Care homes and home

Moving into a care home in later life is often a significant disruption to the experiences and meanings that an older person may ascribe to their sense of home and connection with home. Fundamentally, moving into a care home re-locates (or dislocates) the individual physically, psychologically and biographically from their previous home, necessitating the need to create/recreate a new sense of home somewhere else (Rowles and Bernard, Reference Rowles and Bernard2013). Given the extent to which a sense of home is linked to place and social connections, recreating home can be hard to do, especially where the move was at short notice or unwanted. Moving to a care home often occurs following either a crisis event such as a hospital admission, or gradual deterioration in physical or cognitive health (Cole et al., Reference Cole, Samsi and Manthorpe2018), meaning older individuals may be facing multiple concurrent sources of disruption, loss, uncertainty and adjustment. This may reduce a person's capacity to invest the physical and emotional energy and effort that may be needed to make a new home in a care setting (Peace, Reference Peace2015).

Features of the care home environment may tend to inhibit home-making activities. For example, domestic tasks such as laundry are likely to be managed on an institutional level (Buse et al., Reference Buse, Twigg, Nettleton and Martin2018), and activities such as taking a walk in the garden or even opening a window may be subject to staff approval or availability (Evans et al., Reference Evans, Perkins, Clarke, Haines, Baldwin and Whittington2018; Lovatt, Reference Lovatt2018). Bedrooms – typically perceived as the space which most clearly represents the person's ‘own’ space – may be primarily designed to meet the economic requirements of the care home operator as a business, e.g. in providing the most economically profitable mixture of standard-sized and larger ‘premium’ rooms, or in laying out rooms for efficiency of staff access (Nettleton et al., Reference Nettleton, Buse and Martin2018). Horton (Reference Horton2021) notes that investors in the care home market may equate care homes to hotels from an economic modelling perspective. This suggests that they may fail to respond to the significance of care homes as residents' homes, despite rhetoric that encourages the older person to consider the care home as home.

Attempts to support older people in recreating a sense of home within a care home often emphasise the importance of a sense of ‘connectedness’ (Bradshaw et al., Reference Bradshaw, Playford and Riazi2012; Cooney et al., Reference Cooney, Dowling, Gannon, Dempsey and Murphy2014). However, there are varying accounts of what connectedness means. Typically, there is a strong emphasis on social dimensions of connectedness, such as meaningful interactions with family, friends and wider society, and engaging in activity which is purposeful and meaningful (Murphy et al., Reference Murphy, Shea and Cooney2007; Cooney, Reference Cooney2012). Knight and Mellor (Reference Knight and Mellor2007) similarly emphasise social connection and suggest that there is sometimes a tendency to over-focus on providing activities in care homes rather than supporting people to develop new social connections and maintain long-standing social connections. Other research has highlighted that connection is more complex than a focus on social connection and includes domains such as spiritual, biological, connection to others, environmental, metaphysical and connection to society (Register and Herman, Reference Register and Herman2010).

Another line of scholarship has looked at material practices of home-making within care homes. Lovatt (Reference Lovatt2018) highlights how care home residents engage in home-making through activities such as cleaning their bedroom or offering hospitality to guests. Being able to arrange and organise personal possessions within the care home and having a sense of privacy (e.g. through staff knocking before entering a bedroom) facilitate a sense of home through the demonstration of personal agency, whereas decisions which emphasise a lack or loss of agency (lack of privacy, the absence of defensible space; decisions made for the person about retaining person possessions) inhibit opportunity and motivation to try to find or establish a sense of home (Fitzpatrick and Tzouvara, Reference Fitzpatrick and Tzouvara2019). As well as these more day-to-day practices of exercising control over one's own home space, Sury et al. (Reference Sury, Burns and Brodaty2013) additionally indicate that involvement in the initial decision-making about entering a care home also appears to facilitate adjustment to a move into a care home and motivation to feel or be at home.

There are, however, significant constraints associated with facilitating or achieving a sense of home within a care home. The combination of demands on staff time, the numbers of older people under a single roof who may need support to engage in activities safely, achieving the care and support needs of a population with complex and changing needs, as well as concerns about risk may result in individual preferences being overlooked or perceived as too difficult or time-consuming to meet (Evans et al., Reference Evans, Perkins, Clarke, Haines, Baldwin and Whittington2018; Paddock et al., Reference Paddock, Brown Wilson, Walshe and Todd2019). In the economic context of care homes frequently being modelled as ‘hotel-like’, or as bedrooms for staff to service as quickly as possible (Nettleton et al., Reference Nettleton, Buse and Martin2018; Horton, Reference Horton2021), homeliness may be judged implicitly inefficient.

Animals in the care home

Scholarship on pet ownership in later life tends to focus on community-dwelling older adults (see e.g. the majority of pet ownership studies described in Gee and Mueller, Reference Gee and Mueller2019). Conversely, much of the scholarship on animals within care homes focuses on animals as a visiting presence within the care home. Often this is with an expressly therapeutic purpose, such as dog-assisted therapy for people living with dementia (Jain et al., Reference Jain, Syed, Hafford-Letchfield and O'Farrell-Pearce2020). Reviews of both areas of research report some evidence of potential benefits, e.g. increased levels of physical activity and improved mood, although they also note that studies are often small, low-quality and heterogeneous in method and focus (Barker and Wolen, Reference Barker and Wolen2008; Perkins et al., Reference Perkins, Bartlett, Travers and Rand2008; Cherniack and Cherniack, Reference Cherniack and Cherniack2014; Gee and Mueller, Reference Gee and Mueller2019; Jain et al., Reference Jain, Syed, Hafford-Letchfield and O'Farrell-Pearce2020). Arguably, however, operationalising the animal–human bond in terms of seeking to prove therapeutic benefit to older people rather detracts from the moral case of the importance of promoting personal connections, choices and sense of home in later life. If, for example, an older person wants to live with her dog in somewhere she is told she should consider to be her home, it is reasonable to ask why that should be contingent upon a demonstrable health benefit. An alternative perspective is that the companionship relationship between a vulnerable adult and their companion animal should be given ethical and legal weight, recognising the substantial elements of loss that older people often undergo as they move into care (Fox and Ray, Reference Fox and Ray2019).

McNicholas (Reference McNicholas2008) looked specifically at the question of older people living with their own animals within either care homes or sheltered housing, and reported that such settings typically did not have clear policies on permitting companion animals. Managers and staff were generally conscious of the possibility that separation from a pet could be distressing to an older resident, but in some cases inappropriately minimised potential distress for certain groups of residents (e.g. people living with dementia). Managers tended to highlight the perceived challenges of managing animals in a communal setting and often presented the logic of the care home market as a solution: that ideally there should be a mix of care homes that did and did not permit animals, allowing individuals a choice. Visiting animal schemes, however, were regarded by residents primarily as entertainment rather than creating any real sense of affection, connection or relationship with the animal. This may in part be because arranged animal visits are often classed as part of an ‘activities’ schedule, organised by staff who decide upon matters such as frequency and timing of visits. This can perhaps be related back to the earlier-discussed observation of Knight and Mellor (Reference Knight and Mellor2007) that there is sometimes a tendency to conflate activity with connection within care homes. An enjoyable visit from an animal, arranged by someone else for a set timespan, is unlikely to create a satisfactory alternative connection for those people who have been separated from their own companion animal. Indeed, it could exacerbate feelings of loss and grief associated with the separation.

A small number of other studies with care home staff and managers have similarly highlighted that they often have ambivalent views on pets permanently residing within care homes, and perhaps as a consequence, policies are often also unclear or absent (Smith et al., Reference Smith, Johnson and Rolph2011; Fossey and Lawrence, Reference Fossey and Lawrence2013). The broader wellbeing considerations for residents were borne out by a recent small phenomenological study of residents living with animals in care homes (Freedman et al., Reference Freedman, Paramova and Senior2021). However, research with staff and managers suggests that they perceive a need to strike a balance between the recognised benefits of maintaining a connection with animals, and concerns about animals as posing a risk or causing inconvenience to the care home's operation (Fossey and Lawrence, Reference Fossey and Lawrence2013).

The question of companion animals in care homes, therefore, sits at the centre of a wider debate about the extent to which care homes are or can be judged to have the same quality and meaning as a domestic home. This debate includes factors such as connectedness, the extent to which individual biographical continuities can truly be honoured, motivation to live in a care home, experiences associated with a domestic home and the practices of home-making within the care home. This paper explores participant perceptions of older people living with companion animals in care homes, and the implications for connectedness and a sense of home.

The research questions for the project were:

1. (1) What proportion of care homes in the United Kingdom (UK) currently allow/exclude animals?

2. (2) What, in practice, does advertising a care home as ‘animal-friendly’ mean?

3. (3) What are the perceived benefits and challenges (including costs) associated with permitting companion animals to accompany older people into care homes?

4. (4) What are the implications when older people are not allowed to take their companion animals with them when they move to care homes, (a) for the older person and (b) for the animal(s)?

5. (5) To what extent are policies which exclude pets in conflict with the principles of person-centred care and human rights?

6. (6) What role can law play in promoting improved care home policies, and what form should such legal interventions take?

7. (7) paper focuses on the second and third research questions, addressing them through the lens of ‘home’.

Connectedness and a sense of home

Participants, when reflecting on the emotional benefits of companion animals in care homes, made frequent references to them creating a sense of home, comfort, and continued connection and purpose for the older person living with their animal:

In discussing the importance of residents' personal connections with animals, care home workers and managers sometimes specifically referenced how this might affect the process of ‘settling in’ to the care home as their new home. They emphasised the close relationship an individual might have with their companion animal. In addition, providing care to an animal might be helpful in settling into a new environment and create opportunities, or the necessity, for interaction with care home staff and other residents (whereas, conversely, worrying about an absent animal might be unsettling):

Another care home manager described a situation where a resident's family had decided (in the manager's opinion, incorrectly) that total separation from the resident's dogs would minimise disruption:

The manager's narrative suggests that the family may have believed that it was better for an older person to have a ‘clean break’ from pre-existing sources of connection, such as dogs. It appeared that the older person's views had not been considered in decision-making, and that the family tended to dismiss her questions and her distress about the dogs. In contrast, the manager considered that while it would not have been practical for that particular resident to keep her dogs within the care home, attempting to maintain the relationship via daily visits would have eased the process of moving into the home.

Other relatives recognised how significant separation from companion animals might be. One participant explained in written comments how distressing it had been for her great-grandmother to experience cumulative losses of connection to vitally important relationships, including her cats being rehomed, during the combination of a move to a care home and the COVID-19 lockdown:

This account highlights the profound dislocation and loss of connection older people may experience when moving into care, especially in combination with factors such as bereavement or being unable to see family.

Shared domestic space

Despite the widespread acceptance that animals could contribute to helping older people to feel at home in a care home, there was substantial variations in views as to how animals could be practically accommodated in a care home setting. This often related to the constraints around shared space within care homes, with bedrooms being understood to be an individual's personal area, while other space was shared. As such, accommodating animals such as cats and dogs required consideration as to how they could occupy shared space.

Within the care homes that did accept cats and dogs, the material practices of animal care that were described often sounded relatively domestic in scale and structure. Animals were described as moving flexibly between personal and shared space:

In contrast, participants who had little or no experience of animals living in care homes often had difficulty envisaging how arrangements might work. Some simply assumed animals were never permitted in care homes:

Other participants were aware of the concept of a care home permitting dogs but assumed that the dog would need to be living separately rather than occupying domestic space within the care home:

Some residents similarly highlighted that while they enjoyed having animals visiting, they would have concerns about the possibility of resident animals entering private bedroom space overnight:

Some care homes were sub-divided into units, and this arrangement was sometimes seen as a useful arrangement to resolve issues over shared space. Both care homes that currently had cats living in the care home had initially put arrangements in place where the cat was only permitted in one unit. In one case this had persisted. The cat lived in the downstairs section of the home, and residents and staff based upstairs stated that they had little contact with her. In the other, the arrangement had been relaxed over time:

Overall, therefore, decisions about keeping animals within care homes were frequently influenced by the fact that care homes are not straightforwardly a private domestic home. For animals such as cats and dogs, which could not be confined to a private bedroom, there was a need to consider how they could occupy shared space.

Care home culture and decision-making

Linked closely to issues of how animals might use space in the care home was a tension between, on the one hand, recognising the potential benefit for an older adult to live in the care home with their animal, and on the other, managing other aspects of care home operation, such as risk management, demands on staff and financial arrangements. As a result, decision-making was often perceived as the need to balance the perspectives of the individual resident and their family/friends with those of other residents who used shared space, and care home staff.

In care homes that accepted companion animals, the ultimate decision to accept an animal resided with the registered manager. However, all the homes in this study were part of a group, and hence also subject to corporate policy. For care homes 1–4, the group policy encouraged accepting animals where possible. Care home 6 accepted animals but this had been heavily championed by the home's current manager rather than reflecting the policy of the care home group. The manager of a care home that did not accept animals would have referred any inquiries on the subject to a more senior level:

Risk was a key consideration in such assessments and was often explicitly balanced against the emotional and other benefits of having animals present:

As Maggie acknowledged, the decision to accept pets involved substantial planning, that went beyond domestic-scale decision-making. Managers who had housed animals described drawing up detailed plans for animal care, considering issues of where the animal would be permitted to go, mitigation of identified risks and the extent of staff involvement. Even for care homes within the same group, there seemed to be different perspectives on how far it would be reasonable to expect care home staff to contribute to animal care, for example whether a carer could be expected to walk a dog:

Claire's concerns focus on staff capacity. Managers often highlighted an expectation that family would be heavily involved in most aspects of supporting their relative to keep their animal, for example through arranging veterinary care, regular flea and worming treatments, vaccinations and insurance. Care home 6 was an exception to this, possibly due to apparent differences in the demographic profile of residents. Many of their residents did not have families who could or would support them with companion animals:

In contrast, the relatives we spoke to generally highlighted the overall difficulty of finding a suitable care home. Such decisions were often already heavily constrained by factors such as geography, costs and care needs. In this context, relatives were doubtful about whether it would have been feasible to find a care home that would also accept a companion animal:

Grace, an older person living in the community, had attempted to ring round care homes for a friend who wished to keep his cat with him, but after several calls had been unable to find any homes that would consider it. Care home managers also acknowledged the challenge for families:

Overall, it appeared that circumstances in which an older person could remain living with a companion animal were often dependent on an alignment of factors, including a care home in the area that was willing to consider animals; a favourable assessment of the older person and the companion animal by the care home manager; and family who were able to advocate for the older person and the animal, as well as provide practical and financial support.