In December 2023 CQC published guidance on alcohol in care homes, produced with the University of Bedfordshire. This is our short summary for care home managers and staff, with links to the full documents at the end.
The guidance is for care home managers and for members of the public. It rests on research in which the university’s team spoke with residents, their families, care home managers and CQC inspectors. They talked about how homes manage alcohol. The National Institute for Health and Care Research School for Social Care Research funded the study.
What the CQC alcohol in care homes guidance found
Residents and their relatives saw a drink as part of living well in old age. They felt people should be able to carry on drinking after moving into a home. Care staff described benefits too, such as better mood, wellbeing and confidence, easier relaxation and sleep, a better appetite and more social contact.
Staff also named the risks: medication interactions, confusion, intoxication, falls and injuries, and dehydration. The guide’s view is that good practice can reduce these risks. So the aim is a balance between lower risk and a better quality of life.
Offering a drink, and why blanket bans are a problem
Homes in the study varied a lot. Some offered alcohol every day, at mealtimes or from a bar inside the home. Others offered it only now and then, so residents had to ask. Some felt uncomfortable asking and went without. So the guide recommends that staff offer a drink to anyone who has said they enjoy one. Staff should not wait to be asked.
A small number of homes banned alcohol outright. The guide says a ban conflicts with a basic principle. People in care homes should have as much freedom, choice and control over their lives as possible. A ban may still suit some homes, for example one caring for people who do not drink for religious or medical reasons. In that case, the home must make its policy clear before anyone moves in.
Who pays for alcohol
In most homes in the study the weekly fee included alcohol, usually with some limit. Elsewhere, residents relied on family, friends or delivery services, which can leave out people who have no visitors or cannot order for themselves. The guide says homes should tell people who pays for alcohol before they move in.
Assessment, care plans and mental capacity
Before someone moves in, the home’s assessment of their needs and preferences should include alcohol. Staff can ask in a conversational way: do you like a drink, what do you like, when, and how often? If the person cannot communicate, staff should take their previous preferences into account.
After the move, staff record those preferences in the care plan. A risk assessment can then identify any risks, how likely harm is and how serious it could be. When there are risks, staff help the person weigh them against the benefits, and they may consult the home’s GP or a pharmacist. The care plan and risk assessment then need regular review, because preferences and circumstances change.
Mental capacity and dementia
People with mental capacity can decide for themselves once they understand the risks, and they have the right to make unwise decisions. Dementia does not by itself mean someone has to stop drinking. Staff should respect the person’s previous choices and apply the principles of the Mental Capacity Act. A person may lack capacity for some decisions but still have capacity to decide about alcohol.
Where a best interests decision is needed, it should involve others in the person’s care, such as relatives and health professionals. It should also look for a less restrictive option, for example a smaller or weaker drink that staff serve and monitor. Anyone who cannot drink alcohol should get an alcohol-free alternative when others are drinking.
Storing alcohol safely
The research heard of rare but serious incidents. In one, a resident with a history of alcohol dependence got to an unattended drinks trolley and went to hospital with alcohol poisoning. The guide therefore recommends that homes do not leave alcohol unsupervised or unlocked in communal areas.
Some homes would not let residents keep alcohol in their rooms, in case another resident found it. The guide asks homes to consider whether that is proportionate. A less restrictive option may work, such as a locked drawer or cupboard in the resident’s room.
Alcohol dependence and withdrawal
Before someone moves in, staff should watch for signs that they may be physically dependent on alcohol, so the home can avoid withdrawal. Red flags include drinking first thing in the morning, self-neglect, repeated accidents or falls, and the smell of alcohol on the breath. If staff suspect dependence, they should ask a healthcare professional or the local alcohol service to assess the person.
Withdrawal symptoms can start within a few hours of the last drink, and severe withdrawal can be life threatening. Staff therefore need to recognise the signs and get medical advice. For anyone drinking heavily or dependent on alcohol, the guide says to reduce drinking only under supervision from a healthcare professional or alcohol service. Conversations should be supportive and non-judgemental, and if the person does not want to change, staff should not force the issue.
What CQC focuses on if something goes wrong
Some staff in the study worried about what CQC might do if something went wrong, and that worry made their practice too risk averse. The guide points to Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. It requires providers to assess risks to people’s health and safety and to prevent avoidable harm. The guide also explains that CQC understands person-centred care carries some risk.
The focus, then, is on whether the provider can show it took all reasonable steps. In practice that means assessing and reducing the risks, recording decisions and sharing them with staff, and learning when things go wrong. The guide does not say which incidents would or would not lead to action, because every case is different.
Checking your policy against the CQC alcohol in care homes guidance
If your home has an alcohol policy, or covers alcohol in a wider policy, these are the points to check it against:
- Who pays for alcohol, and how you tell people before they move in
- Staff offer a drink to residents who enjoy one, rather than waiting to be asked
- Any ban, and the reason for it, is clear before someone moves in
- Needs assessments and care plans record alcohol preferences, with regular review
- Risk assessments weigh risks against benefits and involve the GP or a pharmacist where needed
- Capacity and best interests decisions follow the Mental Capacity Act and look for the least restrictive option
- Alcohol in communal areas is supervised or locked away
- Staff know the signs of dependence and withdrawal, and when to get medical advice
Read the full CQC alcohol in care homes guidance
CQC’s announcement is on its website: Guidance on the management of alcohol in care settings, published on 14 December 2023. The documents themselves are on the University of Bedfordshire’s Alcohol Use in Care Homes Study page: a good practice guide for care staff, a guide for residents and the public, and a summary report.