Thinking about supported living, residential care, and nursing care

What this means 

Home isn’t just a private dwelling. Home can be in a variety of supported living or different types of care homes. How these are designed and run is likely to benefit from co-production and co-design – and will make the transition of moving into, and experience of living in, supported living or care placements a more positive experience. 

The research 

Architecture, interior design, objects, sense of space, and opportunities for both privacy and sociability, all impact how people living in residential and nursing care homes feel about their home (Johansson et al., 2022; Chaudrhury et al., 2018; Fleming et al., 2016; Kenkmann et al., 2017). 

There is usually, particularly in modern residential and nursing care homes, a conscious effort to avoid features of what Goffman (1990) called the ‘total institution’. These are features like locked doors, enclosed buildings, long internal corridors, and a spatial feeling of being cut off (or hidden from) wider society. However, the mere absence of these features doesn’t immediately make residential or nursing care ‘homely’ – and there is no clear definition in the research as to what makes somewhere feel like a home (Marquardt et al., 2014). It’s important to guard against stereotypical ideas of what homeliness is, and not only think about physical features (Johansson et al., 2022; Rijnaard et al., 2016). 

When thinking about communal areas in particular, Johansson et al. (2022) offered four key qualities that support a feeling of home and belonging:  

1. A cornerstone for stability and everydayness
   This could represent everything from pleasant cooking smells, to fresh flowers, to coffee, cake and fruit always being available for people to help themselves to. It expresses care and safety, but also participation and agency.
   
   
2. ‘The beating heart’  
   This means at least one key place where all residents feel especially proud of their home, and is often an easily-accessible space where visitors join in with activities. In some residential and nursing homes, the ‘beating heart’ can also encompass, or focus on, shared aspects of the religious or cultural identity of those who live there.
   
   
3. Spatial dynamics 
   This is about how responsive a space can be – providing scope for variations of activity, different group sizes, and changes in mood. For instance, big spaces can still have ‘inviting corners’, where the mood and décor is subtly different. This is not only about physical space – it’s also about staff in the homes being sensitive to changes of mood, and being able to support people to move between different areas.
   
   
4. Magnetic places 
   In the research, there were certain spots where people spontaneously gathered, and were not dependent on staff interaction. These might be, for example, around entrances, near post-boxes, or beside a window with an interesting view. 

What this research also suggests is that understanding what people value about a residential or nursing care home can be embedded through co-design and ongoing co-production of environments. If people are somewhere they feel that they, or their peers, have a real say in how it looks, works, and feels, this is more likely to feel like a place they call home. King et al. (2021) suggest local co-production forums involving people in the design, planning, commissioning and delivery of residential and nursing care. 

While research into co-production in residential and nursing care is limited, and has been slower to develop than in other aspects of health and social care (Hallam-Bowles et al., 2022), there are some indicators of what co-production needs to be successful in this context. These include the continual support of staff and managers, flexibility, open-mindedness, and early engagement of people who live there (Hallam-Bowles et al., 2022). This chimes with what is known about co-production in a wider context, which stresses that co-production initiatives should engage with what’s already in place, while being clear on the need for co-production, and realistic about the time and resources it may take (Sutton, 2020). 

There are many more options than residential or nursing care for people who require support, although not as many as are needed (Burgess et al., 2021). Co-housing (communities that combine private and shared space, and which are created and run by their residents), offer scope for benefits from informal support and greater independence. However, research suggests that they currently require significant personal resources – in terms of time, expertise, networks and capital (Burgess et al., 2021). 

It's also important to remember the part that identity and culture can play in choice, or lack of choice, in supported living options. For example, older LGBTQ+ people may feel vulnerable to homophobia or transphobia when moving into supported living or residential care, have their identity ignored, or feel expected to ‘come out’ all over again (Burgess et al., 2021; Hafford-Letchford et al., 2018). (There’s more information on supporting intimacy in later life, including for older people who identify as LGBTQ+, in the Research in Practice briefing on this topic).

The experiences of Black and ethnically minoritised older and disabled people in supported living are under-researched in the UK. However, one older study flags the need to guard against the assumption that, in some communities, families are more likely to provide care. Looking at the evidence suggesting an under-representation of Black and ethnically minoritised older people in care homes, the researchers did not find that this was because more families took care of their older relatives; instead, Black and ethnically minoritised older people ‘…did not regard care homes as accessible, due to differences in language, culture and diet. In addition, older people were doubtful about the ability of staff to support their cultural or religious practices’ (Badger et al., 2009, p.3). 

What you can do 

If you are a commissioner: Make co-production and co-design an important element in your commissioning choices for residential and nursing care. Using Co-production for care homes: A guide to co-production and how it can benefit your care home, from Alive, open up conversations with providers about whether they currently co-produce any aspect of the running of the communal spaces, and look for ways to increase this. 

Co-produce commissioning decisions on residential and nursing care, and supported living options. You can find more information on the principles on this, alongside practical advice, within Think Local Act Personal’s Co-producing commissioning and commissioning co-production and the New Economics Foundation’s Commissioning for outcomes and co-production: A practical guide for local authorities.  

Remain open-minded towards alternative living spaces, and try to see a spectrum of supported living rather than a dichotomy between living independently and ‘going into’ residential or nursing care. 

Consider, when commissioning decisions, how issues of equity, diversity, and inclusion are present in all supported living options. 

If you are in direct practice: When working with people in residential or nursing care, or supported living, you may consider using the four qualities of ‘homeliness’ in residential care to explore whether they feel at home. For instance:  

• Do people feel safe and cared for, alongside feeling they can be themselves - including expressing their different identities? 
• Is there at least one ‘beating heart’, where they enjoy spending time, and can feel proud of the place they call home? 
• Are there a variety of spaces for different moods and activities, and are staff sensitive to this? 
• Where are the ‘magnetic places’, where people naturally congregate? 

In addition, how can you support their personal space looking the way they would like it to – decorating and adorning it in the way they choose, with their own possessions and pictures?  

If there are any areas for improvement, you might consider talking to your manager about how the local authority can work with the home to address these issues. 

Further information 

Read  

Alive, a UK charity that represents the voice of older people in residential and nursing care, has published Co-production for care homes: A guide to co-production and how it can benefit your care home. Although primarily aimed at care home providers, it also contains important messages for commissioners and can open up conversations between commissioners and providers.  

Listen  

Research in Practice has a podcast, Ageing well: Housing options and alternative modes for living for later life - Co-housing that explores innovative and under-used models of housing. 

Connect

Stonewall Housing provides help and advice for older LGBTQ+ people on housing options in later life.