff-final.pdf
ROBERT’S STORY
Robert is a resident at Aspinden Care Home, a CQC-registered facility in South East London. Operated by the Social Interest Group (SIG), its staff are fully trained to look after people with long-term alcohol issues.
Robert came to Aspinden in April 2021 after he was evicted from a supported living service. They were unable to manage his high alcohol intake, erratic and anti-social behaviour and deteriorating mental health. He presented with very challenging behaviours and non-engagement for the first few months. However through our harm minimisation model and our caring, supportive and stigma-free environment, Robert was able to develop trust in our service and staff. We were able to work closely in partnership with our local GP, on-site nurses, and community mental health teams to stabilise Robert. He has an agreed daily plan for his alcohol, which he adheres to, and he participates in many of the home’s activities, keeps his environment clean and is independent with his personal care. There have been no signs of him going into crisis or evidence of any anti-social behaviours and he is a joy to work with.
At Aspinden our client group tends to be older adults who’ve been known to social services for many years and ‘bounced around’ due to their complex health conditions and support needs. This is a barrier we have to overcome with most new residents as they tend to have lost faith and trust in professionals. Our aim is to be the long-term, stable environment that they’ve never had but ultimately all deserve.
Aspinden Care Home: socialinterestgroup.org.uk/our-services/aspinden-care-home/