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Care Home Journey


Welcome to our care home resource.  It is specifically designed to support nursing care in older peoples care homes. It is the first time the RCN has provided bespoke web pages for nurses working this area of the independent sector and the content has been reviewed by current experts.

You will have the opportunity to follow a resident’s journey through from pre admission to end of life or you can simply access individual sections to meet your learning needs and seek clinical inspiration.
Each section will articulate the role of the nurse when supporting the resident, their families and nursing colleagues at a particular stage of the resident’s journey. The website is easy to navigate and provides real life scenarios signposting high quality, evidence based resources to answer the clinical questions that frequently affect those caring for older people.

We recognise that in order to care for older people to a high standard you need to be well supported and the resource gives examples of the excellent personal benefits membership of the Royal College of Nursing brings.



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 met 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 Nightingale Lodge a care home with nursing nearby.


Seema is an 86 year old Gujarati lady who has been cared for 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


Jane has lived with her friend Eileen for 50 years in a small bungalow on the coast. 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 and the remote location of their cottage increases the difficulties they are experiencing. Jane has decided to fund her own care in a nursing home.


Sue has had a long career in nursing, initially as a registered nurse in acute trusts then as a district nurse 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.



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.



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.

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.

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 marshalling 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 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.   

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

Below you will find some further links to resources

Short Stay

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.

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.

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 we see how these roles can support both care and colleagues.

Below you will find some further links to resources


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 have 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.

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

Fundamental/Essential Care

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

Becky and Lisa at the Hollies

Here we see care home staff in conversation explaining about the need for staff to be inclusive within the care home community.

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 neutral 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

Acute Admission

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

Below you will find some further links to resources

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.

Below you will find some further links to resources

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.

Below you will find some further links to resources

Demo Stage

Demo stage showing the various components which can be added to a  Journey Stage

This Point of Interest shows a Sound Cloud audio clip.

Some Extra text on the Stage

You can add as many Text Blocks as you want directly on to the stage after the Points of Interest list.