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Widowed and in their eighties, a couple fall in love while in care and experiencing mild dementia. But while they found happiness, other residents, their families and some staff were less than enamoured with the situation. Paula Green explains the dilemma to Mike George.

It could be said that much of the work of social care staff depends on their understanding and application of the ‘3 Rs’ - rights, responsibilities, and reasonableness. They must balance clients’ rights, staff responsibilities towards both clients and the law, and the reasonableness with which they work to reconcile the often-conflicting interests of different parties.

As everyone knows, this is sometimes easier said than done - as Paula Green has found. She manages a care home for people with dementia, and during much of this year has been faced with a number of dilemmas arising from a relationship between two residents.

Hugh Taylor and Frances Evans (not their real names), both in their eighties, both widowed and in the early stages of dementia, began a romantic relationship. This was  evident to all because of their uninhibited  behaviour towards each other.

Finding love in later life can be thought of as a tremendous, life-affirming gift. But despite the couple’s right to privacy and dignity, in these circumstances Green and her staff had a clear duty to investigate the possibility of abuse or coercion. She obtained the help of a community psychiatric nurse, who was trained in emotional and physical relationship issues, to assess the situation. Following conversations with the partners, both together and singly, they concluded that the relationship was consensual.

However, says Green, she then found herself facing difficulties on other fronts. She was aware that some staff found the situation disturbing or amusing; some were heard to snigger or make unpleasant asides. “I realised that these attitudes could create a major problem within the home unless they were tackled quickly,” she says.

She also found that some residents were becoming upset about the couple’s behaviour. In part, this resulted from their demonstrative behaviour, but was also, she says, the result of a certain amount of envy or resentment among a few.

Meanwhile, members of Evans’s family, who visited regularly, were upset about what was happening. Mainly, says Green, they felt that their mother was betraying the memory of their father; they had been married for a great many years before he died. “I talked the whole situation through with them,” she says, “especially about their mother’s consent to the relationship. Nevertheless, at first they wanted me to somehow separate them. We had lengthy discussions about their feelings, and established that essentially they were concerned about the memory of their father. It was then that we were able to move on.” Taylor’s family, however, did not find the situation upsetting.

Green prepared an action plan designed to both preserve the couple’s rights, and to address the concerns of other residents. One of her first steps was to train staff: “They were reminded about our policies on the abuse of residents by staff, and about the laws which preserve people’s rights to privacy and dignity. I also discussed with them their attitudes towards ageism, and through various informal means encouraged them to open up about their own feelings. The informal approach definitely helped.”

The plan, which Green had discussed with registration and inspection officers, included a specific policy on loving relationships, which formally laid out people’s rights, and staff were required to sign up to it. It also covered ways of encouraging the couple to be more discreet in their demonstrations of affection, while preserving their rights. “This had to be done with care,” says Green. “On one hand we made adjustments, for example in seating and dining arrangements, which demonstrated that we respected their wishes to be together, but we also spoke with them about ways in which their more demonstrably affectionate behaviour could continue but cause less distress to other residents.” Green also spoke with residents individually, and encouraged them to express their feelings. Some, she says were disgusted at the public demonstrations of affection in what was, after all, their home too.

Meanwhile, the adjustments made in attitudes and practices within the home began to take effect. As a result, the couple continued their relationship until Evans died a few months ago. Since then, Taylor’s dementia has worsened markedly. “It sounds unfeeling to say so, but it has meant that his grief has been lessened,” adds Green.

“This was a difficult situation for us, but it did teach us a lot about our assumptions about older people, and about how to balance residents’ rights in a practical manner,” she concludes.

Case notes

Practitioner: Paula Green

Field: Manager of an Abbeyfield dementia care home

Location: West London

Client: Hugh Taylor and Frances Evans (not their real names) are both in their 80s, and in the early stages of dementia. Both are widowed. They have short-term memory loss and are unable to carry out everyday tasks without supervision.

Case history: Taylor has been a resident for more than 18 months; Evans for the past few months. They became close friends and developed a loving relationship. This became evident to staff and other residents. Evans’s family were upset about this development, as were some of the other residents, and staff too found the situation problematic. Green was concerned about either resident being coerced, and notified a community psychiatric nurse. Both concluded that neither partner was being coerced in any way. She then put into place a plan to reinforce staff’s understanding of residents’ rights and their duties of care, and she discussed the situation at length with Evans’s family.

Dilemma: The couple had every right to fall in love, but other residents’ feelings also had to be protected, and the feelings of Evans’s family taken into account.

Risk factor: Both partners were vulnerable to abuse, from each other, from other residents, and from staff and Evans’s family.

Outcome: Their relationship continued until Evans died.

Independent comment

It will be interesting to see how relationships such as those between Taylor and Evans are affected by the new national minimum standards in care homes for older people.

The standards that give direction on meeting needs, health care, privacy and dignity, dying, social contact, autonomy and choice, meals, complaints, rights, protection, shared facilities, staff training, ethos, and record-keeping could all influence the handling of such scenarios.

The standards will, of course, cover all residents in the home. In the situation faced by Paula Green there would  be conflicting claims from several parties that their needs, privacy, dignity, or rights had been affected for a variety reasons.

Sexual activity by older people, or people with learning difficulties, or disabled people causes the public discomfort. In the case of older people it is generally “they should know better at their age”.

The other residents had a right to voice their views because it was their home as well and they were entitled not to feel embarrassed in communal areas.

The story illustrates the dilemmas for staff in dealing with everyone’s rights in a residential home and perhaps crucially just how much bureaucracy comes into play when two residents want to get together.

Dick Clough is secretary of the Social Care Association.

Arguments for risk

- Although both partners had early stage dementia and appeared able to give informed consent, it might have been very difficult to detect changes in the degree of consent given, especially if the condition of one of them deteriorated.

- Their uninhibited behaviour, especially in open or public areas of the home, would normally be regarded as entirely inappropriate in any social care setting.  

- The behaviour was obviously very upsetting for other residents, causing everything from increased and intense feelings of loneliness among some to moral repugnance among others.

- There was a danger that Evans’s family could have felt rejected by Green’s decision to uphold their mother’s rights; this could have led them to withdraw their support.

- Similarly, if one or more members of staff had taken the view that the situation was unsupportable, a variety of workplace problems could have occurred.

Arguments against risk

- Once informed consent was confirmed, both partners had a clear right to engage in a loving relationship, provided that others weren’t needlessly made anxious or upset; this was aided by the fact that there was a double bed in Taylor’s room.

- The relationship led to a distinct improvement in Evans’s self-confidence and abilities; apart from anything else, this suggested that she at least was not being coerced.

- The episode led to a re-evaluation by staff of their assumptions and practice with regard to residents’ relationships, feelings and behaviour, and about older people’s abilities.

- Similarly, it made them more aware of other residents’ feelings and anxieties, and about all residents’ rights.

- The relationship clearly made both of them feel valued, and provided them with a life-affirming and joyful period during a time when otherwise they could have experienced feelings of emotional loss and loss of dignity.