In 2005, we were awarded a grant by the ESRC, to revisit Peter Townsend’s seminal study of residential care for older people, published in 1962 as The Last Refuge. Townsend’s fieldwork, which was carried out in the late 1950s, involved visits to 173 local authority, voluntary and privately owned old people’s homes across England and Wales. The original data are now deposited at the University of Essex. Drawing on these data, we investigated what became of the 173 homes and revisited 20 of the 39 that we found to be still functioning as care homes, replicating Townsend’s original methods of inquiry so that we could compare now with then (see: www.lastrefugerevisited.org.uk).

Here we look at just one of the 39 voluntary homes he visited which we revisited in 2006. Whereas most of the homes we visited were still in the same building, albeit a much changed one, in the mid-1980s this home was replaced by a new purpose-built one.

The home then

When Townsend visited this home it was housed in a gothic Victorian building which still stands but is now used as a retreat and conference centre. The building was acquired by the voluntary organisation in the late 1940s to provide residential care for men returning from the Second World War who had nowhere to go or who had been wounded and needed care and attention. It was (and still is) situated in 62 acres of parkland with a drive nearly a mile long, and is about one and a half miles from the nearest village and shops. The isolation of many of the homes Townsend visited is something about which he was critical.

In 1958 it accommodated 53 men. Most were not local and few had been seen before arriving. Indeed, some of the men had just turned up unannounced. All but six slept in large dormitories, with bare floors and iron beds. There was insufficient space for drawers and wardrobes and few personal possessions were in evidence. Townsend says little about rules and regulations but he does describe the matron as ‘very authoritarian about keeping everything in order’. She was one of ten resident staff who also included the secretary, five untrained ‘nursing orderlies’ and three ‘maids’. The eighteen non-resident staff included four trained nurses, five domestics, two porter cleaners, a driver, three gardeners, a boiler-handy man, a chef and a kitchen porter.

Townsend reports that several of the residents were involved in the home’s domestic work: washing up, peeling potatoes, helping in the laundry, cleaning the silver and brass, making beds and looking after the shop. There was also an ‘occupational therapy’ room where some of the men made stools or lampshades for very little remuneration. Most interest, however, was shown in crib schools, whist drives and billiards and activities organised at Christmas. There was a 16mm projector used for film shows, and there were occasional concerts from visiting choirs although the warden reported that these in-house activities were being undermined by the newly acquired television set.

Despite the remoteness of the home, about half the men went out at least once a week. A few were able to visit the cinema nine miles away. In the summer, there were outings to the seaside in the home’s bus and some went away for two weeks’ holiday. Although only 15 of the 53 men had any visitors over the course of the year, Townsend noted that they were not lonely and there was a ‘mateyness’ based on their shared wartime experiences. Most seemed to be physically able but a few were observed to be ‘crippled’. Two were in bed, another lay flat in a spinal carriage and Townsend noted four bed hoists.

In the early 1980s it was decided that this building and its extensive grounds had become too expensive to maintain and that it was no longer fit for purpose. So a new, 60 bedded home was built on some entrusted land 40 miles away. When it was completed (in October 1985), all the residents and seven members of the 28 staff from the old home were transported to it. The driver at the time, who still works at the home, told us that on the day of the move, a 24-seater Mercedes bus was hired to supplement the home’s 12-seater Bedford mini bus and the residents were waved off by those staff who didn’t follow on. The new home had its official opening six months later and it took the name of the old home.

The home now

In 2006, the home accommodated 35 men and 23 women in three relatively discrete units: one for residential care, one for nursing care and one for dementia care.

Although the home is again situated in a very rural area, unlike the old one, it is on the edge of a small market town the centre of which is within ten minutes walk. When a new manager was appointed in the mid 1990s, the first thing he did was to have all the leylandii bushes in front of the home cut down to make it more open and visible to the local community. Arguably the home is better integrated into the community now than the old home was.

One of the most important differences from the past is of course the building. All residents now have their own bedrooms although this was not the case when the home opened. At that time there were some resident staff and some residents slept in dormitories. However, even today, only four of the bedrooms rooms are en-suite. The rest rely on communal toilet and bathroom facilities which remain in urgent need of modernisation. Furthermore, most of the bedrooms are less than ten square metres and on the nursing wing they are not big enough to allow access to both sides of the bed making the use of lifting equipment difficult. One reason that the residents were moved to the new purpose built home was because the old home was no longer suitable, particularly for those requiring nursing care. Twenty years on, the new home has become unsuitable. Not only is it failing to match up to some of the physical requirements of the Care Standards Act, but also it is proving inadequate for meeting the needs and preferences of the residents. Consequently, plans to build a replacement home are once again being discussed.

As for the staff, the present-day home employs three times as many staff as the old home, although there are only five more residents than in the past. Of course a majority work part time hours and none are resident. Not surprisingly given the rural location, recruitment is a problem. It is the category of care staff which is the major development: the 44 care staff currently employed now perform the tasks that the five untrained nursing orderlies did in the past. Proportionately more are trained although it is still the case that a substantial number have no qualifications. Clearly a hierarchy and differentiation of staff roles have evolved that did not exist in 1958 and different categories of staff can be identified through their different uniforms.

In regard to the residents, one major change is that the home is no longer single sex. The first woman was admitted in 1988 and she was there for nine months before the second woman was admitted. Unusually for 2006, the men still outnumbered the women. A second difference is that the organisation running the home has had to modify its admission criteria to match current demands. Consequently, although many still come from afar because of the occupational identity attached to the home, a greater proportion of the residents than in the past are local. This suggests that, like other interest based voluntary homes, the spirit of ‘mutuality’ identified by Kellaher (2000) is being undermined. A third difference relates to physical capacity. Although, unlike some homes we visited, the median age of the residents has not changed dramatically (84 compared to 80), only seven were reported as requiring no help with dressing and only five as being able to go out without assistance.

As with many of the homes we visited, the increasing emphasis on health and safety creates an institutional feel of a different order to the past: fire doors, fire extinguishers and warning notices. Freedom and autonomy for residents is strongly espoused, but on closer examination there are many qualifiers. Residents are apparently subject to risk assessments for all manner of things: using the lift unaccompanied, making a cup of tea; administering their own medicines and so on. Pets are not allowed because they pose a health risk, likewise smoking in your own room is prohibited and the consumption of alcohol is controlled. The home has a bar, but the licence, despite requests from the residents, has not been renewed for two years. Nevertheless, we found evidence of residents taking matters into their own hands. One for example had installed a SKY TV satellite dish on the wall outside his bedroom while the manager was away on holiday. And even on our relatively brief spell of fieldwork one of us was able to observe something of the backstage world of the home: two men who had wheeled themselves out onto a terrace, one wearing a duffle coat over his pyjamas, to bask in the October sun and have a smoke.

Involvement by residents in domestic occupations has declined: just one worked in the garden and another helped with the tea. The most frequently undertaken activity is watching TV, often in the privacy of the bedroom. Like other homes we visited, an activities organiser had been appointed. However it would still appear to be the case that, as Townsend observed 50 years ago, while what was then referred to as ‘occupational therapy’ may be thought desirable

… such therapy can rarely be organized successfully for more than a tiny proportion of residents, not because the residents are too infirm or apathetic but largely because their interests, talents and capacities are too diverse to conform to a single scheme.

(Townsend 1962, p.384).

The home also has the usual round of fund-raising events which are open to friends of the home and there is a house committee, comprising in the main representatives from local branches of the voluntary organisation that owns the home, which is responsible for fundraising.

Visitors can come at any time and there is a flat they can stay in if they wish. Thirty four (over half) of the residents were visited at least once a month. This is considerably more than in the past. In addition, telephone contact with family and friends is a much greater possibility than it was in 1958. A quarter of the residents have their own phone, some a mobile phone. Only five residents regularly go out of the home alone and none take holidays away. However, the home still has its own transport (two mini buses) and trips out - every week in the summer - are arranged on a rotational basis. On Fridays some of the men are taken to the pub and the women have coffee in town. On Mondays about half a dozen residents attend a local day centre. In addition, if someone has an appointment at the hospital or elsewhere, another resident may be taken along for the ride and there were plans to organise more individual outings.

The dementia care unit was secured by locked doors accessible by a keypad. Nevertheless, the residents in this unit had free access to an enclosed garden. Despite the fine weather, we did not see this being used.

Continuity and change

Although the above simply describes just one of the homes we revisited, it does illustrate some of our findings more generally about continuity and change in residential care for older people.

Data on the 20 homes we revisited show that, overall, they are now caring for an older and more infirm population of residents, although there is still a significant proportion of residents who are relatively independent. The gender balance has changed and there are now greater proportions of women as compared to men accommodated in these homes. Segregation by gender has been replaced by segregation on lines of functional ability with discrete nursing and/or dementia care units in several of the homes we visited. Put simply, care home provision in the early 2000s is a different instrument of social policy to what it was 50 years ago.

The continuities with the past, that only a longitudinal study can reveal, are, however, as striking as the changes. For example, in the case of the home described here, there is the continuing preponderance of men, the connection with military service and the long tradition of providing nursing care. It is these kinds of continuities that make each surviving home, particularly those that have not changed ownership or tenure like this one, so distinctive in character. And it is through them that we are able to see the past in the present.

Acknowledgement

The research on which this paper is based was funded by the ESRC, Grant Reference: RES-000-23-0995.

References

Kellaher, L. (2000) A Choice Well Made: Mutuality as a Governing Principle in Residential Care, London, Centre for Policy on Ageing.

Townsend, P. (1962) The Last Refuge: A Survey of Institutions and Homes for the Aged in England and Wales, London, Routledge and Kegan Paul.