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Care home journey

Care Home Journey

An online resource to support nursing care in older peoples care homes

This resource allows you to follow a resident’s care home journey through from pre-admission to end of life, or to simply access individual sections to meet your learning needs and seek clinical inspiration.

Each section demonstrates the role of nursing staff when supporting the resident, their families and nursing colleagues at a particular stage of the resident’s journey. The resource provides real life scenarios signposting to high quality, evidence based resources to answer the clinical questions that frequently affect those caring for older people.

Introduction to characters

John is an 86 year old man, a retired mechanic who loves the physical act of fixing things, improving machines, fiddling with clocks and household objects to make them run more smoothly.

John is living with chronic respiratory disease and dementia and this has restricted his life outside his home. His memory difficulties mean he sometimes forgets to switch things off or eat properly. John also has an arterial leg ulcer and frequently experiences tremendous pain; recently he has not been able to take analgesia safely.

His neighbours have become aware of his difficulties as he has stopped taking his dog Graham out for walks, and now they can see Graham has destroyed John's garden. John is a realistic man and understands that despite the increasing care he is having at home, his memory loss is impacting on his quality of life and safety.

John's respiratory specialist nurse recently examined him and has explained he will now need oxygen. Following a discussion with a social worker, the district nurse, who has worked with John for a number of years, has asked John if they might all meet together to discuss the options available.

The meeting is open and honest, John is supported by his neighbours and acknowledges that he needs further help as his quality of life is deteriorating. Following assessment, he agrees to go to Red Cedars, a care home with nursing nearby.
Seema is an 86 year old Gujarati lady who has been cared for by her family for many years. She speaks a little English and now has severely reduced mobility and frequently suffers falls.

Seema enjoys preparing meals, attending temple and being in the company of her great grandchildren. Sadly Seema has started displaying distress in the evenings and despite expert intervention this has not been fully resolved.

Seema has a diagnosis of vascular dementia as well as heart failure and experiences urinary incontinence. Recently Seema has been distressed to the point where she started to throw objects and the family feels it is unsafe for her to remain at home. They are very troubled about not being able to care for Seema and having considerable support from social care services.

Following a mental health review and in discussion with her CPN and social worker, Seema is going to Red Cedars for a two week respite stay with ongoing CPN intervention and trial of medication.
Jane has lived with her friend Eileen for 50 years. Jane is a retired nurse as is Eileen; they have been caring for themselves without any social care support for the last 10 years, largely due to their professional knowledge and skill.

Jane is diabetic with very erratic blood sugars, she now has a diagnosis of moderate cognitive impairment, and has recently started to experience seizures. This combination has meant that Eileen who is living with frailty is unable to continue to provide a level of support that Jane needs.

Jane has decided to fund her own care in the care home with nursing at Red Cedars whilst Eileen remains in their apartment.

Eileen is still able to spend much of her time with Jane in the nursing home.
Sue has had a long career in nursing, initially as a registered nurse in acute trusts. She then qualified as a district nurse and v100 prescriber, and worked in rural Wales. 

She is now a senior member of the care home team with a special interest in end of life care.  Sue also provides childcare for her daughter’s child one day a week and enjoys a flexible working pattern.

Sue is currently experiencing some health issues related to her menopause but remains very committed to her career and the residents at Red Cedars.
Danilo is a staff nurse who has come to work in a care home from the Philippines; his wife and children remain there. 

Danilo is keen to progress his career and would like to live in the UK permanently. 

Danilo enjoys the family based culture that is evident in a care home environment.
Rachel is a recent school leaver who is working in a care home as a volunteer to improve her CV. 

Rachel has not considered a career in health or social care but volunteered because her school had links with the home and it was only in the next village.

She now works at Red Cedars as a nursing assistant. Rachel is keen to develop and enjoys learning.


Nurse talking to two people

Prior to admission to a care home the nurse's role is key in the assessment of the person's needs, support for the family and subsequent care planning.

The role of the nurse is to support the person and their family to communicate their wishes and concerns.  The nurse will have knowledge of, and be able to signpost to, additional services and will act as liaison and advocate on their behalf when necessary. Prior to admission the nurse will complete a holistic assessment, complete required documentation and identify nursing needs.

The decision to become a resident in a care home is never made lightly and the journey and emotions as a person makes that transition are individual and complex. Certainly we can all agree it is a major change in anyone’s life, sometime tinged with sadness or fear, sometimes with relief and hope. The issue of choice is very powerful; if someone has chosen to join a care home their views may be very different than someone who has moved by necessity or in their best interests. The RCN has developed some principles for nurses to use to promote a smooth transition for home to care home and NICE has some guidance which is useful if a resident is admitted from hospital.

John - moving into Red Cedars

John neutral John understands that despite the increasing care he is having at home his memory loss is impacting on his quality of life and safety.

John's respiratory specialist nurse recently examined him and has explained he will now need oxygen therapy. The community nurse Melanie meets with Sue at one of her regular visits to the home to talk through John's nursing needs.

The registered nurse has a lead role in supporting this event and can make the difference between a smooth transition or a move which is distressing. Where possible joining a care home should be carefully planned. Ideally a new resident would have seen the home and perhaps had opportunity to stay overnight, visit for lunch or take part in the activities in order to become familiar with their new home.

Many of us experience concerns when moving home and we frequently have time to prepare for the change. It is possible to imagine how the combination of ill health, sensory loss and cognitive impairment will make such moves more unnerving and the nurse's skill in supporting someone through a change is essential. Nurses draw on professional education and demonstrate high level interpersonal skills. They have the ability to adapt and modify their interactions whilst interpreting the physical and psychological needs of the person they are working alongside.

John and Graham - addressing concerns

John is an 86 year old man, a retired mechanic who loves the physical act of fixing things, improving machines, fiddling with clocks and household objects to make them run more smoothly.

John is living with chronic respiratory disease and dementia and this has restricted his life outside his home. His memory difficulties mean he sometimes forgets to switch things off or eat properly.

John also has an arterial leg ulcer and frequently experiences tremendous pain - recently he has not been able to take analgesia safely.

His neighbours have become aware of his difficulties as he has stopped taking his dog Graham out for walks and now they can see Graham has destroyed John's garden.

John is a realistic man and understands that despite the increasing care he is having at home his memory loss is impacting on his quality of life and safety. John's respiratory specialist nurse recently examined him and has explained he will now need oxygen.

Following a discussion with a social worker, the district nurse, who has worked with John for a number of years, has asked John if they might all meet together to discuss the options available.

Whilst John is sad about leaving his home his overwhelming concern is what will happen to Graham. Fortunately Dave, John's neighbour, is prepared to look after Graham.

Sue, Melanie and Dave - making arrangements

Dave has agreed to look after Graham and Melanie is ringing Sue at Red Cedars to help formalise the arrangements. They discuss possible arrangements which will be confirmed with John who has chosen not to be present. The conversation explores the frequency of the visits, issues related to the other residents and to ensure both John and Graham’s wellbeing, as well as the commitment Dave will need to make. These will be written into the care plan for John and reviewed regularly.

The RCN has sought the views of experts in the transition from home to a new home within a care home and provide some principles that support a smooth transition.

When supporting the family/friends of someone moving to a care home it is the nurse’s role to ensure their involvement in care planning, provide information or guidance regarding the process of selecting a care home, and that information is shared regarding access to support agencies and financial assistance/options.

Concerns from family members

For many family members and friends a new resident joining your care home will be the culmination of a long and sometimes difficult journey. Despite the good care and companionship offered in our care homes most residents would rather remain in their own home. This major life transition brings with it a wide range of emotions and this will influence people’s behaviour. Naturally there will be concerns when joining a new environment and as this is often coupled with ill health and cognitive impairment the initial period requires great skill and empathy to set the tone for the new life ahead.

The nurse has a lead role in articulating how important this transition period is and in pacing and planning any assessments or interventions to allow the person to acclimatise to the new environment. You home will have tried and tested methods of accomplishing this and their skills and experience should be used.

When supporting nursing colleagues the nurse’s role is to provide leadership, support, education, audit and practice development.The RCN supports the professional leadership function with a suite of leadership programmes.

Sue - carer responsibilities

It is increasingly likely that nursing colleagues may be caring for a family member themselves and the senior nurse will have a role in providing access to support in the workplace.

Sue is one of the senior nurses in the team, she is grandmother to Veronica who has recently started school. Sue's daughter, who is also a nurse, has found it hard to collect Veronica from school in time on the three days a week she goes to work, as her shifts are so busy. This has become particularly difficult since her daughter's partner has been working away in Hong Kong.

Sue knows her employers have been very flexible with other staff's hours at the home and she would like to be able to help her daughter on at least one day a week. Sue is keen to understand her rights and responsibilities in relation to a caring role and flexible working so she can negotiate a workable solution with her employer.

Sue contacts the RCN for advice by ringing RCN Direct.


During admission to a care home the nurse plays the pivotal role in supporting the transition process for the person and their family.  The nurse’s role will include practical interventions such as assessment of the new resident’s needs, care planning and medicines management.  As importantly is creating a sense of home and safety for the person.  It is an opportunity to mark a new phase in someone’s life that can retain hope and meaning.

The nurse’s role is concerned with meeting the resident’s needs including spirituality, sexuality, privacy and comfort. The nurse will be skilled in recognising and managing distress, and will support acclimatisation of the resident to home life by providing orientation to the home, introduction to other residents and encourage engagement in activities. This will involve marshaling other members of the multi-disciplinary team.

Seema - respite care at Red Cedars

When Seema was admitted to the care home she was disorientated in place and time and understandably frightened. She was welcomed to the home by Sue and shown to her room.

As Seema moved towards the door she started to back away and stumbled. Sue was able to safely steady Seema, to gain eye contact, smile and encourage Seema's family to explain what was happening. Sue also knew Rachel was available, observing the situation but not overwhelming Seema.

Sue was aware of Seema's past history and her current confusion. Sue was alerted to the possibility that Seema is experiencing a delirium in addition to her mental health issues. Sue has recently become a delirium champion through the RCN's delirium champion campaign.

When supporting the family/friends of someone joining a care home it is the nurse's role to ensure they feel able to continue in a caring role at a level they are comfortable with this might include joining in meal times and social events or continuing to provide personal care. The nurse should be able to anticipate the potential needs of family/friends at this time and to provide opportunity to discuss specific details.

People often find it helpful to have the support of others in similar situations and to engage in the home community by being introduced to relative groups or educational sessions.

Below is a film of a home which has created a memory café for their residents, residents from other homes and people from the local community.

When supporting nursing colleagues the nurse’s role is to provide education, share good practice, support revalidation and ensure clinical supervision takes place.  

Sue - Supporting Seema's wellbeing

We can see that Sue had prepared for Seema's admission, was well informed and empathetic and had experience in managing situations which are emotionally sensitive.

The RCN has previously set out many aspects of the role of a registered nurse working in a care home which reflect the diverse nature of nursing. Sue's actions clearly fall into the supportive category which includes psychosocial and emotional support, assisting with easing transition, enhancing lifestyles and relationships ensuring cultural sensitivity.

The scenario may have been very different in unskilled hands, had Seema been guided in a different way without understanding her communication and perceptual needs. Seema might have displayed distress, perhaps by being physically or verbally protective. Distressed reactions can be disturbing to the person, their families, staff and other residents.

The RCN has prepared some guidance for those staff managing difficult situations, these are really useful for staff like Rachel who was unfamiliar with the situation and relatively new to her role.

Sue - clinical supervision

Sue, as a senior member of the team, has responsibility for managing staff.

As RCN publications have previously explained the registered nurse in a care home undertakes a wide range of administrative and supervisory responsibilities that call for the exercise of managerial skills. Such responsibilities include the supervision of care delivered by other staff and the overall management of the home environment. This includes clinical supervision and the debriefing of staff who have experienced difficult or emotive situations.

Ongoing assessment/Care planning/Risk assessment

Nurse talking to a patient

This section looks at the role of nursing when providing long term care.

Working as a nurse in a care home means many things. Definitions of home vary and are very individual. Here are two broad definitions of home: "the place where one lives permanently, especially as a member of a family or household"; and "an institution for people needing professional care or supervision".

Of course living in a care home is both, the person's permanent residence where they should feel joy and comfort, safe and in control, but additionally where they receive high quality person-centred care that meets their needs.

We know that many people living in care homes have some of the most complex needs of anyone in our society and this includes the need for skilled informed nursing care. We should be proud to say we are nurses and articulate the way in which evidence based nursing care improves quality of life, prevents deterioration and, when the time comes, supports people at the end of life.

The nurse uses clinical skills and evidence based knowledge to assess the resident's needs throughout the day. This might be in general conversations or whilst providing a nursing intervention such as giving medication; alternatively it might be whilst reviewing the residents care plan with them. The "gold standard" of assessment is Comprehensive older age assessment.

Following assessment the nurse will work with the resident and families to ensure the plan of care meets their needs and can guide other staff to deliver the care the person requires. Care plans need to be dynamic and highly personalised to be effective. The need to manage risk but not be risk adverse, the focus should be a balance of risks versus benefits.

Comprehensive geriatric assessment - Comprehensive older age assessment

Comprehensive geriatric assessment (CGA) comprises interdisciplinary and interagency working which places the patient and their supporters at the heart of care. The holistic nature of CGA covering physical, psychological, functional, social and environmental needs of older people may be an encumbrance if not managed effectively. This is particularly true within the community setting where services are affected by local geography and availability.

The assessment process requires co-ordination to ensure that the experience is positive for both the patient and their families. As older people's needs are frequently complex and always unique, those co-ordinating the process must display advanced communication skills in addition to their clinical knowledge to ensure purposeful and timely assessment. 

Co-ordinating CGA can be undertaken by any member of the health and social care team but is best carried out by someone the patient and their family trusts to enable open and sensitive discussions.

Nurses are well placed to manage the complexity of assessment in an efficient way, drawing together the different strands to co-ordinate a personalised treatment plan in which the patient and their family share their aspirations and choices. Nurses have a duty to act as patient advocate, empowering people to make shared decisions; these roles are set out within the Nursing and Midwifery Council (NMC) Code for nurses and midwives.

Frequently commissioned for its ability to provide person-centred, cost effective, accessible care, comprehensive older age assessment is congruent with many models of nursing assessment and makes nurses very effective in a co-ordinator role.

Jane and Eileen - planning care

It is Jane and Eileen's anniversary. Eileen tells Sue she would like to take Jane out for some supper and then go to listen to a local operatic evening. Tentatively she also suggests Jane might stay the night at Eileen's. Sue is delighted that Eileen would like to do something special on their anniversary and says she will do everything she can to help. She sets time aside to talk with Jane and Eileen and they are both very keen to go out. Eileen recognises that there needs to be extra preparation for the evening out and they agree a plan, including transport, medication, a short clinical summary in case Jane experiences a seizure and contact numbers should they need help. Sue arranges for Eileen to come in one evening before their anniversary to ensure Eileen is able to support Jane's mobility and manage her medication.

Providing information and advice as well as ensuring family members have the skills to keep a resident safe are an essential part of good nursing care.

Sue then speaks with Jane and Eileen about them staying at Eileen's together. Sue's concerns relate to Jane's mental capacity and she is aware of the legislation around consent to sexual relations, having recently read the RCN's document. Eileen is also concerned about her small home and Jane's safety overnight and they agree that Eileen will come back with Jane and spend the night with Jane at Red Cedars.

Care planning overview

Care planning is a personalised means of supporting the resident, their families and professionals to direct the care received in order to meet their individual needs. Care plans are created following comprehensive assessment, which may include input from a number of professionals.

The majority of residents will be living with multiple pathology and complexity, and frequently experience cognitive impairment. In order to meet their nursing and care needs they require personalised, tailored care planning which recognises:

  • the best available clinical evidence
  • the personal wishes of the patients/family usually set out as goals of the care
  • the patient’s/ family role in self care or self management
  • the most appropriate interventions: physical, pharmacological, psychological and educational
  • ceilings of care ( the point at which care should not be escalated above)
  • proactive management of deterioration (such as acute infection or electrolyte imbalance)
  • treatments that have been unsuccessful/unwanted.

The tenets of self care mean that care plans are formed in conjunction with patient/family and other professionals/agencies and draw on the following skills:

  • effective /advanced communication
  • support /education to make informed choices
  • the development of skills in self care
  • management of risk.

Care plans should be held by the patient/family with mechanisms in place to ensure that all members of the health and social care team across all settings can access the plan. There are some widely used healthcare systems that can carry diagnosis based care plans within the community/primary care.

Evaluating care/Managing risk

Following their anniversary Sue and Rachel ask how the evening went for Jane and Eileen and are delighted with the happy response from both who have decided it should be a regular event. Sue and Danilo speak with the rest of the team at their staff meeting to ensure everyone is aware of the arrangements and that the staff have an opportunity to discuss any risks of concerns. Some members of staff are concerned that Eileen staying may pose practical difficulties as they monitor Jane regularly during the night, other staff are concerned that it might be a "safeguarding" issue as Jane has cognitive impairment. Sue and Danilo work through these concerns using both the RCN led Safeguarding Competency framework and the publication on sexual intimacy (to be published October 2018) to allow staff to discuss their concerns. Both Sue and Danilo acknowledge they will need to monitor the situation but will do this as sensitively as possible. They arrange for the staff to have further training on this area of practice and have informal discussions with their local regulator to ensure they are demonstrating best practice.

Roz Hooper - Decision making in Care Homes: Insights from the NMC (England only)

Short stay

Woman in wheelchair reading a book

When a patient enters a care home for a short stay it is the nurse’s role to know the reason for the stay so that appropriate plans can be put in place. Is the stay to provide respite care, rehabilitation following a hospital admission/illness or for end of life care?

Regardless of the reason for the care home stay it is likely that the nurse will be leading/working as part of a multi-disciplinary team and will contribute to assessment, goal setting and measurement of progress as well as co co-ordinating care.

Danilo - clinical scenario

Seema has recently moved into a care home that is covered by the integrated healthcare team. The home manager has contacted the team coordinator with concerns regarding Seema as her decreased mobility has led to a high risk to her pressure ulcers, and her recent falls have also led to wounds to Seema's arms and a wound to her right leg. The care home manager points out that Seema speaks only a small amount of English. 

The community physiotherapist visited to assess Seema's needs with Seema's daughter present to enable translation. An attempt to access the local translation service did not help as they did not have anyone who spoke Seema's particular dialect.

Staff nurse Danilo provides an initial assessment which also includes establishing if others involved are covering key areas of Seema's healthcare needs. Danilo establishes that a mental health nurse is monitoring Seema's acute mental health and in particular how the new medication is helping Seema with her distress.

The following issues are listed as needing investigation or intervention:

  • wound care
  • risk of pressure ulcers
  • urinary incontinence
  • falls
  • mobility problems
  • social situation.

Danilo prioritises Seema's healthcare needs with concerns for pressure ulcers being highest. Pressure area equipment is provided and advice given to Seema and the care staff on how to prevent pressure ulcers, including a helpful leaflet written in Seema's own language.

The wounds are superficial but the nurse ensures that a suitable wound dressing is applied to promote wound healing in a warm moist environment. Cleaning of the wounds was not necessary as they were visibly clean and she knows that unnecessary washing of wounds can damage the healing process. Once the wound has improved and requires less frequent reassessment, Danilo delegates this dressing to Rachel the care assistant. Danilo makes this decision in line with the home's policy, his professional code and guidance from the RCN about accountability and delegation.

A continence assessment is started with thought towards reversible conditions such as infections and pelvic floor weakness. Danilo uses a continence pathway tool which enables him to methodically consider all the potential causes of urinary incontinence and assures Seema that urinary incontinence is not a normal part of ageing.

Danilo also considers if any of Seema's medication may be affecting the urinary incontinence or her falls. Although he is not a nurse prescriber, Danilo has ensured he understands the side effects of medication which is essential for all nurses that administer medication. He also starts a falls assessment although this will take a few days and includes a multi-professional assessment looking at physical, environmental and medical reasons for Seema's falls. Danilo will ensure that the falls assessment is co-ordinated and any possible causes for Seema's falls are removed to make Seema safe and improve her mobility.

Danilo has completed additional training on assessing for the use of walking aids and he has brought a walking frame to the care home: he adjusts this to the correct height for Seema and demonstrates safe use of the frame. The walking frame will help to keep Seema safe while the falls investigation is being competed.

When Danilo returns to the team office, a call is made to the social worker involved to discuss Seema's ongoing needs and to start to consider what will happen when she returns to her usual home address. A review is planned for Seema for the following week.

The nurse’s role in supporting family/friends during a short stay might be to offer suggestions for maximising their own wellbeing and to maintain a dialogue with them – providing reassurance and communicating with them as per their wishes.

Sue - gaining feedback

Sue was keen to understand what the experience of respite care had been like for Seema and her family and sought direct feedback. As the senior nurse, evaluation of the stay and the clinical outcomes were part of Sue's role.

Feedback can be sought in a variety of ways:

- direct conversations
- follow-up questionnaires
- follow-up phone calls
- feedback via other professionals
- feedback through independent agencies

As part of our professional revalidation requirements, feedback from residents and families is essential.

Seeking feedback from residents and families - the role of the nurse

As nurses our focus is on getting it right for all of our residents, all of the time. In being professional we must be willing and able to hear the developmental comments as well as the positive detail. It means being able to take feedback, good or bad, to improve the way you and your team works. The aim is to ensure that the care you provide really does meet the needs of your residents, their families and loved ones.

Actively seeking feedback is really important particularly for residents who might find it hard to communicate or have their voice heard. Often this will involve a number of different ways of engagement so that the messages can be got across clearly. Examples might include residents groups, regular meetings or quiet enquiries when providing care. For families there may be drop in "surgeries", support groups and email discussions.

In addition to this, your home might also look at other measures that indicate high quality care; staffing levels, adverse events, drug errors, measure of distress or contentment. As a nurse you will be mindful of non-verbal clues that indicate both pleasure and discomfort. It is important to discuss both the positive and negative feedback to establish if there are patterns within the home, then action to improve care and share good practice.

The way you have handled feedback is important for your revalidation and you may wish to complete a reflective account.

The nurse’s role will be to support colleagues and encourage the sharing of learning from working in a multi-disciplinary team.  The nurse’s role will include using evidence based practice, evaluation and resident feedback. Using resources such as specialist nurses is part of the leadership and coordination required of senior care home nurses.  In the video below, which focuses on a specialist dementia nurse role, we see how these roles can support both care and colleagues.


Woman standing next to another woman in a wheelchair

The notion of discharge from a care home was not commonly considered, however as care homes offer a wide range of services including, respite, intermediate and rehabilitative care residents being discharged is much more common.

The role of the nurse in the process of discharge includes both a coordinating and educative activity. The registered nurse teaches self-care, organises services and arranges medicines and follow up interventions.

Research evidence shows that periods of transition can be a difficult time for people and there is an increased need for joined up care where the person and their family understand what can be expected, and what to do if further help is needed.

The principles which apply when someone joins a residential home can be used to support the resident leaving the care home.

A named nurse is responsible for coordinating discharge home. The nurse will be the central point of contact for health and social care practitioners, the person and their family during discharge planning. He or she is responsible for liaising with family members and the multidisciplinary team, providing information, care planning and support such as:

  • printed information
  • face to face meetings
  • phone calls
  • hands on training, including practical support and advice
  • the need for assessments for eligibility for health and social care funding
  • details of community nursing and voluntary service.

The home will provide details of who to contact about medication and equipment problems that occur after the return home.  The nurse should give a plan of care to the person and all those involved in their ongoing care and support, including families and carers (if the person agrees).

Seema returns home

Seema returned home to live with her family with ongoing care from community nursing and the community mental health team as well as visits by formal carers to help with her personal care.

Sue was responsible for Seema's transfer home and worked closely with her family and community teams to meet Seema's needs and ensure a smooth transition. Sue's experience made her consider if Seema was entitled to further funding and started the assessment process. This assessment was done in conjunction with Seema's family, GP and the community teams. Sue also referred Seema's family to the local authority for a new carer's assessment.

The RCN has a number of resources to help staff identify and support people's mental health needs.

The nurse's role will be to support family members in re-establishing and maintaining the caring role. The nurse will provide information and address education needs with regard to changes in treatment and medication, and will support family members as they learn about new equipment. The nurse will discuss how to access support, such as ensuring they are aware of carers groups and community support.

Following Seema's return home, she settled back family life well, but her family found that whist Seema enjoyed the noisy young family members there were occasions when this seemed to overwhelm her and Seema retreated into herself. Her family spoke with their community mental health nurse, who suggested to Seema that she might enjoy some time with people of her own age.

Many care homes are offering day or sessional opportunities, "taster events" and overnight stays. The video below describes how one care home worked with the RCN on a dementia care development programme.

Discharging a resident is an increasingly common scenario now that care homes provide a wide range of services including respite and rehabilitative care. We know that discharge care needs to be seamless. In addition to involving the resident in their care, a meticulous handover to community teams and the person's family is necessary. In this section we will focus on medicines optimisation.

Seema - Medicines management

When Seema returned home she was taking different medicines to the ones she was admitted to Red Cedars. Her dosage of medication had been changed a number of times and she was now on a maintenance dose which would need to be reviewed by the CMHT.

Seema found it hard to remember her dose of new medication but her previous regular medication she remember the time for administration and the reasons why she was taking them. 

Good medicines management, or optimisation of medicines, is an integral part of most nursing and midwifery practice and includes the administration of medicines, prescribing and supporting people to take their medicines correctly.

The term medicines optimisation is now more generally used to encompass a more people centred approach to the use of medicine as part of a person's care. The Royal Pharmaceutical Society (RPS) good practice states that medicines optimisation is vital to health care and that the evidence base clearly demonstrates that health care professionals and patients need to work together to improve the quality of medicines use.

There is good evidence that medicines management supports better and more cost effective care.

Danilo - advancing career

Seema returned to Red Cedars for one afternoon every other week to attend their memory café; whilst there she met with Danilo again and discussed some concerns she was having with her medication.

Danilo liaised with the GP surgery and mental health team and became increasingly interested in broadening his scope of practice to address both prescribing and physical assessment.

Danillo was keen to undertake an advanced programme and sought support and advice through the RCN credentialing programme to ensure any further study meets the requirements of the programme.

The video below gives an example of a colleague's career pathway and like him, advanced practice would be a further development Danilo might wish to undertake.

Fundamental/Essential care

Nursing staff member helping patient to drink a glass of water

The RCN promotes the role of registered nursing in care homes to ensure that high quality care and optimal outcomes are sustained. The right staff in the right place at the right time is required in order to ensure safe, effective, good quality care is delivered.

Care staff working with nurses in care homes are a significant part of the delivery of quality care and their contribution must be valued and recognised within care home teams. The RCN encourages membership from non-registered care staff where duties are delegated by a registered nurse.

This section uses a number of stories relating to Jane, John and Seema and our care home team at Red Cedars to demonstrate aspects of the RCN principles of nursing practice.

Principle A states that nurses and nursing staff must treat everyone in their care with dignity and humanity - they understand their individual needs, show compassion and sensitivity, and provide care in a way that respects all people equally.

Principle A

Brenda at Weavers

Here we see a care home leader in conversation explaining the need for staff to develop their skills to provide high quality resident care.

Principle F states that nurses and nursing staff have up-to-date knowledge and skills, and use these with intelligence, insight and understanding in line with the needs of each individual in their care.

Principle F

John and Rachel

John has started to enjoy life at Red Cedars and sees Graham on a regular basis. Rachel provides a lot of care for John and has started to understand a lot more about dementia. Rachel is keen to develop her knowledge and wants to put this to good effect within the care home. She recognises the number of people with dementia is increasing and represents a significant number of residents in care homes. She knows it is vital that all nurses who support people living with dementia have a sound understanding of dementia and the impact the condition has on the individual and their families. For example, staff can deliver public health messages that can minimise or prevent vascular dementia through a healthy lifestyle.

Nurses can lead the development of dementia friendly environments and ensure care is tailored to meet residents' needs. 

The RCN has supported a range of care homes across the UK to implement its SPACE dementia principles to improve care.

Principle D states that nurses and nursing staff must provide and promote care that puts people at the centre, involves patients, service users, their families and their carers in decisions and helps them make informed choices about their treatment and care. Many care homes are finding ingenious ways of ensuring families and carers remain involved in their loved ones care which include using carer's expertise in care planning and delivery, and enabling relatives remote access to residents notes.

Principle D

Caring in changing circumstances

Eileen has been undertaking a caring role for Jane for some years now, Eileen would never describe herself as a carer but provides significant personal care and prompting for Jane. Eileen has also helped Jane manage her diabetes and takes urgent action if Jane becomes hypoglycaemic.

Since Jane has joined Red Cedars, Eileen has remained engaged in Jane's care. To assist staff in promoting partnership in caring, the RCN has published the Triangle of Care in conjunction with The Carers Trust.

The Triangle of Care is a guide to improve the relationship between the patient, staff member and carer by promoting safety, supporting communication and sustained wellbeing. The original document is designed for hospital wards but the principles are highly relevant to a care home.

The Triangle of Care is made up of six key standards which aim to improve collaboration between carers and health care workers.

Six key standards

  1. Carers and their essential role are identified as soon as possible
  2. Staff are carer aware and trained to engage with and understand carers' needs
  3. Policy and practice regarding confidentiality and sharing information are in place
  4. Defined posts responsible for carers are in place
  5. A carer introduction to the service and staff is available
  6. A range of carer support services are available

Principle B states that nurses and nursing staff take responsibility for the care they provide and answer for their own judgments and actions -they carry out these actions in a way that is agreed with their patients, and the families and carers of their patients, and in a way that meets the requirements of their professional bodies and the law.

Principle B

Views and experiences of nursing colleagues

Dawne Garrett - Sexual Intimacy

Acute admission

The nurse’s role in an acute admission situation is primarily to act quickly and in accordance with the residents wishes. 

The nurse's role in supporting the resident in an emergency situation is to be aware of patient records for DNR or similar documentation, and to communicate these wishes with respect and accuracy. The nurse will also be key in providing acute life support to the deteriorating patient.

Clinical scenario: emergency situation

Jane was on her way to bed in the evening: before retiring for the night, Jane always checks her blood sugar, although since joining the care home she sometimes needs prompting due to her cognitive impairment; the night staff always check it has been done and what the measurement is.

The RCN has provided education for staff about diabetes essentials which the team have used.

Sue was handing over to Danilo who was working on night duty, when the emergency alarm rang indicating an issue in Jane's room. On arrival, Jane was lying on the floor experiencing a seizure; there was damage to her arm, which was bleeding, and she had been incontinent of urine. Sue and Danilo immediately re-checked Jane's blood sugar as low blood sugars were previously thought to be the cause of her seizures. However, this was within the normal range.

Jane's seizure had been continuing for over 4 minutes and Sue called for emergency assistance via 999. During the time it took for the paramedics to arrive, Jane had experienced two further seizures and had not been fully conscious in-between. Danilo stayed with Jane whilst Sue attempted to contact Eileen but she was not at home.

The paramedics assessed Jane and in view of the continued seizures. Jane was taken to hospital.

The nurse's role will be to support family through this difficult time. The nurse will need advanced communication skills and be skilled at breaking bad news.

The following is adapted from the RCN guidance, Breaking bad news: supporting parents when they are told of their child's diagnosis.

Key points for sensitive communication

  • Preparation - of yourself, the environment and the person(s)
  • Planning
  • Communication
  • Support


  • Where ever possible speak face to face, in a private space with a do not disturb sign
  • Block time include time for support and questions
  • Consider any additional needs
  • Ethnicity
  • Language
  • Sensory loss
  • Cognitive impairment


  • Know the back ground 
  • Plan what you are going to say - rehearse if needed 
  • Predict questions
  • Consider the options and what choice might be made


  • Confirm who you are and who are speaking to 
  • Ask them what they know so far
  • Break messages into smaller parts
  • Check back what has been heard and understood
  • Project time and privacy afterwards
  • Attend to physical needs, lavatory, drinks, tissues


  • Provide additional access to the key information e.g. a leaflet or web link
  • Arrange a follow up meeting or phone call
  • Document the conversation
  • Make appropriate referrals or access to services
  • Ensure the team are aware of the conversation and the information shared (where appropriate)

In summary the role of the nurse in these circumstances is to:

  • take responsibility
  • organise 
  • co-ordinate
  • record

When supporting nursing colleagues the nurse's role is to ensure access to Continuing Professional Development (CPD)

Eileen, living with frailty

The staff were aware that Eileen is living with frailty but remains in her own home in the village visiting every day to see Jane. Rachel is keen to understand more about frailty and knows Danilo has completed some online learning. She asks Danilo if he is able to offer a brief teaching session in the afternoon and suggests that some of the residents' relatives might like to come. Danilo explains that;

People often have an image of someone who is "frail", perhaps a stooped thin shuffling older lady, but this is often inaccurate. Frailty is a distinctive health state related to the ageing process in which multiple body systems gradually lose their in-built reserves both physical and psychological. It is often described as not having the ability to "bounce back" from such things as infections or a physical trauma. However, frailty is not an inevitable part of ageing: it is a long-term condition, like diabetes or Alzheimer's disease.

Older people living with frailty are at risk of poor health and social outcomes such as dramatic changes in their physical and mental wellbeing after an apparently minor event which challenges their health. Frailty varies in its severity and individuals should not be labelled as being frail or not frail but simply that they have frailty. The degree of frailty of an individual changes, it naturally varies over time and can be made better and worse. Our role as nurses is to optimise the wellbeing of people who are living with frailty and to educate and support the person and their families so that they plan for the future.

How do we know if someone has frailty?

Sometimes we think we know someone has frailty by the way the look, speak or move, but more important indicators of frailty are frailty syndromes. Frailty syndromes include:

  • Falls (e.g. ‘collapse’, ‘legs gave way’, ‘found lying on floor)’
  • Immobility (e.g. sudden change in mobility, ‘gone off legs’ ‘stuck on toilet’)
  • Delirium (e.g. acute confusion, worsening of pre-existing confusion/short term memory loss)
  • Incontinence (e.g. new onset or worsening of urinary or faecal incontinence)
  • Susceptibility to side effects of medication (e.g. confusion with codeine, hypotension with antidepressants).

This example demonstrates how CPD can come in many different forms.  Whilst open learning is often used, it is really useful to use colleagues' expertise and can be helpful and informative to provide education sessions that involve both residents and family members. Learning together cements a sense of community and can provide illuminating insights.

Other transfer

Sometimes residents need to be transferred to other permanent residences, this might be the residents own choice for example to be closer to family members, on other occasions residents have needs that cannot be met by the home they are currently living in. Occasionally residents need to be transferred to other residences as the home they are living in needs to close.

It must be remembered that sometimes a transfer to another residence can be rewarding as people move closer to family or friends or couples move in together.

Jane and Eileen

Following Jane's return from hospital, Eileen was exhausted and decided to move into Red Cedars to be with Jane.  This was a time for them to live back together and spend time with each other as Jane entered the end of her life.

Intimacy in latter life is something people sometimes find difficult to support, whether this is couples who had relationships before living in care or new relationships that develop. A particular issue which can cause concern is when either or both people in the couple have cognitive impairment. The RCN has provided guidance about this for nurses (published July 2018).


When a home or part of a home closes (either temporarily or permanently), the nurse must support the residents who live there so that, despite the difficult circumstances, people have a good experience of moving to a suitable, safe alternative home that meets their needs. Moving home can be traumatic even when people plan and choose to do this, so the impact when people have to move at short notice due to unforeseen circumstances or emergencies should not be underestimated. This also applies to people affected indirectly by the closure, such as those already resident in care homes where people move to. Friends and families will be deeply affected by any involuntary move.

The management team at Red Cedars asked for an urgent staff meeting and explained to staff their financial model was no longer working and despite the excellent care being delivered there was a very real danger that the home might have to close. The team were shocked and were asked not to share this information with residents or families until it was confirmed and all other solutions had been explored. Rachel was deeply concerned for the residents, and that the staff had been told this without plans being in place. Rachel immediately contacted the RCN for further support from her local branch.

In the event of care home change of ownership or closure

The RCN understands that you are likely to be feeling anxious due to the uncertainty over the future of your care home and the impact this will have on the residents and your job. Please be reassured that as an RCN member, you will be provided with advice and support throughout these changes and beyond.

As part of any reorganisation your employer has a duty to consult with you directly over any changes to your job, including transfer to another employer. It is important that you have a say in whatever changes may be proposed and we would encourage you to get involved in any consultation. More detailed information can be obtained from the RCN website advice pages.

It is also important that during this transition you feel supported to maintain your high standards of care for residents, and able to manage the anxieties of the residents and their relatives regarding any potential move to a new home or transfer of ownership. Safe care requires sufficient resources and staff to be able to give residents information, consult with them over choices, and to help them feel safe through and following transition.

See further information and advice about questions to ask and support you can expect in the RCN guidance sheet (below).

In the meantime please ensure your contact details are up to date, particularly your email address, online at MyRCN.

When and if you are given details of any proposed changes likely to affect you please contact us on 0345 772 6100 between 8.30am - 8.30pm for support and advice.

End of life care

Whilst some deaths occur suddenly, the majority of people die after a period of chronic illness, with three quarters of all deaths being expected. Many people entering a care home with nursing will be at the end of their lives. A person is ‘approaching the end of life’ when they are likely to die within the next 12 months. During this time people often require ongoing care which may include end of life care. It helps them to live as well as possible until they die, and to die with dignity. It also includes support for their family or carers.

Here are some fundamentals of end of life care that apply to all care settings in England, Northern Ireland, Scotland and Wales.

  • People should be seen as individuals, asked what is important to them and involved in all discussions and decisions about their wishes and care.
  • Everyone should get fair access to care no matter where they live or what their circumstances.
  • People should be supported to be as comfortable as possible and all care and treatment should be reviewed regularly to ensure that this happens.
  • The care the individual receives should be coordinated so that everyone involved is aware of the plans; changes should be shared and transitions managed in a way that ensures the person and the people who are important to them are part of this. The individual should be able to access support from informed staff day or night.
  • The individual should be assured that all staff involved in their care are competent, confident and compassionate.
  • The community and the public also have a role to play. They should be able to have conversations about death and dying, including what can be done outside the health and social care systems.

Situation, Background, Assessment and Recommendation

Inadequate verbal and written communication is recognised as being the most common causes of errors and poor resident experience, this being particularly true during periods of transition. Communication is more effective in teams and between teams where there are standard communication structures in place.

"SBAR" is a way of standardising handovers. SBAR stands for Situation, Background, Assessment and Recommendation. It is used frequently in care homes, particularly when speaking with external health professionals. SBAR is particularly useful if staff are trying to get complex needs across such as care at end of life. SBAR is easy to remember and encourages staff to think and prepare before communicating.

An example of how SBAR might be used is:


This is Sue Smith a registered nurse at Red Cedars care home. The reason I'm calling is that John Clark has become confused, his oxygen saturation has dropped to 78 per cent on room air, his respiration rate is 30 per minute, his heart rate is 110 and his blood pressure is 85/50.


Mr Clark is a 86-year-old gentleman who has lived here for a year. He has chronic pulmonary disease and his oxygen saturations are usually 89 per cent. He has been on oral antibiotics for three days. He has cardiovascular disease and moderate dementia. John does not wish to be admitted to hospital and has an advance direction in place.


Mr Clark's vital signs have been stable since he has been on antibiotics but deteriorated suddenly this evening. He is not complaining of pain and he does not have an increased cough. He has been eating and drinking. He has not been this confused before and I think he is experiencing delirium.


I would like an urgent review to enable us to treat him within our care home with appropriate support.


Amanda Cheesley - Planning and Preparation for the End of Life

Nurses are pivotal in ensuring that people who are approaching the end of their lives are supported to die in the place of their choice, as far is practically possible, in the way that they wish with the people they love. Nurses are, of course, part of a team and should not be expected to work in isolation in providing end of life care. However, they are often the people who are seen most by dying people and their families and are also perceived as being approachable and knowledgeable. The key skills include:

  • Communication skills - the ability to initiate or take part in conversations about death and dying
  • Assessment - the ability to assess people's needs, in partnership with the individual and those who are part of their lives, discuss them with everyone involved and make sure this is written down and shared
  • Co-ordination - all the care and treatment needs and wishes of the person who is dying are shared with everyone who might have contact with them. If possible one person takes responsibility for this and that individual ensures that they or a nominated deputy are available for both the dying person, their family and other care professionals to ensure that the plan of care is followed and unnecessary confusion, stress and distress are avoided
  • Competence - all nurses should be competent to provide compassionate and sensitive end of life care with the support of the wider multi-disciplinary team. This is a fundamental nursing skill and not one that should be avoided.

The RCN recognises that nurses and health care support workers (HCSWs) may find themselves in situations where a patient approaches them about their "desire to die". In these cases, the RCN seeks to provide guidance and support for nursing staff for what we recognise can be very difficult scenarios. Conversations can often begin with a patient asking about, or requesting, assistance to die, but can lead to a nurse being able to help and support that person better through to the end of their life. Through addressing a patient's concerns regarding end of life, around pain, anxiety, financial considerations or family matters, the patient feels more supported. For this reason, it is of the utmost importance that the RCN's position on assisted dying does not potentially undermine the relationship between nurse and patient and obstruct those conversations.

The RCN's guidance, When someone asks for your assistance to die, provides nursing staff with information and signposting, should a patient, relative or carer, ask about assisted dying or actively hastening death. This guidance strongly states that assisting a person to die is illegal in all parts of the UK. The guidance sets out the legal, ethical and clinical frameworks around assisted dying in respect of current legislation. The RCN is aware that should the law be amended, it will be necessary to amend this guidance and we will work with the relevant bodies to ensure that our members are fully informed.

All of us are touched by death and for staff working in care a care there will be times when death is hard to come to terms with. We also need to acknowledge that non family members and professional can experience grief when someone they are caring for dies.

In care home settings other residents are also bereaved and need support. Grief affects everyone differently and we need to understand the normal grieving process, how it can manifest itself and recognise when it is more complex and signpost people to specialist help.

The nurse has a role in leading the support to the team, allowing time for staff to grieve and to discuss the events surrounding a death, which might be of a resident or of a family member. Making time to debrief from difficult situations and learning from event is important. The nurse might use structured reflection or compassionate words and actions to support colleagues.

As leaders it is important to recognise when staff need further support and intervention and the RCN membership service provide counselling service free to members.

Ruth Burey - Decision Making at the End of Life

The end and rebirth of Red Cedars

Sue and the team felt very strongly about the high quality care they were able to offer at Red Cedars and felt there was an opportunity for the home to continue if they delivered additional services. Sue's husband had just taken early retirement and worked with Sue and financial partners to propose a new model of care which included delivering contracted intermediate care, providing domiciliary care and meals to the local community, and running a day nursery within the home.

The accommodation in the grounds will be used as rental accommodation for student nurses and the home now offers high quality placements and bank work to ensure there is succession planning for the registered nurses.

The residents

John continues to live at Red Cedars with Dave and Graham visiting regularly; he is a member of the residents' forum and had just arranged for a broken vintage car to be delivered so that he can work on it with some of the other residents.

Following Jane's death, Eileen decided to move into the home and she arranges visits from the local operatic group to help with fundraising evenings for the home's chosen charity. The team are supporting her in her grief.

Seema now visits for respite care every other month and her great grandchildren attend the day nursery which is on site. Seema's granddaughter is doing work experience at Red Cedars prior to her application to university.

The staff

Rachel is undertaking her nursing degree and still works with the team doing occasional bank work. Danilo has undertaken further study including independent prescribing and is working at an advanced level as the clinical lead in the intermediate care unit. His wife and children are now able to join him. Sue is the registered home manager and is developing colleagues so that the home can continue long into the future.

Page last updated - 24/06/2024