How can you make the right choice when choosing nursing home care, asks Anne Dempsey
Revelations of poor practice in some nursing homes have upset many people with a relative in care, worried others who face that future prospect, and highlighted larger questions about consumer rights in this area.
How can you choose well? Because appearances may be deceptive, how can you know if a nursing home is as good as it looks? What could alert you later if things are not as they should be, and who can you turn to when you are concerned about a relative's welfare?
Irish nursing homes are classified as public, voluntary or private and there are 27,000 older people in long-stay beds. Public nursing homes are run directly by the health board, under the Health Services Executive (HSE), and provide public beds. A small number of voluntary (public and private) beds are available in homes run by non-profit organisations or trusts. A private nursing home is run as a commercial business. Just over half of all residents are in private nursing homes.
If looking for a public bed, you need a letter from your GP requesting an assessment from a geriatrician. Public bed admission is means tested and every older person with a medical card is, in theory, entitled to one. In practice, such beds are scarce.
Where demand exceeds supply, the HSE can "buy" a bed in a private nursing home. These are known as contract beds, and the contract is between the local HSE and the nursing home.
It's also the case that thousands of families don't qualify financially for a public bed but can't afford the cost of private care. In acknowledgment, the Government will pay a subvention to help meet the bill - 42 per cent of which can be claimed against tax.
Sixteen years ago, having cared for family members for over a decade, Ann O'Dwyer opened Retirement Home Information Services Ltd, which offers independent information on nursing, retirement and accommodation. She has visited every nursing home she recommends, and takes no fee or commission from them.
"Generally I am made welcome. Some pretend to welcome but I know the difference and that home does not go on my database. There are other places where I wouldn't like the atmosphere, and so don't offer information about them."
Ideally, she says, people should begin thinking about a nursing home before they need to, making their choice in good time before a vacancy arises. She meets each family and gives an hour's consultation, which costs €70, before coming up with a shortlist of four homes for family vetting.
"My aim would be to identify places that meet individual needs. For example, you could have someone quite well mentally, but frail. So let's try to get a bungalow with a garden, where there is no need for lifts, where she is not always having to ask for help, so her independence is maximised.
"I get families across the social divide. Some want a place that's cosy, others want matching curtains and duvet. A nursing home that looks lovely can be lovely but it may not be. My bottom line is that you have to like the person running the home and feel your relative will like them. You need to be able to trust them, and know you will be met should problems arise. This is a people industry, it's about relationships and accountability."
While private nursing homes must be registered with the HSE and meet standards set out in the 1990 Health (Nursing Home) Act, recent problems highlight obvious inadequacies. Staff/patient ratio regulations are vague and talk about "a sufficient number of competent staff" being on duty at all times.
The Irish Times has heard unofficially of nursing homes with no nurse on duty at night. Secondly, there is no standard training for care staff, and many receive on-the-job tuition only, varying greatly in quality, quantity and duration
"When a family approaches a private nursing home to place a relative, they enter a legally binding contract, consequently they have the right to fully inspect and ask any questions they like about the way it's run. If they are not given a straight answer, they should be concerned," says Gerard Scully, information officer with Age Action Ireland. "You should ask when the home was last inspected and if you can contact the HSE for the results of that inspection. Again, reluctance to answer this question is a warning sign," he says.
The owner of a long-established family run nursing home encourages families to ask to see the inspector's report in the nursing home itself. "In our area, we get no warning of an inspection and it is extremely thorough. Last time we had a dirty tooth mug which was written in the report and later checked up on. We have no problem with this, maintaining high standards is in our interests too," he says.
Unfortunately, families do not have the same rights with public nursing homes or a public bed in a private nursing home. "As the numbers are limited, the individual is not given the same rights when choosing a public bed. It is often a take it or leave it option - though the HSE remains answerable to the patient or carer," says Scully.
At the same time, whether choosing public or private, don't hang back. "People should ask questions about the care of the residents which will be related to staff numbers, qualifications and staff-
resident ratios. What's the atmosphere like; do other residents appear happy?" he says.
"Check out the standard of hygiene and standards, variety and choices regarding food. Are there activities for residents? Can they retain the services of their own GP? Who is in charge day to day and is there someone you can go to with problems or issues?"
It is important to read your contract carefully. Typically, fees cover accommodation, meals, laundry, nursing care, activities and medical-related transport. There may be additional charges for hairdressing, chiropody, dry cleaning, physiotherapy and other services. Ask about fees - legally there is no limit to the amount a private establishment may charge, nor the level of increase.
Does membership of a professional group contribute to standards of care? Pat Durkan is chairman of the Irish Nursing Home Federation, representing 56 private and voluntary nursing homes, and about 2,500 residents in the eastern region: "We require those who apply to submit their HSE inspection report to us and we must be happy with it. We don't provide a separate inspection, we do offer staff development courses and these are relatively well attended.
"Families should ensure the home they are considering is registered with the HSE and is a member of a professional body, as this implies a certain commitment. Choose a nursing home that is convenient for visiting, ask to see its HSE inspection report, ask about it locally and, particularly, talk to the local GP," he says.
In the future, families may also ask if a home is a member of the Health Promoting Residential Care Initiative, launched in January by the National Council for Ageing and Older People and the Irish Health Promoting Hospitals Network to give residents a say.
The initiative recognises that supporting best practice in nursing homes is crucial to promoting healthy ageing. It has drawn up Ten Steps to Health Ageing designed to achieve person-centred care, a positive working environment for staff and a family friendly atmosphere.
Patricia Jaycock is its national co-ordinator. Step 1: Being Person-centred involves consulting 25-50 per cent of residents, inviting them to identify the five most important things that would maintain their wellbeing, leading to an overall top five. From this, staff work on a short and long-term action plan. "Already a number of activities, including arts, holiday schemes, dancing, music, physical exercise and reminiscence therapy, have begun in nursing homes," she says.
The three As of appetite, appearance and agitation can, says Scully, provide an early warning system if a resident is in trouble.
"If an appetite is bigger than usual with you, they may not be eating properly; if it drops offdramatically, they may be suffering from depression or other ailment. They should be clean, with clean dentures, brushed hair, wearing their own clothes and there should be no unexplained injuries. Signs of unusually agitation or nervousness may indicate they are being bullied."
Durkan agrees: "A sudden loss of weight could alert you that something is wrong. Your relative may also begin complaining and you must use your judgment about this.
"When residents retain their own GPs there will be many doctors going in and out which is helpful. Some homes employ one GP to look after all the residents, and he or she could be potentially compromised if a big portion of their income arises from this," he says.
"Go to your GP if concerned about your resident, they are responsible for the medical care package and can, and do, bring concerns about particular establishments to the health inspectorate."
Complaints should initially be made to the matron or sister in charge in a public or private home. If the situation is not resolved, contact the HSE regional office which has responsibility for managing public nursing homes in its area, and for ensuring that standards are maintained in all nursing homes.
Finally, Ann O'Dwyer says: "Irish people can be very bad about complaining. Nursing home inspections are a joke. I've never heard of one where they lift the bed covers or examine the patients. They count light bulbs, examine the drugs cupboard and fill in loads and loads of forms.
"Under the Patient's Charter, you can visit a nursing home any time you like, so if you believe something is wrong, begin visiting at different times. Trust your judgment and keep your focus," she says.