A new inspection regime for nursing homes is changing the culture of care for their residents, reports
JAMIE SMYTH,
Social Affairs Correspondent
THE NEW standards and inspection regime introduced for nursing homes last year is improving standards of care and reducing the use of physical restraints for elderly residents, says Ireland’s chief inspector.
Just over a year after inspections began, Dr Marion Witton, chief inspector of social services at the Health Information and Quality Authority (Hiqa), says there is evidence of a changing culture of care because of the standards.
She also dismisses criticism that higher standards imposed by the authority are causing nursing homes to close due to the cost of compliance.
“When considering standards at nursing homes you really have to ask yourself the question: is this the type of nursing home you would want to spend your final years in?” says Witton, who admits she was shocked by some of the poor standards and practices she came across when she began working at the authority’s inspectorate.
“In other countries such as Britain or Sweden, nursing homes are set up as a home from home and there is an enabling environment. People generally have their own rooms with en suite facilities and there is a communal area for people to meet and chat,” she says.
“What really struck me in Ireland was the very medical concept here. It was a ‘doing to people’ model rather than ‘doing with people’.
“Some homes here are still set up like geriatric wards with shared facilities. These went out of commission in most other countries in the 1980s . . . In some homes there are up to 30 people in a ward,” she says.
Witton says this type of environment can create a dependency culture among residents that leads to a lower quality of life and shorter lives.
“Restraint is not really acceptable in any form. It is often introduced to make life easier for staff rather than help a resident. There have also been some tragic incidents when residents have died after becoming jammed between their beds and the rails used to keep them in bed,” she says.
Restraints are often used when staff fear residents suffering from dementia could fall or wander off. Bed rails, chest straps, lap straps and Buxton Chairs are commonly used restraints.
Witton says the use of restraint varies widely in Ireland: some homes using no restraints at all while others use restraints on almost all their residents. She says homes should look at alternatives to using restraints, which restrict movement and can make residents more agitated.
“Installing handrails and new floor coverings that make it easier to move around a home safely is often preferable to tying residents to chairs,” she says.
“If I do nothing else as chief inspector, I want to stop the use of restraints,” says Witton.
Another big difference in Ireland compared with other countries is that nursing homes are often seen as a community service that can house younger people with physical frailties or brain injuries, says Witton.
“The problem with this is that someone young living in a nursing home will inevitably take on the characteristics of an elderly person over time. This is particularly true of people with a learning disability and makes it even more difficult for them to assert independence.”
Older people at this type of nursing home may also suffer as staff may have to provide intensive support to a younger person with a brain injury, which means an elderly person may lose out on time with staff, she says.
HIQA started its inspections in July 2009 and have now visited every nursing home in the country.
Some 63 inspections were initiated following specific concerns raised by a member of the public, politicians, journalists or social workers. Some 52 centres have received three visits or more from inspectors, signalling that some serious concerns were identified during inspections.
“About half the inspections are announced beforehand to the nursing home and half are unannounced. Some are carried out at night and at weekends. All our inspections are resident focused. We sit with the residents, eat with the residents and chat with them. This allows us to monitor how staff interact with residents,” she says.
Witton says the quality of management at a home is critical to the standard of care provided.
“In the past, owning a private nursing home was seen as an investment, but now, with the registration process in place, there is a growing appreciation by management of needing to meet people’s needs,” she says.
Despite the fears expressed by some nursing home providers prior to the introduction of the new inspection regime, the authority has closed down just one nursing home (Glenbervie in Bray, Co Dublin) over fears for the safety of residents. But there are concerns that the cost of meeting the new standards is driving the HSE and some private operators to close down nursing homes.
“People were very concerned about the costs of meeting the standards, but this is very much about the quality of life for people. People have worked very hard all their lives and, as a society, I think we owe it to them to give them a decent place to live in, one that enables them to keep their independence,” she says.
In many cases the problems at homes can be solved simply and cheaply. “It is often the case that elderly residents don’t get enough water to drink. This causes more complex problems, for example, they get constipated, become toxic, become disoriented and end up falling over and hurting themselves,” says Witton.
She also points to the critical importance of exercise, mental stimulation and promoting independence among residents.
“The Leas Cross scandal was a wake- up call for the country and showed rigorous regulation was required. We can’t guarantee 100 per cent that this type of situation won’t happen again, but by putting in place the best systems and inspections we make it more unlikely,” she says.
WORK IN PROGRESS:'THE DAY-TO-DAY LIVES OF THE PEOPLE LIVING IN THIS HOME SIGNIFICANTLY IMPROVED'
A day in the life of Finbarr Colfer, HIQA inspector manager
In February 2010, another inspector and I visited a centre in our area. We were taken aback by many issues, but particularly by the day-to-day life for residents. For example, a third of the residents were restrained in old-style Buxton Chairs which were in a poor state of repair. None had a safety or therapeutic assessment or care plan for using these chairs, and none had been seen by an occupational therapist.
During the day, many of the residents were put sitting in the day room in rows facing the door to the hallway and the view they had was of the back of another resident’s head. A lot of the residents did not leave their rooms during the day. There were no arrangements to make the day interesting and staff did not have time to spend promoting social interaction among residents.
By the end of the inspection, we had identified significant improvements that were required across all six of the inspection domains, covering areas such as the quality of life and safety issues.
The providers (people in charge of the centre) stated that they had not familiarised themselves with the regulations or the national standards. They believed that they had three years to address the requirements and were waiting for inspectors to tell them how to do it.
Following the inspection, there were a number of challenging discussions with the providers about addressing their legal responsibilities and about improving the quality of life for residents in the centre.
These culminated in a meeting in our Dublin office. This meeting was a turning point, at which the providers acknowledged their legal responsibilities and produced a detailed plan of how they intended to address the items identified on inspection. After the meeting, the providers sent us regular progress updates and a registration inspection was arranged for a few months later.
On that inspection, the difference in the quality of life for residents was immediately visible. Instead of rows, residents sat in small groups in the day room. Many were chatting with each other. A staff member was spending time with residents encouraging them to chat and to take part in various activities.
Residents told inspectors of the wonderful improvements in the way they spent their days, in the meals provided and in the physical décor of the building. Residents who had appeared withdrawn in the original inspection were animated and enjoying their day.
The providers still have a significant amount of work to do to meet their responsibilities and to provide a good quality service to residents, but they have recognised this, have identified the work that needs to be done and are well on the way to addressing that work.
They and their staff have also recognised the improvements in the quality of life for residents since this work commenced. They have developed a sense of pride in their achievements and developed an interest in continuously improving the service for residents.
In this situation, using influence to change the attitude of the provider allowed for significant improvements in the quality of life for residents of that centre. Because the attitude of the providers changed during the process, it was not necessary for inspectors to escalate their responses and to engage in enforcement action. The day-to-day lives of the people living in this home significantly improved: that’s part of what our inspection process is all about.
INSPECTIONS RECORD
Inspections by Health Information and Quality Authority
* 81 per cent of inspections at private nursing homes
* 19 per cent of inspections at public nursing homes
* One nursing home has been closed since July 2009 (Glenbervie in Bray)
Source: Hiqa (report on inspections carried out since July 2009)