This study describes a registered care home in England and a registered nursing home in Norway which provide permanent care for alcohol-dependent older people who are unable or unwilling to stop drinking and cannot maintain an adequate standard of self-care and/or live independently. Prior to admission, most residents have been living unsafely in their own home or were homeless. They have high levels of contact with health, social and criminal justice services and complex needs as a result of mental illness, poor physical health and physical disabilities. Most have lost contact with their families.
The aim is to stabilise drinking, physical and mental health and improve quality of life. The homes are based on a harm reduction philosophy, that is, they focus on strategies to reduce harm from high-risk alcohol use, rather than insisting on abstinence. Residents can drink as much alcohol as they want on the premises but staff encourage them to drink less and in a less harmful way (e.g. spreading drinking throughout the day and having ‘dry’ days).
We carried out interviews and focus groups with staff and residents, observed verbal exchanges, experiences and routines in communal areas, took field notes during staff rounds and analysed documents such as care plans for individual residents.
Following admission, drinking usually becomes more controlled and some residents become abstinent whilst others become stable enough to move on to detox and community alcohol treatment.
Primary health care is available on-site either in the form of medical staff based in the home (the nursing home in Norway) or by regular visits from professionals e.g. a GP, district nurse, community psychiatric nurse, dentist, chiropodist, optician, dietician and physiotherapist (the care home in England). This, combined with less harmful alcohol consumption, regular health checks, better medication management and increased compliance with secondary health care usually leads to stabilisation of physical and mental health conditions and better symptom control. The provision of nutritional meals often leads to weight gain and further health improvements. The homes provide 24-hour-a-day assistance with self-care such as bathing, dressing and continence and this can have a positive effect on self-esteem and sense of dignity. Quality of life is enhanced by constancy, daily routines and providing a safe environment where residents have the company of their peers and can engage in social activities. The homes offer palliative care and somewhere to have a peaceful, natural and dignified death.
In the English care home, some residents felt that the home provided a safe refuge and a lifesaving intervention for which they were grateful. However, other residents had been judged to lack capacity under the Mental Capacity Act and their residence was imposed to protect their welfare. The staff had been legally authorised to make decisions on their behalf in their best interests. One resident described the home as being “like a prison” and another resident expressed anger at being “forced” to have a shower once a week. Some residents described being bored and not having much to do whilst staff in both homes said that motivating residents to join and pursue activities was a constant challenge. There were frequent altercations between residents which meant that CCTV had been installed in the communal areas of the home and staff were frequently verbally, racially and physically abused.
Defining and measuring “success” in wet care homes can be difficult. However, suitable outcomes include improved hygiene and nutrition, increased self-esteem, better compliance with healthcare, healthier living which is not entirely alcohol focused and more hope for the future. In the homes we visited, processes were not in place to collect quantitative measures in a way that could provide clear evidence of impact. The care homes are trying to achieve many different types of outcomes and no single outcome instrument exists which will measure them. However, a combination of standard tools administered on admission and at regular intervals thereafter could give a rounded picture across multiple domains. Placement in the homes is expensive but costs may be offset by a reduction in the use of other health, social and criminal justice services.
Placement in wet care homes is expensive, but they can have positive outcomes for individuals whose needs cannot be met elsewhere. Costs may be offset by a reduction in the use of other health, social and criminal justice services. Future research and service monitoring should include economic analysis.
Contact details for corresponding author: Michelle McCann, Room B401, University of Bedfordshire, University Square, Luton LU1 3JU.
