A positive choice: choosing a home

The right to choice

When the social work department agrees that long-stay care is appropriate, they will then decide on the amount of money they are willing to pay for a place in a home. Each local authority has a maximum amount it normally pays, although in some cases where the person has special needs (for example, to be near relatives or cultural needs) you could ask for a higher amount, and if necessary use the complaints procedure to argue for it to be paid.

They should offer the person a place in a suitable home. However, there is often a waiting list for places in homes and it may be several months before they are able to offer a place. Or they may ask you to choose from a list of suitable homes, because you know the person and his or her preferences best. The social work department should help you and the person with dementia with the decision.

Whether or not you want to select a home yourself, it is a good idea for you, and if possible the person you care for, to visit a few homes. This will give you an idea of what facilities are available. If the local authority then suggests a home, you will have a better idea if you like it. You may then feel less worried afterwards about having made the right decision. See below for what to look for when you visit a home.

Don't feel pressurised into accepting the first place offered by the local authority. You have the right to wait for another place or to suggest a home of your own choice. This can be anywhere in the UK. The council must arrange a place there, provided:

• it is suitable for the assessed needs of the person you care for
• a place is available
• the home is willing to deal with the local authority on the authority’s terms and conditions
• it does not cost more than the authority would normally pay.

Involving an independent advocate, who will represent the wishes of the person with dementia without being emotionally involved, can be helpful in choosing a home.

‘Topping up’ the fees

If you choose a home that costs more than the local authority would usually pay, they must still arrange a place there if someone is willing and able to pay the difference. The local authority is responsible for ensuring that any arrangement to pay a top up fee is sustainable; the person paying the extra will need to show that he or she can keep up the payments for as long as the person is in the home. If he or she stops paying, the local authority may well not pay the extra and the person would have to move.

The person going into the home could pay the extra him or herself only if he or she is getting free personal or nursing care payments but not other help towards the fees, or if the council agrees to a deferred payment (see section headed "The house" in part two).

If you disagree

You will probably reach an agreement with the social worker about the way ahead. If not, or if you are unhappy about any part of the assessment, you have the right to complain. Each local authority has a complaints procedure. Ring up the social work department for a copy of the procedure if you want to complain; it will tell you what steps to take.

Information about homes

All care homes in Scotland are registered with the Care Commission (see Further information part five). The Dementia Helpline can send you a list of care homes which cater for people with dementia in any area of the UK, or you can get a list from the local Care Commission office.

You are unlikely to get opinions about specific homes from any of the above sources. It can be helpful if you know someone who has a relative in care and knows about homes in your area. He or she may be able to advise you based on personal experience. Ask at your carers' support group. The Dementia Helpline can tell you how to contact groups in your area. But remember, these are only individual opinions.

Once you have a list of homes, make a shortlist and ask for brochures and information about vacancies. Make sure that you state the level and kind of care that the person you care for will need. Tell them that the person has dementia.

Try to visit as many homes as possible before making a decision, so that you can compare the facilities and care being offered. Some brochures may give a slightly misleading impression. So when you get there spend time looking around and talking to staff and residents. Don't be afraid to ask questions and keep your eyes and ears open. It will help if you have a checklist of things to look out for and to ask about. A trial stay can be helpful if this is possible.

Standards and inspection

All care homes are inspected by the Care Commission twice a year, including an unannounced visit. Ask to see the inspection reports for the homes you are interested in. You can get these from the homes themselves, the Care Commission (www.carecommission.com/), or in some areas they are available in public libraries. The Care Commission website will also have inspection reports for selected homes (see Further information part five).

All care homes have to meet the National Care Standards for care homes for older people. These have been produced by the government to allow people to see what standards people who live in care homes should be able to expect. The Care Commission take these standards into account when regulating services. You can get a copy of the National Care Standards for care homes for older people free from the Scottish Executive website (www.scotland.gov.uk/Topics/Health/care/17652/9328) or from Blackwell’s Bookshop, 53 South Bridge, Edinburgh EH1 1YS (0131 622 8283). The Standards are also available through your public library.

You can get a copy of the National Care Standards for care homes for older people free from the Care Commission website (www.carecommission.com/) or download them in pdf format by following the links from the Scottish Executive website. Alternatively, they may be bought for £5 from The Stationery Office Bookshop, 71 Lothian Road, Edinburgh, EH3 9AZ (0870 606 5566). The Standards are also available through your library.

People under 65

Because there are fewer people under 65 with dementia, it can be hard to find a suitable home. While some people will be happy in a home where most residents are a lot older, others may feel out of place, and activities may be unsuitable.

People arranging care for people with dementia under 65 often find that they are forced to compromise – perhaps the home isn’t quite right but is near enough for friends and family to visit often. Or perhaps there is a suitable place but it’s further away and harder to visit.

There is no easy solution to this, but it may be helpful, if possible, to organise trial stays before a permanent move, to see what works best. It may be possible to agree special arrangements with the social work department, such as someone to take the person out. If there is an activities co-ordinator at a home, he or she may be able to arrange activities suited to the individual; try to find out from the home how they plan an individual’s care.

Couples

Sometimes couples will want to move into a care home together. In order to get help with paying the fees, each of the couple must be assessed as needing to be in the care home. If this is the case, the couple’s income and capital would be assessed separately by the local authority as though they were two single people (even though they might be sharing a room). So if the couple has less than £20,000 each in capital, they could qualify for help with the fees. In contrast, in some cases the Department for Work and Pensions (DWP) assesses couples together and so they may qualify for less benefit. If this happens, seek advice, as most couples should be treated as two individuals by the DWP even if they share a room.

What to look for

Following below are some suggestions for your checklist. Don't worry if you can't get answers to all of these questions. They are only a guideline to give you an idea of what to look out for. Some of them may not be important to you.

You may like to photocopy the checklist to take to different homes. You can tick the boxes, give the home marks out of five for each item or tick items when you have found out the information you need. This will give you a way of comparing different homes.

Once you have found somewhere you think is suitable then it is a good idea to visit it again with the person you care for so that you can see how he or she reacts and how he or she might settle in. Perhaps you could also bring a supportive friend or relative for another opinion.

It’s important to find a home that is as suitable as you can because, if possible, the person with dementia should not have to move again. A second move can be very difficult for everyone concerned. Sometimes a change in circumstances will mean there is no other option but, where possible, the person should be able to expect to stay in the home for the rest of his or her life.

Choosing a home – checklist

Location and setting

• Is the home convenient to visit?
• If the person enjoys going out, are there shops, a park or a pub nearby?
• If the person is religious, is there a suitable place of worship nearby?
• Is there a view from the lounge or dining room when residents are sitting? If so, can the residents see trees, plants and sky; or people, traffic and activities? Some people might prefer one type of view over another.
• Are there any trees close to the windows where residents can watch birds or even squirrels?
• Are there any windows open when you visit? Can you smell or feel fresh air in the public rooms?

Outdoor space

• Is there a safe attractive outdoor area? Ask if it is regularly used.
• Is the door kept locked or can residents easily go out for fresh air?
• Is the setting pleasant, with hanging baskets and a variety of colourful and scented plants? Is there a greenhouse or potting shed that residents can use to grow their own plants and seedlings?
• Is there level access (no steps) to an outside sitting area? Is there outdoor furniture such as tables, chairs and benches for residents to use. Is it sturdy, clean and well maintained?
• Is there any equipment for outdoor activities like bowls?

First impressions

• What size is the home? Many people feel that a smaller home is better for people with dementia. However some larger homes have smaller dementia units.
• Is the atmosphere friendly, welcoming and homely?
• What is the lighting like? Dim light can make it harder to see and too much glare from waxed floors or windows can add to confusion.
• Is the home clean without being too tidy and is it pleasantly furnished and decorated?
• Do you notice any unpleasant smells?

Access

• Are the corridors wide enough for a walking frame or wheelchair?
• Are baths and toilets suitably adapted?
• Is there a ramp or lift?

Bedrooms and personal possessions

• Can the person have a single room? This is important in retaining dignity and privacy.
• Can residents bring some of their own furniture and possessions? This can be very important in helping the person to settle in and feel at home.
• Is there room for an armchair in the room?
• Is there enough storage space?
• Can residents go to their room when they want to be alone and do staff respect the need for privacy and always knock on bedroom doors?
• Does the laundry system make sure that clothes don't get lost or returned to the wrong person? How does the home make sure no-one ends up wearing someone else’s clothes?
• Are there ensuite facilities?
• Can the bed be placed so that the person can get out on his or her usual side?
• Is there natural light or will the light always have to be on?
• Is there a view?
• Is there noise or disturbance from other nearby rooms?

Money

• How does the home look after residents' personal money?
• Is cash kept in a secure place?
• Are clear accounts kept?
• How is residents’ money spent?
• Are residents helped to buy small items? It can be important for people to have some money to hand to keep some sense of control.

Toilets and continence

• Are there enough toilets in easy reach of the bedroom and living area?
• Are they large enough for a member of staff to help a resident and keep the door closed at the same time?
• Do staff work out an individual toilet programmme for each of the residents based on his or her needs or do they depend on batch toileting and the use of incontinence pads and catheters?
• Are staff tactful about incontinence? If you notice unpleasant smells or residents with skin sores, this can be an indication that something is wrong.

Living areas

• Is there more than one room where residents can sit?
• Is the television always on or are there quiet areas too? People with dementia can find constant background noise confusing.
• Is there a designated smoking room for residents?
• Are chairs arranged to encourage talking and activity or are they just placed around the room?
• Are there any live or artificial plants or flowers indoors? Do the live plants look healthy and watered?

Meals

• Does the home cater for special diets and do they take into account residents' likes and dislikes?
• Is there any choice at meal times?
• Can residents choose to eat at different times or in their rooms?
• Are there any catering facilities for the residents where they or their visitors can make a snack or a hot drink?
• Do residents enjoy their meals?

Health

• What happens if the person is unwell?
• Which doctor will the person see?
• What arrangements are made about medication?
• What arrangements are made about regular dental care?
• What arrangements are there for eye tests and hearing tests to ensure that spectacles and hearing aids are to the correct prescription?
• Do staff try to ensure residents use their spectacles and hearing aids?

Visitors

• Are visitors welcome at any time?
• Can they join the resident for a meal or make snacks?
• Are children welcome in the home?
• Are visitors able to take the resident out if they want to?
• Are there any regulations on the number of visitors?
• Can animals/pets come to visit residents? Does the home or unit allow residents to keep pets or are there any resident pets owned by the home?

Transfers

• What will happen if the person’s condition worsens?
• Is the home able to cope with more severe levels of dementia or will the person have to move if he or she develops problems such as incontinence or challenging behaviour? Further moves may be unsettling for someone with dementia.

Residents

• What type of residents does the home take? The type of company around the person you care for can make a difference. If the other residents are much more advanced in dementia, then you may find that the person goes downhill quickly. Equally, if there are few other people with dementia the person may feel excluded or unwelcome. The mix of residents may also affect the amount of time and attention they get from the staff.
• Do the residents seem to be involved in activities and chatting or are they just sitting around doing nothing?
• Do they seem alert and interested?
• Are they nicely dressed and groomed?
• Do they seem content?
• Can some of the residents tell you what they think of the home and staff?
• Do residents seem panicky, in pain or vacant?

Activities

• Are activities arranged for each day or are residents just left in front of the television?
• Are there games and activities designed for people with dementia?
• Are outings and outdoor activities planned?
• Are birthdays and special events celebrated?
• Do people come in from the community to visit, to help with activities or entertain?
• Are residents encouraged to get involved with day-to-day life in the home, for example, with household chores or meal preparation?
• Are residents encouraged to do as much for themselves as they can?
• Does the level of activity appear to be too stimulating or too boring for your family member?
• Would he or she enjoy the activities offered?
• Is there familiar old music to listen to?
• Is there a record of residents’ meetings?
• Is there a noticeboard for events? Try to see the programme of events for the last month too, to see how much variety there is.

Cultural

• If the person you care for comes from a different background or culture to most of the other residents, will his or her particular needs be catered for in an understanding and sensitive manner?
• Do staff seem interested in and respectful of differences such as diet, religious observance, hygiene practices, clothing and ways of relating to other people?

Staff

• How many staff are there compared to the number of residents?
• Are they full-time or part-time?
• How often does the home use agency staff? A lot of new faces can be difficult for residents, and agency staff will not get to know them. Sometimes agency staff may have less training.
• Is there much staff turnover? Ask a few individuals how long they have been there and how happy they are in their jobs.
• Do staff have experience of dementia?
• What opportunities do they get for training?
• Are staff qualified or are they untrained care assistants?
• How many staff are on duty during the day and at night?
• Do the staff seem friendly and caring?
• How do staff respond to residents? Do they treat them with dignity, humour and affection or do they talk down to them, bully or ignore them?
• Do staff treat residents as individuals and know about their backgrounds and interests?
• Do they seem to enjoy their work and are they warm and approachable?
• Are they willing to tell you what they think of the home?

Management

• Does the manager have a special knowledge of dementia?
• Does the manager own the home or is he or she appointed?
• If the manager is appointed, what input does the owner have in the day-to-day running of the home?
• Does the manager seem over-concerned with rules and regulations or does he or she treat the home as belonging to the residents?
• Does the manager seem tolerant and caring as well as efficient and capable and is he or she friendly and considerate to staff and residents?
• Does the manager openly answer your questions and does he or she understand your worries?
• Can he or she deal with special problems such as unpredictable behaviour in sympathetic way?
• Is he or she interested in the residents as individuals and does he or she try to meet their particular needs?
• Does the home have a carers' group or regular relatives' meeting with senior staff? This is a sign that the management is prepared to listen to suggestions or complaints.

Admission

• What kind of admissions procedure does a home carry out before admitting residents?
• Do they offer to compile a detailed list of the person’s habits and preferences or will you have to insist on this yourself? (You may of course prefer to do it yourself.)
• Will there be a member of staff who is particularly responsible for the person?
• Does each resident have a personal care plan? Each resident should have their care plan reviewed annually and it is good practice to review it 4-6 weeks after admission.
• How does the home welcome new residents and help them settle in?
• Do you think that you will be able to talk to staff about your own feelings and anxieties?
• Does the home offer day care or temporary stays so that the person can get used to the home before moving in?
• Is there a waiting list?
• Is there a review of the placement after the first few weeks so that everyone can discuss how the person with dementia has settled in, what has been achieved and what problems have arisen?
• Does the home actively encourage you to be involved?

The contract with the home

There are three kinds of contract that may be made with the care home:

1. For people not eligible for or not claiming free personal or nursing care – a ‘Route 1’ contract arranged privately and independently between the care home and the resident.
2. For people getting free personal or nursing care payments – a ‘Route 2’ contract, where both the council and the resident have their separate contracts with the home. The local authority pays the care home directly for the free personal or nursing care while the resident pays directly for the rest, covering the accommodation and living costs. This route may be chosen because the resident (or his or her representative) wants to negotiate and pay for a place in a particular care home or wants to specify a particular type of care without involving the local authority in their private agreement.
3. Alternatively, for people getting free personal or nursing care payments – a ‘Route 3’ contract, where the council manages the contractual arrangements with the home on behalf of the resident. The council also contracts with the resident to reclaim the part of the fees the resident is due to pay. It is also possible, if all three parties agree, for the person to pay the home directly.

Checking the contract

If you are setting up a Route 1 or Route 2 contract it is important to read it through and check the terms and conditions before you sign it. You may wish to take legal advice first. If you are arranging a care home place on behalf of someone with dementia, you need to have the appropriate legal authority to be able to sign on his or her behalf (see Legal arrangements section below).

Care and services

The contract should include information about the care and services the person with dementia will receive, including arrangements for meals, drinks and laundry services. It should also state how the home will meet any special requirements such as dietary and spiritual needs. Does it say how any changes to the person’s care needs will be managed? Can the home make any significant changes to the service it provides without consultation?

Fees and payments

You should make sure that the contract is clear about the fees that have to be paid, how they are calculated, how often they should be paid and who is responsible for paying them. Are there any ‘extras’ to be paid for? As fees are likely to rise over time, how much notice will you get of an increase? What happens if the person has to go into hospital or dies – how long would fees be payable? How much notice does the home require if a resident moves out?

Accommodation

The contract should also give information about the room the person will occupy – can the care home move the person to a different room without consulting you, for example?

Insurance and liability

The contract should state how residents’ money, valuables or other property will be kept safely and also who is responsible for insuring any property, particularly if the resident has brought any possessions from home such as furniture or a TV. You should check to see what the contract says about liability insurance and whether the home excludes itself from responsibility for damage to a resident’s property or injury to any resident.

Even if the council arranges the contract with the care home, you should still ask to see it to make sure it includes any special requirements set out in the care plan produced as a result of the person’s community care assessment. You should also check if there are any extra charges which would not be covered by the contract such as the cost of hairdressing or outings.

Legal arrangements

Very often when someone with dementia is going into a care home, he or she is no longer fully mentally capable of making decisions, providing financial information or signing contracts. If someone has power of attorney for the person, he or she is legally entitled to act on the person’s behalf. There are two kinds of power of attorney in Scotland:

• continuing (also called financial) power of attorney, which gives the power to manage the person’s financial affairs, such as entering into contracts and paying bills
• welfare power of attorney, which gives the power to take welfare decisions, such as where the person should live, on his or her behalf.

Some care homes ask relatives to sign contracts, which include a clause establishing liability, as a guarantor, for the relative to pay fees in the event the person in care is unable to do so. Seek advice before signing any agreement of this kind. In some cases, relatives are asked to sign contracts even though they don’t have the legal authority to do so. If no-one has a power of attorney with the right powers, it may be necessary to apply to the court to give someone the power to take the decision on where the person should live or to sign the contract if he or she can’t. This might be an ‘intervener’, with just these powers, or a ‘guardian’, who could look after the person’s affairs long-term. You could do this yourself, or the local authority could do it – and they must do it if a guardianship or intervention is needed and no-one else is applying. See Dementia – money & legal matters – a guide for more information – you can get a copy from the Dementia Helpline, or visit the money and legal issues section of this website.

The person with dementia must always be consulted as fully as possible about what he or she wants, and his or her past wishes must also be taken into account.

Where a person has no-one else to look after his or her money, most care homes can now manage finances for their residents, usually up to £10,000. There are careful safeguards, and homes are supervised by the Care Commission