It is twenty past seven in the morning, and a woman is being helped to have a shower.

That is one way of putting it. Here is another.

Margaret has been awake since about five, although nobody knows that, because she has been lying still in the dark. At twenty past seven the door opens without a knock. The overhead light goes on. Two people are in the room and she recognises neither of them, because the home is short-staffed and has called in agency cover.

Margaret says no.

At half past eight it goes in the daily notes. Margaret resisted personal care this morning and struck out at staff. Continues to display aggressive behaviour. Two staff required. GP review requested.

Everything in that entry is true. It is also almost entirely useless, because it describes what Margaret did and says nothing whatever about what happened to her. A description of what a person did, with no account of what was done to them first, is not a clinical record. It is a complaint.

The book returns to Margaret in the final chapter, on the same morning, in a home that asked one extra question about her first.

The argument

Dementia care asks one question extremely well. There is a second one.

The first question is what has changed, and it is the right question, because dementia is defined by decline from a person's own previous functioning. The trouble is that you cannot answer a question about change without knowing where the person started. Change is measured from a baseline, and if the baseline is wrong you will get the wrong answer, confidently, every single time.

So the book adds a second question, to be asked alongside the first rather than after it: who has this person always been? Not in the sentimental sense of what job they did and what music they liked, valuable as that is. How have they always processed the world? Have they always found noise unbearable? Have they always needed to know exactly what would happen and when? Have they always hated being touched without warning?

Ask only the first question and Margaret's notes read: became aggressive during personal care, new behaviour, query dementia progression, consider medication.

Ask both and they read: Margaret has always washed in the evening, has always found unexpected touch difficult, and has never in her life been able to tolerate water on her face.

Same woman. Same morning. One of those entries leads to a prescription. The other leads to a flannel, a different time of day, and a member of staff she recognises.

The square peg is not broken. It is not defective, awkward, difficult, attention-seeking or non-compliant. It is a peg of a perfectly good shape that has been put in a hole cut for a different one. Nothing about it needs correcting. The round home is not the building: it is everything we have built inside it, almost none of which is written down as policy, which is precisely why it is so hard to see and so easy to change once you can.

The contents

Eighteen chapters

Every chapter ends the same way: a page of things to try tomorrow that cost nothing, a plain account of what the evidence does and does not support, and the two questions asked of one real resident.

The square peg and the round home
The generation nobody looked forWhy the admission paperwork is empty, and why a blank space on a form is weak evidence
Autism and ADHD at eighty
Dementia is not one thing
When the masking runs outWhy dementia reveals as much as it takes away
Change or differenceThe four boxes, and diagnostic overshadowing in both directions
Does being neurodivergent change the riskThe emerging dementia evidence, hedged honestly
When the test does not fit the person
The prescription reflex

Who has this person always beenThe eight baseline areas, and how to ask
The sensory home
Saying it so it lands
Mealtimes without a battle
A day worth having
Distress always has a reason
Care plans that read like a person
Training a whole home
A less round home

And four appendices

Built to be photocopied

A. The baseline question bankEvery question from Chapter Ten, grouped into the eight areas. Prompts for a conversation, not a form to read aloud.
B. The sensory auditNot a walk-round. A sit-down. Fifteen minutes in a resident's chair, three times, and the findings sorted into stop this week, under a hundred pounds, and capital plan.
C. Care plan rewritesSeven worked examples. The test for each is whether an agency worker who has never met the person could use it at eleven at night.
D. Four pages for the staff roomThe two questions, the four boxes, the list to work through before anybody reaches for a prescription, and the words that stop the thinking. Copy them, put them on the wall, and stop reading the rest of the book.

Being straight with you

What this book will not do

It will not teach you to diagnose anybody, and you should be suspicious of anything claiming it can. Diagnosing autism or ADHD in an eighty-six-year-old who also has dementia is genuinely difficult work for specialist clinicians, and nothing in these pages will qualify you to do it. That is not a limitation of the book. It is the point of it. You do not need a diagnosis to turn a television off.

It will not replace clinical assessment, safeguarding processes, medical advice or your own home's policies. If a resident is in pain, or unwell, or at risk, that comes first, and the book will still be there afterwards.

It will not tell you that every difficult moment is somebody's fault. Care homes are often understaffed, underfunded and full of people doing skilled work at speed for very little reward. Nothing in it is written to make a carer at the end of a twelve-hour shift feel worse than they already do.

And it is honest about the evidence. Where something is well established it says so. Where a framework is the author's own reasoning from practice rather than a validated instrument, it says that too. There is very little research on neurodivergent older people living in care homes at all, and the book returns to that gap more than once rather than papering over it.

Who it is for

Anyone who writes it down, or has to read it at three in the morning

Registered managers, deputies, dementia leads, nurses, senior carers, quality and training leads, and the people in a group who decide what training gets bought. It is written in plain English, on purpose, because the person it most needs to reach is a carer at the end of a long shift and not a committee.

Families will find it useful too, particularly Chapter Ten and Appendix A, which are the questions worth answering about somebody before they move into a home rather than after.

Build a profile for every resident, not only the ones with a diagnosis. The eight areas describe how a person takes in the world, and everybody takes in the world somehow. A woman who has washed at night since 1961 and cannot bear water on her face needs that written down whether or not anybody ever puts a name to it.

The tools follow the method. The Personhood Profile asks the questions from Appendix A in the same order, keeps the four boxes, flags the words that stop the thinking, and turns what you record into draft care plan wording. If you are working through the chapters, you can record as you go rather than afterwards. The family version is free, and always will be.

A Square Peg in a Round Home

By Kerry Billson. Available now on Amazon. If you read it and it changes one care plan, please leave a review: it is the only thing that gets a book like this in front of the next manager.

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