Reflection on the ‘Small Houses’ Movement and the concept of ‘Universal Worker’

During my stay in Ohio, I had the chance to join a postgraduate gerontology class on a field trip to Otterbein Senior Living, AKA the ‘small houses’. The concept emerged from a movement to deinstitutionalise nursing homes by providing a more personalised environment in the form of small, self-contained homes for 10-14 people. All levels of care are provided, as the small houses are skilled nursing homes.

In this concept, signposts of the medical model are eliminated, as each resident has a private en-suite room that they can fully personalise, the environment looks like a real home, the bedrooms are a short distance from the communal areas, and residents have access to all indoor and outdoor areas. The residents are not typically separated by level of care, meaning that people living with dementia are not placed in separate units, unlike in most traditional care homes. Furthermore, there is no kitchen or domestic staff. Instead, the healthcare assistants serve as ‘universal workers’, cooking meals together with the residents, cleaning and participating in the social life.

Having worked in traditional care home environments usually made for 80-100 residents, it was refreshing to see a more personalised approach to care. The environment itself was friendlier and more ‘homey’ than the usual care home, feeling like a house instead of a medical institution. I was also happy to see that people living with dementia were not secluded and locked on a floor, as is too often the case, but were instead able to enjoy outdoor space and actively participate in the daily life of the home. The Home Manager seemed to genuinely care about the quality of life of the residents, allowing people to bring their pets and always seeking their feedback to improve.

However, the model is not perfect and still has its challenges. For example, the concept of the universal worker is mentally and physically very challenging for the staff. I was shocked to learn that these workers were initially offered a lower wage than traditional care workers, considering the extra tasks which were asked of them. This was reflected in the staff retention number, as the home manager openly talked about his struggle to attract competent staff with such a low salary. I would have been curious to see how the home worked on a daily basis. Could the team really, efficiently, be able to do care, prepare delicious and bespoke meals, do the laundry, clean the house and actively participate in the daily life of the home? This seems difficult to believe, except perhaps with a very high ratio of staff per residents (which was not the case).

I was also surprised to hear that the neighbourhood of small houses was sharing only one, part-time, Activity Director, when nowadays most homes offer activities every day of the week. Again, the Home Manager seemed to have a clear and innovative understanding of what activities should look like, but this did not seem to translate into practice, and this was visible in the daily activity schedule.

To conclude, it seems to me that the concept comes from the right frame of mind and is a step forward. However, the reality and application of it are still suffering from the value of an ageist society which still places too little importance on the care of older adults and drastically suffers from a lack of financial capital. To me, one of the first and most important steps toward better care practice is to value those who care for our loved ones. This means better pay and better work conditions. You have to ask yourself, how can a person who has just worked his/her fourth 16h shift remain focused, patient and compassionate? Can we blame the workers for leaving and finding a job which will be better paid and allow them to enjoy more time with their family? For person-centred care to become a reality, more attention needs to be placed on staff retention and happiness.


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