Chapter 3 – Homes for Life3.0 Homes for Life3.1 IntroductionWell-managed almshouses will provide warm, comfortable and secure homes for their residents with regular and sympathetic support from trustees, wardens/scheme managers in keeping with residents’ needs. Sadly, there may come a time when it becomes impractacle to provide the necessary level of support for residents in their present homes and a move, usually to a residential care home, is the only option. Such moves are becoming increasingly difficult to arrange with the reduction in the number of homes and the inability of social services to meet the costs of residential care. It is Government policy to encourage providers of housing to adopt the philosophy of ‘Homes for Life’ so that residents can expect to end their days in the home that they have come to love. Whilst this objective may not always be achievable, foresight and good planning by trustees will enable residents to remain longer in their homes.The provision of sheltered housing with care will certainly necessitate an upgrade of equipment and accommodation along with an infrastructure to deliver the appropriate level of services. The latter aspect will be easier in areas where the local social services department has been able to meet its commitment to Care in the Community but trustees may decide to provide their own services. In some cases the physical properties of the buildings may make them unsuitable for further care or support and the feasibility of a new development could be investigated. It is always worth exploring what can have a zero rating on VAT i.e. stair lifts and level access showers. (See Chapter 5.2 for information on the Rights of Disabled People.)Trustees have a duty of care and those wishing to extend or increase the amount of support for residents should carry out a comprehensive study of the degree of support that they would like to be able to provide to ensure that the accommodation is suitable for the purpose. This would include a review ranging from the likely limitations of an older person regarding mobility and access to the kind of help and support that they would be likely to need from another person. This person might be a member of staff, a relative, friend, or a carer from an outside body such as social services. Anyone providing personal care whether it is an organisation or an individual, should be registered with Care Quality Commission (CQC), unless it is a family member. It is probable that frail residents will need help with one or more activities such as housework, shopping, laundry, preparation of meals, dressing, washing, bathing or the use of the toilet.This chapter sets out some principles and practical ideas that will help trustees in planning their ‘Homes for Life’. Trustees should, however, have in mind the fact that the installation of equipment, unless carried out in a sensitive manner, can have the effect of making a homely dwelling appear institutional. It is likely that a purpose-designed residential or nursing care unit will incorporate most types of aid equipment. Careful thought is necessary to minimise any feeling of institutionalisation3.2 Supported HousingThere are a range of expressions and definitions that describe the welfare of older people and while the majority of almshouses provide homes for independent living, a small percentage of almshouse charities offer extra care, residential care or nursing care. Below are descriptions of different types of provision which are commonly used but even within these definitions there may be variations in different areas. When considering new developments, The Almshouse Association recommends that charities build to extra care standards. Any type of health care provision would require registration with the Care Quality Commission (CQC).3.2.1 Sheltered Housing This provides housing with privacy and independence with the reassurance that help can be summoned if required. Nevertheless, The Almshouse Association does recommend the installation of emergency care lines which gives reassurance both to residents and the charity, irrespective of whether a warden/scheme manager is employed.3.2.2 Extra CareThe provision of extra care describes the care packages offered by social services to enable people to continue living independently for as long as possible. This is clearly advantageous to both residents and the State since extra care is inevitably considerably more cost effective than residential or nursing care. Extra care accommodation will generally be self contained and comprise a separate living room, kitchen and bathroom. Each dwelling would offer fully disabled access incorporating features such as height adjustable units, two way bathroom doors, alarm cords etc. However, there is likely to be shared specialist bathing facilities that can be used by on-site or visiting health professionals. Communal areas might have colour coordinated walls and carpet to help residents orientate themselves, lifts and storage and battery charging facilities for mobility scooters. Some medium or larger almshouse charities might provide treatment rooms, small libraries, computer rooms, day/TV rooms and either a cafe or restaurant where residents can purchase meals as an alternative to cooking themselves. Almshouse charities building new almshouses would generally build to extra care standards which recognise that residents can become frail over time.Some almshouse charities offer 24-hour care provided by on-site care teams for which extra charges are raised in addition to accommodation charges. These would cover a 24-hour on call service, usually in the form of a flat weekly charge for all residents and charges for actual care provided. Almshouse charities providing on-site care teams would need to register with the Care Quality Commission. For other almshouse charities, this level of care would be offered by social services to individual residents as required. The provision of extra care is a means tested benefit, assessed by social services.3.2.3 Residential CareThis refers to 24-hour assistance for residents but excludes nursing care. The accommodation is likely to be arranged as a bedsit but may have a kitchenette to enable residents to prepare hot drinks/ light meals. The almshouse charity would provide centralised meals in a communal dining room, household cleaning, laundry and assistance with dressing and bathing.As with any almshouse charity, a guest room may be provided for families to stay overnight for occasional visits. It is probable that those living in residential care will also be in receipt of care packages provided by social services. The purpose of care packages is to prolong the time that people can live independently, an option that is likely to be favoured by all parties as it provides a better quality of life for the resident and avoids the considerable expense that is involved with residential nursing care. Even so, charges for residential care are inevitably going to be substantially higher than the traditional almshouse dwelling.3.2.4 Nursing CareAs the name implies, nursing care is the highest level of care which is given to those unable to look after themselves. In addition to the services offered in residential care, nursing care addresses all the health needs of the person. Only a small number of almshouse charities provide nursing care as staffing levels are inevitably very high and the nature of the care needed is likely to require the charities to contract in specialist health providers that are compliant with the CQC.For the majority of almshouse charities, residents requiring residential or nursing care would need to move elsewhere. Chapter 9 offers advice on the approach that almshouse charities might adopt and Standards of Almshouse Management describes the challenging process of Setting Aside an Appointment.Chapter 5 covers the benefits available to older people as they become more frail.3.3 Practical DesignWhere the construction of new accommodation or major alterations to existing buildings are being considered, trustees should ensure that their architect is adequately briefed. The Association maintains a Panel of Consultants. Panel members will prepare a feasibility study on the understanding that costs will be incorporated into a project when it is finalised, however, if the project is abandoned, they will expect to be paid for the feasibility study. This enables trustees who wish to explore the possibilities of converting, extending or modernising their almshouses to do so without committing the charity to initial expense. If the project is approved and funding can be raised, the consultant will charge agreed fees. The Association can provide trustees with contacts for almshouse charities that have undertaken a similar project and also advise on funding. Funding through the Homes and Communities Agencies (HCA) can also be explored with The Almshouse Association. In some cases The Almshouse Association is able to provide financial assistance with both upgrades and new constructions through low-cost, short-term loans.Some basic requirements for ‘Homes for Life’ are:Illuminated entrances and stairs with level access thresholdEntrances should have adequate weather protectionAdequate space for storing and charging wheelchairs/electric buggiesConvenient bed space downstairsLevel access shower or adapted bathWalls capable of taking handrails or adaptationsStairways wide enough to take a stair lift with handrails on both sidesDesign for overhead hoist/liftLow living room window sillsWide doorways and turning circles for wheelchairs in all living spaces.(Please also refer to Standards of Almshouse Management Chapter 8 and Patron’s Award Committee Guidance.)3.4 External Access and SecurityConsideration of access should include level access, gentle slopes, ramps, non-slip paths around the premises and in gardens, the width and surface of which should be suitable for a wheelchair or walking frame. Doors should be wide enough with hand-holds provided where steps leading up to them are unavoidable, ‘spy holes’ at a suitable height and a door bell. The design should ensure that the distances from car parking areas and buggy stores and residents’ front doors are manageable and level. Consult the Crime Reduction Officer to advise on security lighting and the positioning of fences and shrubs.3.5 Interior ConsiderationsHeights of work surfaces, storage cupboards, light switches, door bells, power points, cupboard handles and other equipment requiring manipulation should be determined with the likely stature, posture and joint mobility of the older person in mind. The same consideration should be applied to the position of items such as window catches. For example, a sink unit located under a kitchen window may make it impossible for an elderly resident to open the window, although there is a long-handled window opener available for this. Motorised handles are now also available from various retailers.Arthritic hands more easily operate lever taps than knob taps. Short levers are available which do not give the impression of a hospital. The same consideration applies to door handles where levers are easier to turn than knobs. Cupboard and drawer handles should be of an ‘easy-grip’ type.3.6 Level Access Showers and Electric Bath SeatsOlder people suffering decreased mobility may find a shower more suitable. It is strongly recommended level access showers are installed when building or in programmes of upgrading bathrooms. It is easier for a disabled person, even if wheelchair-bound, to enter and leave the shower but care must be taken with the design and installation to minimise the risk of slipping on a wet floor. The floor in the shower and in the surrounding area must be of British Standard non-slip specification material and the floor should slope to the drain. Another means of providing level-access is by sinking a shallow tray into the floor with a removable grid at floor level. Grab rails are essential for both baths and showers and ideally they will be positioned to meet the needs of the current occupant. A seat, fixed or fold-down and with legs, should be provided in showers.Temperature Mixing Valves (TMVs) to control water temperature are essential. They should be tamper-proof and the operating mechanisms capable of being used safely by a person with poor eyesight. Some showers are fitted with a ‘set and forget’ thermostat and flow control so that only an on-off button need be used on a daily basis. It may also be necessary to fit a pump for better shower pressure or to remove waste water. As most elderly persons wear glasses, a convenient holder should be provided for them adjacent to the shower. Independence can be maintained for longer with level access shower space. Residents should be advised to run showers for several minutes before use if the shower has not been used for five days or more. (See guidance on avoiding Legionnaire’s disease in Chapter 2.6.3.)Local Authority Disabled Facilities Grants may be available to replace a bath with a suitable shower unit. Ricability and the Disabled Living Foundation publish several useful guides to aids (see Appendix B).3.6.1 Bath OptionIn cases where it is impractical to install a level or low-entry shower, trustees may wish to consider the installation of a bath designed for independent use by residents with limited mobility. These range from walk-in units to baths with power operated seats which lower and raise the user. Although these are easy to operate, trustees should ensure that residents are properly instructed in their use and are capable of understanding the instructions.The power operated seats can be very useful for a while but require the user to be able to lift their legs over the side of the bath and this may become difficult as mobility reduces. Falls are common when residents are getting in and out of the bath; it is for this reason that level access showers or wet rooms are recommended.In the case of shared bathroom facilities, infection control may be an issue and consideration may need to be given to additional cleaning regimes: www.dhgov.uk is a website that offers guidance on infection control.3.7 Stair LiftsWhere accommodation is on an upper floor or on two levels the installation of a stair lift can help surmount a wide range of health and mobility problems. Trustees are recommended to seek grants for the installation of these lifts. Individual residents may qualify for a local authority Disabled Facilities Grant on assessment of need. Some grant making charities will assist with funding.The regulations regarding the fitting of stair lifts are complex. Building Regulation approval is usually required; this is dependent on the width of the stairs and the ability of the chair to fold away so as not to impede normal access. If in any doubt about the likelihood of receiving approval, telephone the local authority’s Building Control Department quoting the make of stair lift and the width of the stairs. You will be alerted to any anticipated problem and advised accordingly. Listed Building Consent will also be needed when fitting a stair lift in a listed almshouse.It is essential that residents are given proper instruction in the use of the lift, ideally by the manufacturer. A record should be kept of the instruction session and arrangements made for re-training at appropriate intervals. New residents must be similarly instructed; this must not be left to existing residents. It would be prudent to limit the use to authorised persons and most lifts can be supplied with key control that helps to prevent misuse.There is a wide choice of stair lifts as well as various buying, renting or leasing arrangements. Some stair lifts are designed with seats while others are for standing on. For more information, Ricability publishes Ability Guide to Stair Lifts.3.8 StorageMany almshouses are old and were built at a time when expectations of space were different from those of the present day. This is particularly true of storage space. Built-in wardrobes and cupboards, where possible, are preferable as they are more stable and avoid residents bringing with them inappropriately large furniture or stacking items on top of a wardrobe. Adequate storage space should be provided for everyday household tools such as ironing boards, clothes airers and vacuum cleaners.A frail, older person often needs more space not only for reasons of mobility but also to keep essential aids. Wheelchairs and walking frames can themselves be a hazard if they are not properly stored. The location of the storage facility is important or it will become a deterrent to the use of the equipment. Door operated lights in storage units are a good safety feature and also save energy. Electric vehicles require a convenient, covered and secure parking place ideally equipped with a power point. For space and safety reasons this may have to be in a separate building. When designing new accommodation, thought needs to be given to the segregation of waste to facilitate the recycling requirements of Local Authorities.3.9 SecurityFrail and dependent people may feel vulnerable and insecure. It is essential that accommodation is equipped with British Safety Standards approved door and window locks and security chains. It is equally important to ensure that residents know how to use them and are capable of doing so. Double glazing needs to comply with British Safety Standards, ensuring maximum security but giving the ability to open in emergency.Where the accommodation is in a shared block, door entry systems controlled from each flat allow main entrance hall doors to remain locked at agreed times yet enable residents to answer the door and release the lock from the comfort and security of their own flats. These can be integrated with the call system and television/video entry systems. Those systems, where video records are maintained, are controlled by The Data Protection Act. In supported housing the maintenance and installation of these systems may be eligible in the assessment for housing benefit. A neighbourhood watch arrangement, outside lighting, sensible garden planting and fencing can also enhance security. Ask the local Crime Reduction Officer to advise and maintain regular contact and invite visits as this can be reassuring for residents.Where security chains are fitted to doors and door jambs, residents should be guided in the Residents’ Handbook that it is best practice to affix the chain only immediately before opening the door. It is unwise to leave door security chains affixed for long periods as it may be necessary to gain entry in an emergency.Regular reminders help to reinforce the importance of sensible security measures. The fitting of bolts to the inside of doors should be prohibited as these could delay, or even prevent, access in the event of an emergency.3.10 Call SystemsThe provision of an emergency call system is a cost effective means of providing out of hours cover. There is a variety of equipment available. The old pull cord connected to an alarm bell or flashing light has now been superseded by vastly improved systems. The most usual is a two-way communication unit that can be used as a normal telephone but is also linked to a 24-hour control centre and to the mobile phones of wardens or scheme managers.When a warden/scheme manager is on duty either in the home, office or visiting residents, any emergency call can immediately be directed to his/her telephone. This leaves a warden/manager free to visit on site yet able to respond immediately in an emergency. During off duty hours or holiday times all calls should be transferred to the control centre. Pendants or wrist bands can be provided for less able or sick residents.A regular service and testing programme should be in place to ensure that the system is functioning fully.The Almshouse Association advises that those residents over pensionable age should be required to have a landline through which a call system operates. Trustees may accept that younger residents would not necessarily be so dependent upon 24-hour cover and may be allowed to opt out, however trustees may consider inserting a clause in the Letter of Appointment making it a condition of occupation that upon reaching pensionable age, residents must have an acceptable alarm system.Independent advice on choosing community alarms is published in the Ricability booklet Calling for Help: a guide to community alarms 2008) and The National Benevolent Fund for the Aged has established a scheme to provide the short term loan of emergency telephone alarms for older people. (See Appendix B).3.11 Smoke Detector Systems Carbon Monoxide Monitoring and Fire AlarmsAlthough it is not a legal requirement, insurance companies often require the installation of smoke detectors.There are prescribed standards for blocks of flats known as Houses of Multiple Occupation where there are some shared facilities. These are contained in Statutory Instrument 2006 no. 373: The Licensing and Management of Houses in Multiple Occupation and Other Houses (Miscellaneous Provisions) (England) Regulations 2006. The standards require that “appropriate fire precaution facilities and equipment must be provided of such type, number and location as is considered necessary”.As with emergency alarms a wide range of equipment is available and in some instances the systems may be combined, a fact that makes the selection of a suitable system less easy. A comprehensive description is beyond the scope of this publication and it is strongly recommended that trustees seek professional advice. Consultation with the local authority Building Control Department is essential.A detector that is wired into the electrical system is preferable, especially if it is also electrically or radio-linked to the emergency alarm control centre. When the alarm is triggered, the Fire Service is called even if the resident is out or does not hear the klaxon in the house. As an interim measure, trustees can approach the local Fire Service who will affix battery-operated smoke detectors free of charge in most areas. These will be monitored by the Fire Service and the ten year lifespan battery replaced after 9½ years. Older style smoke detectors with limited battery life should be monitored routinely and regularly to make sure that the battery is functioning properly. It is recommended that the local Fire Service is invited to visit. They are keen to assist and often install preventative measures. They will also advise of evacuation policies for individual sites, particularly where there are communal spaces.Carbon monoxide can kill. It is a gas that does not have visible fumes or a smell. Old gas or coal equipment or faulty flues may leak small amounts of carbon monoxide that produce ‘flu-like’ symptoms. Many charities, where there are gas boilers, gas cookers or back burners, install carbon monoxide detectors. The best types of detectors use an electrochemical device that measures the quantity of carbon monoxide over a period of time. Specialist advice should be sought for correct fitment.It is advisable to include a maintenance check on smoke and carbon monoxide detectors at the same time as the annual gas check. If, at the time of the annual gas safety check, the inspecting agent determines any equipment to be defective, the agent, under law, is required to make the equipment inoperable.Where fire alarms are installed, consideration should be given to the type of alarm required for the style and kind of building. The position of the fire panel should be in a common area to enable the emergency services to check the zone of the fire.3.12 Fire Blankets and ExtinguishersMost trustees seek the advice of the local Fire Officer on the supply and fitting of safety equipment. It should be explained that fire blankets are for use by the more able-bodied and that frail residents should not attempt to deal with a fire themselves. In most cases they should get out as quickly as possible, shutting all doors and windows behind them and call for help. In some situations the Fire Officer’s advice is to stay put and wait behind fire doors. Members of staff may find a fire blanket or extinguisher suitable for coping with a small fire, however, the Fire Service should be called immediately a fire is noticed.Regular checks should take place if fire blankets are provided to residents’ properties.3.14 Smart HomesAs technology progresses, a greater number of devices become available to assist more vulnerable people to remain in their own homes. As reported on The King’s Fund website and the Department of Health’s website there are currently 15.4 million people in England with at least one long-term condition and it is thought many are not yet diagnosed. Three out of every five people over the age of 60 in England suffer from a long- term condition. The Department of Health is leading on the development of a cross–government long term conditions strategy which they hope to complete and publish by the end 2012. This will enable social services to supply additional equipment to meet particular needs and thereby reduce unnecessary hospitalisation and the inappropriate use of ambulance staff and other paramedics.Examples of sensors that will link to a 24-hour monitoring centre are:Fall detector, worn on the person and which incorporates a motion sensor set to connect with a rapid response centre at a certain degree of tiltExtreme temperature detector, which will register if a room is becoming too cold or too hotBed/chair sensors to check if a person is getting out of the bed or chair at the expected timesInfra-red detectors to detect unusual movements of the lack of movement, which can be set to connect to a relative’s or friend’s mobile telephoneProperty exit sensor to minimise wandering by people with dementiaMedication reminder which gives a vocal command via the telephone when it is time to take medicinesMedicine dispenser which opens a rotating carousel and gives a bleep to alert.These are all non-intrusive pieces of radio communication and, as there is no need for hard-wiring, they can be moved from place to place as required. There are many other specialist adaptations to help those with poor manual dexterity or who are partially paralysed. All need the consent of the user or the family but, far from being an intrusion into privacy, they provide independence, reassurance and security.Advances in technology may also provide:Automatic opening of windowsAutomatic opening of window coverings (blinds and curtains)Voice operated wall switches for lightingKey safe boxes (off site monitoring aware of codes)Proximity reader keys (with re-programmable codes) to replace conventional keys for doors and gatewaysBogus caller buttons linked to 24-hour monitoring centresSensor operated taps, WCs showers or lightingHold-open door stops de-activated by fire alarm bell frequenciesFire alarm listening devices for the hard of hearing and deaf.This is an advisory list only and is not intended to be an exclusive list or guide.For Further Information:Care Quality Commission: www.cqc.org.ukDisabled Living Foundation: www.dlf.org.ukDepartment of Health: www.dh.gov.ukRicability: www.ricability.org.ukDisabled Living Foundation: www.dlf.org.ukAction on Hearing Loss: www.actiononhearingloss.org.ukRNIB: www.rnib.org.ukAlzheimer’s Society: www.alzheimers.org.uk© 2013. 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