Five-Star Hotel, Five-Star Care? Part 1: a Good Home

[NB: This post was written in 2016, pre-COVID-19. Restrictions on visiting care homes may now apply; please check with the provider.]

Back in 2011, when I faced an emergency search for a care home for my mum, choice was limited.  There were simply not enough homes.  Since then the market has rapidly expanded, and today we see an explosion of predominantly upmarket “luxury” developments boasting lavish facilities and “five-star dining”. The cost of a room in such an establishment and the inequalities of funding provision is another story; but, assuming you (or a funding body) can afford it, does five-star decor mean five-star care?  Not necessarily…

Back in 2011 when I started my quest, I found that most homes were geared either to early stages of dementia (where residents are still able to feed and dress themselves and to socialise with only light supervision), or to late stage (where they are mostly bed-bound and in need of full nursing care).  The difficult mid stage – still mobile, active, and sociable, but increasingly confused, paranoid, and needing secure keypad entry and exit – was the hardest to accommodate.

Our situation was exacerbated by the fact that mum could not by then tolerate any journey longer than twenty minutes from the family home where she still lived, and I am based a hundred miles away (up to three hours’ drive from that hometown).  Should I look for somewhere local and reasonably familiar to her, where she could keep her own GP and have visits from friends, or move her closer to me, where the environment would be completely alien and I would be her only visitor, but could see her more often? 

I investigated both, but in the event the choice was made for me.  Options were so few that only one stood out as suitable: a well-established home ten minutes away from mum’s house, which had a strong local reputation and was already known to us from a family friend, whose relative had lived happily there in former years.  It was still run by the same manager, a nurse of long-standing experience in elderly and dementia care, who had been in charge since the home opened and won consistently excellent inspection reports.

As soon as I stepped onto the premises, I knew this was the place. It was tranquil, with beautiful gardens, tasteful furnishings (similar to mum’s own home), and good food - including a fine daily selection of homemade cakes and desserts, designed to tempt fragile elderly appetites and boost calorie intake, if main courses proved a challenge.  

It was bright, fresh, and clean, with no tell-tale “smell of wee and cabbage”.  Residents were smartly dressed in well-laundered clothes, and looked cheerful and relaxed.  Yes, it was expensive, but no more than others I considered (in such parts of the country, no residential care is cheap!); and, crucially, it was not the decorative surroundings that impressed me - the atmosphere felt right.  

Arriving unannounced one Saturday lunchtime for my exploratory visit (meals are always early in care homes and the busiest times of day; I didn’t know that then), I was taken on an impromptu tour by a care-worker.  It’s a good sign when visitors are always welcome and staff are happy to show you around without appointment.  At that time, I barely knew what I should be asking, but with hindsight can see that my instinctive response picked up on features I have since learned are best practice in dementia care.

While clean, the place was not overly tidy – there was a degree of “clutter” (knickknacks, photos, books, pot plants, soft toys) that made it feel homely and gave the residents familiar landmarks to orientate them to their rooms; toilet doors were painted bright yellow with big, clear picture signs, and there were contrast-coloured handrails around the corridors (people with dementia often have visual, spatial, and balance problems and may not be able to see white-painted rails or doors that blend into walls); meals were served on bright yellow or blue crockery for the same reason; there were no mirrors or shiny surfaces, which can be disturbing to people with dementia who do not recognise their own reflection. 

As mum had always been fond of animals, I was pleased to see there were pets (three cats, a budgie, and a tank of fish). There were plenty of informal seating areas around the building for residents to rest on their perambulations and have some quiet space – for instance, a charming seaside-themed corner. I was particularly taken by the welcoming feel of a small conservatory area, where people could sit and look out at the gardens, surrounded by a cosy jumble of plants, watering-cans, windmills, and an array of dolls and soft toys – spontaneously arranged as if in dialogue, with a sense of humour and affection.

The latter immediately struck a chord with me, because mum had for years been obsessed with collecting soft toys, amassing a whole spare-room-full, which she would religiously “put to bed” each night.  These toys instantly told me that the staff understood and respected the emotional needs and perceptions of people with dementia.  It was evident that everything in the home was geared to the comfort and well-being of the residents – it was first and foremost, their home.

When I met the care staff, I knew nothing of their formal qualifications, but felt that they possessed the most important attributes – kindness and empathy; and though I could not have defined it at the time, there was a sense of firm leadership running through every aspect. These things you can’t learn from a website or inspection rating; you have to go there, feel the vibes.

And so it was that I took a room in this home, before I knew if mum would accept it, dreading her reaction, but conscious that I could not afford to lose the chance of such a rare good place. Despite my misgivings about having to place her in care at all and the emotional and practical hurdle of that move, she settled more readily than I expected. 

Once we had weathered this upheaval, I thought we were on an even keel at last; and for the next four years, while I packed up and sold our house to pay the fees, took over legal management of mum's affairs, started to rebuild my own life, and continued to make the regular 200-mile round-trip to support her, I had complete trust in the home. 

By autumn 2015, mum had been resident for almost twice the national average stay - a testament to the quality care she received. Dementia is a degenerative syndrome, so of course her condition deteriorated in that time and will continue to do so.  But having experienced so much trauma in the preceding decade, when I had struggled to keep her safe at home, I knew she would otherwise have come to grief and was immensely grateful to have her still “with us”.

People often ask me, “Is she happy there?” - sometimes in front of her; please don’t!  Firstly, there’s an underlying judgmental implication that if she isn’t, I must have put her there for my own selfish convenience, while there remains a happier alternative elsewhere. Secondly, the honest answer is too complex.  Although she can still experience pleasure and has good days (as well as bad), I can’t say mum would be truly “happy” anywhere now as a general state, given that she has no context of memory and relationship, and constantly yearns for long-dead parents and the home of her childhood, which can never be restored.  She was already tormented by such feelings when still living in our own house.

Paranoia, delusion, hallucination, and confabulation are her dominant symptoms of dementia and often result in distress, because to her everyone is a stranger and potentially means her harm.  Rather than “happiness” therefore, I find it more realistic to think in terms of peace, contentment, and security – which the home provided.

Continuity is key.  In 2011 mum had first moved into the residential dementia wing, but by 2014 she was no longer independently mobile and needed continence care; she was able to move seamlessly across into the dementia nursing unit – at that time, a small wing of 12/13 residents, with four care staff (including a nurse) on duty by day and two at night.  This is a very good staff/resident ratio and made for excellent care.  As a regular visitor, I knew all the residents and staff and they knew mum and me; they became, in effect, our family.

As mum’s condition progressed, there were times when she seemed to be fading, and plans for end of life care were made.  Although she rallied, I prepared myself, confident in the belief that when the time did come, both of us would be supported by familiar people, who cared about us, in peaceful, familiar surroundings.

But just before Christmas 2015 that confidence was brutally shaken.  A crisis brewing throughout the autumn came to a shocking head - and I learned that, even if you have found a good home, vigilance must never be relaxed…

Part 2: Problems

Part 3: Crisis

Part 4: Conclusion

My Biggest Lie: Part 2

It was the summer of 2011. After many years of struggle, I had finally accepted that mum’s dementia had progressed to a stage where I could no longer keep her safe at home; encouraged by the social worker, I had found her a residential place. But as mum believed there was nothing at all wrong with her, how could I persuade her to move?

I had spent the August Bank Holiday with her at our family home as usual, but had returned to London to make the final arrangements. This might seem odd, given that the care home was in mum’s town; but I could not visit it openly (or indeed go out by myself at all, except briefly to the shops), neither could I use the computer or phone in mum’s presence, because, if I were out of sight for even a moment, she would come looking for me, and would interpret any outside communication as suspicious. She’d had paranoid symptoms for years; it was a horrible irony that I was now really plotting behind her back.

I needed to wait a few days to speak to the unit manager at the home, who was away on holiday. I was also waiting for the psychiatrist to return, in order to assess mum’s mental capacity for my Court of Protection Deputyship application. This would give me legal authority to manage her finances, which I would need to pay the care fees. The psychiatrist and I had agreed that I would always stay away when she visited, so that she could see how mum was on her own, and so that I would not be associated in mum’s mind with any unwelcome professional approaches. She would usually visit with Jenny, the independent care-worker mum liked, in order to maintain her trust.

A couple of days before this visit was due, I was disturbed to receive a phone call from an old friend of mum’s, whom she had not seen for a while. This friend told me that mum had rung her out of the blue, and said some very strange and upsetting things. She did not go into detail, but the fact that I never heard from her again, despite continuing to send Christmas cards, good wishes, and letters of explanation, suggests that it must have been something extremely offensive. 

The psychiatrist’s visit passed apparently without incident, although she did call me at the time to ask some background details, such as whether our dog and various relatives were dead; as so often the case, mum presented well verbally and socially, but what she said and believed was highly delusional – something you would only know by checking the facts.

I was reasonably assured that all was proceeding to plan. The next day, Jenny reported that she had looked in on mum and supervised her eating an early supper, so I felt it was safe to go out for a few hours with friends. Little did I know that mum’s symptoms had been building to an acute psychotic episode…

It was on my way home that I received a call from her Aid-Call alarm service, asking me to ring the police, who were at our house. At the time, all they could tell me was that some neighbours had found mum in distress and called the police to take her home. It was not until later in the week that I learned the full story. 

Desperate to find someone to stay with mum until I could get there, I rang round her close friends and next-door neighbours, who had often helped us in crisis – but they were all away. Social services out of hours were also unable to help, and I could not contemplate sending her anywhere alone in an ambulance. 

By this time, it was nearly midnight and I knew I was over the alcohol driving limit, but even so, I would have set off there and then, had I not needed to speak to the care home manager the next morning, when she was due back. I knew that once I returned to mum’s, all verbal communications would be impossible.

I shall never forget the despair of that night, lying awake waiting for daylight, fearful that mum might go out again in my absence and come to grief. In the morning, as soon as I had spoken to the care manager, I set off, stopping at the petrol station to stock up on food, as I would not be able to leave mum to go out shopping unless someone could sit with her.

En route, I also spoke to the social worker and updated her on events. When I arrived, I found all the curtains drawn, every light in the house blazing. In the living room, a cold cup of tea and plate of toast that I had asked the kind policemen to prepare the night before stood untouched on a side table. There was no response to my arrival. 

I found mum upstairs in bed, totally inert. Momentarily alarmed that she might actually be unconscious, I woke her. She looked at me with no curiosity, as if nothing had happened and I had been there all along.

For the rest of that week until the date of her admission to the home, we were both prisoners in the house. I had arranged for Jenny to come and sit with mum, while I went “to the shops” – in reality, an appointment at the care home, to go through paperwork with the manager. It was a nauseatingly stressful round-trip of a couple of hours, culminating in a frantic “supermarket sweep”, as I had to return with goods to support my cover story.

As the days ticked by, tension mounted. How, how could I ever raise the subject of the impending move with mum? Slipping out for another supermarket trip (covered by the next-door neighbour), I called the home from the car park. The room, they confirmed, would be vacant in a couple of days; ready when you are.  Amid the groceries, I had stashed away toiletries and make-up for mum’s sponge bag; it seemed so pitifully underhand and final. I broke down and sobbed in my car, as boisterous children scooted by on trolleys and mothers loaded their weekly shop. I have lost count of the car-parks and lay-bys I have now wept in.

So how did I do it?  What did I say?  In the end, it was mum who raised it first. Watching TV in silence, she suddenly turned to me and said: “What’s going to happen to me?”  It was a heart-stopping moment.  How did she know?  What did she know? It seemed that somehow, despite having no reasoned knowledge of the situation, she sensed that she was in crisis and that something was afoot.  How could I answer?  I had never lied to her, but neither could I explain the full truth. 

“I think you need to go somewhere, where you can have people around you”, I said.  “People to keep you company when I’m not here and look after you at night, when you get frightened.”  “I don’t get frightened”, she said, despite having repeatedly told me that she was, without ever really knowing why.  Miraculously, we managed to have a tentative discussion along these lines and she didn’t go berserk at me, as I had feared for so long - although there remained an uncomfortable silence at the end. I was hugely relieved to have it out in the open at last.  And yet… 

By the time I had put the kettle on to make a restorative cup of tea, the whole tortuous conversation had of course been forgotten. I would have to broach it again the next day – the very day of the move.

That night, as I lay curled up, weeping, in my bed, mum opened the door and looked at me, strangely dispassionate, more bemused than upset.  “What’s the matter?”, she asked.  “Why are you crying?”  What could I say?  That this was our last night together in our own home?  The house we had moved into in Christmas 1973, when it was new and my father was still alive?  Her last night in the outside world?  The beginning of the end of a relationship that had started with my birth? 

Impatient at my inability to respond, she chided: “Now come on! Stop that.”  Then: “I love you, you know. As if you were my own daughter.” As if? Then who did she think I was?  Were we strangers already?

On the day of the move, I surreptitiously packed an overnight bag, as instructed by the manager - best not to take too many things at once, you can bring in more once she’s settled – and put it ready in the back of the car. Mum came downstairs at lunchtime; I made us something to eat.

I had forwarded her “life story” information (material facts, key events, likes and dislikes) to the home from my phone, filling in the form in my bed overnight. Far from ideal, but the best that I could manage in the circumstances.  I had emailed the social worker to ask if she could stand by to come with me if needed, but she had to be in a meeting that day. All that remained was to get mum into the car.

After lunch, we sat in silence, while I steeled myself to come out with it.  And once again, mum took the lead.  “What are we doing?”, she asked.  “We’re going to look at this place”, I replied.  “What place?”  “A place for you to stay in the week, when I’m not here.  Where they can take care of you…  Shall we go then?  Just have a look?  We can have a cup of tea…?”

And that was my biggest lie.  The only way I knew, to do what had to be done.  “Just a look… Just a cup of tea…”  When I knew it was forever.

She let me zip her into her jacket and got into the car.  The staff, from the manager to the receptionist and finance controller, had been primed to greet her as a visiting guest for tea.  I took her upstairs to the unit at tea-time, and, as instructed by the manager, waited for her to be distracted in conversation, and slipped out quickly without any fuss.  Just like a mother, taking a little child for her first day at school.

A move into residential care is at least as much a watershed for the family carer, as for the person with dementia – and the grief arguably greater, for we know the full story of loss. No-one does this lightly.  One might consider it similar to abortion: a choice you make when it has become the only viable option. A similar stigma, maybe.

To carers, I say it may seem an impossible decision, an overwhelming task.  But sometimes you have to face it and you can survive.

To parents, I say please, please don’t elicit impossible promises from your children; have the courage to confront your own mortality before you lose capacity; have the discussions while you can, be realistic, draw up power of attorney, put some plans of your own in place.

To everyone: don't fear care homes.  The sector is woefully underfunded and undervalued, yes; there are bad homes, true.  But there are also many good ones and wonderful people doing essential work to support the most vulnerable in society.  Don’t let’s stigmatise them. It is not a fate worse than death.

Here are mum and I, as I prefer to remember us, about twenty years ago, outside our home, now sold to pay mum's fees. (Not, by the way, a “mansion”, as so often assumed of those liable for 100% self-funded care at circa £1,000 per week, just an ordinary suburban house.)

So if anyone thinks it’s easy to “put your mother in a home”, read this back. Imagine all those lonely years, when I had dreaded having to break mum’s trust in me, her only child.  I did it to save her. She is still alive today. I have no-one left. 

It will be a long time, if ever, before I can think of August as a happy holiday season.


(This two-part post - read part one here - is a companion piece to an earlier post concerning the issue of "truth-telling" in dementia care.)

My Biggest Lie: Part 1

I have put off writing this for a long time – an episode I’d rather forget. But as August has come around again, the city familiarly desolate, friends posting happy family snaps from far-flung beaches and villas, I find myself back in the bleak summer of 2011: the year I put my mum into care.

Ever since I was a little girl, mum had said to me, “never put me in a home”.  It became a mythic dread, a calamitous fate I would do everything in my power to avoid; but even then, at the age of seven, eight, or ten, I was reluctant to commit myself to a promise. Another little girl would perhaps have said “promise”, knowing this was what a beloved mother wanted to hear and hoping the word would be enough; but as a serious and scrupulously honest only child, even then I sensed it might be too big a guarantee – and if I didn’t know for sure that I could keep my promise, I could not say the word.

What I do know is that mum had never imagined the situation we would face in that summer of 2011, when she was almost eighty-five. Her own parents had both died of acute illness in their early seventies, her mother of cancer, her father of a heart attack six weeks later. My father too died of cancer, at the age of only fifty-two, when I was a student. Shocking, yes; traumatic, certainly.  But not protracted, nor degrading. Morphine for pain relief brought hallucinations, but, though distressing, these were temporary – they did not fundamentally change the personality of those we loved or our relationship with them; both my grandparents and my father were still themselves when they died, cognisant of us and of our love for them.

(Tellingly, when my grandmother was diagnosed with inoperable stomach cancer back in 1978, mum begged the doctors not to tell her, arguing that she would “give up”.  So both medics and family were forced into a deception that she merely had “kidney stones” and “a fissure of the bowel”, from which she could in time recover - rather than an untreatable terminal illness, that in fact killed her eight months later. 

Even as a twelve-year-old, I thought mum was wrong: my grandmother, a highly emotional person, would undoubtedly have been devastated by the news, but she was not cognitively impaired – she could have understood, if not come to terms with it.  And as a family we would not have had the added burden of secrecy; we would have been able to plan for her care and that of my grandfather, whom the rest of us knew would soon be widowed.

Mum, in my view, deluded herself that “not giving up” could cure her mother of an organic disease that had already spread unstoppably through her body.  This starkly illustrates the difference in personality between us: she was an escapist, who thought that if you ignored problems, they would somehow go away; whereas I have always been a realist – equally upset by bad news, but believing that you have to face it, in order to deal with the practical consequences.  All this came into play in the dilemma I faced in 2011.)

Mum remembered her grandmother who, with hindsight, had dementia.  But “Nain”* Thomas had lived in a mountain village in the early years of the 20^th century, where doors were left open, everyone knew everyone and could guide a confused elderly lady gently home - and, crucially, families were large and women stayed at home. There was always a daughter or a sister, a niece or daughter-in-law at hand; and living into very old age with multiple health problems was comparatively rare. 

So mum’s impression of her grandmother’s condition was benign -  affectionate anecdotes of mildly “dotty” behaviour, remembered from her distant childhood.  She had never herself witnessed the more extreme symptoms of late-stage dementia, much less had to cope with them as sole carer; and all those years ago, when she had said “never put me in a home”, she had not known anyone to whom that had actually happened, nor understood why it might.  She had no template for decades of chronic degenerative disease or of bed-bound dependency, believing that “one day I’ll just pop my clogs”. She could not know what she asked of me.

I have written elsewhere about the long progression of her own dementia – twenty years or more from the earliest symptoms to present date – and the blunt reality of end stage needs.  By 2011, mum was almost completely unable to take care of herself, yet equally unaware of that incapacity.  There is a name for this: anosognosia – commonly known as “lack of insight” or “lack of awareness”.  It is a clinical condition, resulting from brain damage (caused by trauma, stroke, or disease), which renders a person unable to acknowledge that they are experiencing disability. 

I didn’t know this. So for many years l had struggled to support mum on my own (often against fierce antagonism from her), desperately hoping and believing that surely one day, when things got bad enough, she would have to admit there was something wrong and accept professional help. But that day never came. It never could, because she was not “in denial”, as I thought – the brain damage that caused her symptoms of dementia also prevented her from recognising them. As far as she was concerned, she was absolutely fine; I was the one behaving strangely. 

So it was not until the previous autumn of 2010 – after another dreadful August that brought her into the general hospital – that she had finally been referred to social services at my request. I had been finding it increasingly hard to cope, and hoped the hospital admission would pave the way for regular home support. But anosognosia struck once again. Mum discharged herself early and refused the hospital’s follow-up services.

Already at breaking point, I persisted behind the scenes, and mum was later assigned a social worker, occupational therapist, and consultant psychiatrist from the community mental health team; but because she did not accept that she had any problems, all these professionals had to tread softly, in order for her to accept them. 

She would not attend clinics, for instance, so they had to visit her at home, alongside familiar community nurses from the GP’s Older Adult Nursing Team, giving the impression that they were all routine “health visitors from the surgery”.  Even then, she would not always let them in and rejected all their suggestions; there was little they could do. 

(She would not agree to any kind of formal testing, so diagnosis could only be made by the psychiatrist’s informal observations, and was not registered until the following autumn of 2011, when I had to apply for legal authority to manage mum's affairs.)

The social worker, to whom I shall always be grateful, put me in touch with a wonderful independent care-worker, Jenny, whom I engaged to visit mum a couple of times a week – just to look in and make sure she was safe, help her to prepare a hot meal, and get to know her, with a view to introducing daily care in due course. 

First signs were encouraging; mum warmed to Jenny. But from spring 2011, her symptoms dramatically escalated, repeatedly putting her at risk, and it became clear that she needed 24-hour care that no one person could provide.  The social worker urged me to seek a residential place, but although I agreed this was now the only practical solution, I just could not see how to achieve it. 

Wasn’t this mum’s greatest fear? The very thing she had always warned me against?  Bad enough to go against her wishes; but, given that she believed there was nothing wrong with her at all, how could I even broach the idea of moving her out of her own house, to end her days in a “home” - let alone actually get her to go there?  It seemed insurmountable. 

By the summer, however, I was shocked to realise that she no longer recognised our family home, where she had lived for nearly forty years; she couldn’t remember which of the two main bedrooms was hers, or recall any room on the other side of a door.  Distressed by the apparent “strangeness” of the place, she obsessively packed shopping bags to flee, sometimes sallying forth at night to try and get her bearings.  I knew then that the home she had loved was no longer a cherished sanctuary, but a frightening jail to her; and if it was not a comfort, nor even familiar, would she not at least be physically safer in care? 

So in that terrible summer of 2011, I began my lonely and frantic search of care homes.  Lonely, because I could not consult mum about it or involve her in this, the biggest choice I would ever have to make; and frantic, because I had to contact and visit all these places in snatched moments, behind her back, en route between my flat and our family home, a hundred miles away. 

Novelist Penny Hancock has written about the heartbreak and guilt of choosing a care home with her mother, and writer Pippa Kelly has detailed a similarly harrowing experience alongside her father and siblings. Imagine the pain of having to do it alone in secret, bearing sole responsibility for that decision.

I soon discovered that residential care for those in the mid stages of dementia (as mum then was) is the hardest to find, as most homes cater either for early stage (where residents are still mobile and sociable, and don’t require secure, key-pad entry/exit or all-day supervision) or late stage, where they are mostly bed-bound, in receipt of nursing care. 

This narrowed down the options considerably (something I may discuss in a future post), but I was lucky to secure a provisional place in an excellent specialist unit ten minutes from our family home – by that time, mum could barely endure a twenty-minute journey in the car, so even if I had been able to find a suitable home near me in London, it would have been far too traumatic a move.  The problem remained of how to persuade her. 

With no other immediate family, I knew I would have to do this alone. I considered involving one or two of her close friends, but decided it was too big a request, as I wanted mum to maintain a positive relationship with them in future.  I canvassed the professionals for advice on how to open the discussion with her, but they admitted that, given both her lack of insight and lack of short-term memory (that meant any conversation would instantly be forgotten) there was no easy answer. 

The only practical suggestion, which totally shocked me, was this: as mum and I had been accustomed to going out for lunch and still managed this occasionally, if the worst came to the worst, I might have to take her out one day for our usual pleasant meal and then drive her straight to the home.  Unimaginably brutal!  How could I possibly do that to my mum? 

With any other illness or disability, you would of course expect to plan such a major life change openly and equally with the person needing care over a gradual time-scale, take them to look at potential homes, and help them to make the choice.  But dementia is not like other disabilities: anosognosia, paranoia, confabulation, delusion, and hallucination (all of which mum experienced) are mind-altering symptoms that trample the parameters of judgment and normal social exchange.  And sometimes they confront us with terrible decisions and actions that would otherwise be unconscionable, in order to safeguard our loved ones.

The social worker offered to come with me on the day if I couldn’t manage, and I was glad of this notional support, although wary that her unaccustomed appearance at our house might inflame an already volatile situation. I had reserved the only available room in the unit, and knew that if mum didn’t take it up on the due date, we might lose the chance of a place in the best home in the district, the only one I considered to be at all suitable. With this date fast approaching, I still had no idea how I was going to effect the move. 

Could I go through with it? Wracked with guilt at the impending betrayal of mum’s lifelong trust, I became physically sick with apprehension.  But one final, awful incident just after the August Bank Holiday convinced me I could not turn back: whatever it took, I had to get mum into the home…

Continued in Part 2

* Welsh for grandmother (pronounced "nine").


(This two-part post is a companion piece to an earlier post concerning the issue of "truth-telling" in dementia care.)