Legislation on nursing home standards is increasingly being seen as inadequate, writes Carl O'Brien.
Therese Lipsett is displaying some handwritten letters of support from residents and GPs which, she says, show their level of satisfaction with her Rathgar nursing home.
"Generally, if people are concerned about their mother or father, they won't have them there," she says. "Finding a home is a domestic situation. It has to be suitable to a family, and the family has to be content. Otherwise, it won't work. If they're not happy, we're not happy."
The South Western Area Health Board, however, has a different view. It went to the High Court last month seeking to close down the home because it claimed 23 residents there were at risk due to a series of lapses in care.
It said drugs had been improperly administered, medical records were missing, fire safety procedures were inadequate and there was a lack of qualified staff on duty.
The High Court ruled that authority to close down the home rested with the District Court, a process which may take several months to complete.
The health board was left looking clumsy and impulsive, trying to bypass normal procedures to close down the home. Residents at the nursing home were in a lather of anxiety, not knowing whether the home was going to be shut down or not, while the substantive allegations remained unresolved.
One of the few certainties to emerge from the confusion surrounding the debacle was that legislation governing standards in nursing homes is increasingly being viewed as inadequate across a wide range of areas.
The Nursing Home Act (1990) was aimed at improving standards in nursing homes by establishing twice-yearly inspections of privately-run homes and enforcing care standards for the first time.
However, the 1993 regulations attached to this legislation on inspections and standards of care for private hospitals, according to social workers and inspection officials, are often ambiguous, undefined and non-specific.
As well as this amorphous regulatory regime, health boards must follow a protracted route which takes months to complete if they wish to shut down a home where it believes residents are at risk.
The regulations made under the 1990 legislation make general requirements about "appropriate", "adequate" and "reasonable" standards. One of the few specific requirements is that one qualified nurse must be on the premises of a nursing home at all times.
An internal guide, used by the public health officials who inspect the homes, gives inspectors a large degree of freedom when interpreting requirements and at one point states that there should not be "unnecessarily onerous" requirements.
The health board inspectors, who themselves are understaffed, acknowledge these problems privately and say they result in few nursing homes being taken to task for breaches of care.
"After a while you get to know the good ones and bad ones," said one senior Dublin-based inspection official, speaking on condition of anonynimity.
"If there is something wrong, or there's a breach in the regulations, a letter goes to the nursing home section, to the client, and they are given time to rectify it. We go back and do a spot inspection, but staff constraints often mean we don't get to do a spot check."
The official said that while standards vary dramatically from nursing home to nursing home, it is often difficult to prosecute those who repeatedly breach regulations for a range of reasons.
"Legally it is difficult to prosecute. If you have, say, two professionals going in and checking things out, you can easily overlook things. The legislation is also vague. That means its difficult to implement anything, unless it's specially stated in regulations or legislation. There are no specific provisions for providing activities of any sort, for example."
Inspection files released under the Freedom of Information Act appear to bear this out. It took a nursing home in the north east more than 12 months to deal adequately with criticism that some residents were wearing winter clothes in bed to keep warm.
Records show officials in another Dublin nursing home suspected patients were not being washed regularly as, during an early morning spot-check, residents were already up and dressed. The home is still operating, albeit under new management.
Professionals familiar with the nursing home sector believe just one nursing home has been de-registered since the 1990 legislation was introduced, while a number of others may have closed for financial reasons or due to negative publicity.
Paul Murray of Age Action Ireland believes an independent inspectorate is needed and that spot-checks are no way to adequately police nursing homes.
"If the financial institutions and the gardaí have an independent inspectorate, surely we should have one for frail, older people," he says.
"If we had some kind of inspectorate that could report, we might get some handle on the extent of the problem. There is no doubt that there is abuse, and no doubt that there is abuse in a lot of places."
His request hardly seems unreasonable given that residential units for young people are inspected by the Irish Social Services Inspectorate, an independent body, while psychiatric hospitals are inspected by the Inspector of Mental Health Services, an independent statutory body.
The Irish Nursing Home Operators group says that, whatever about the inspections regime, standards in private homes were high and homes that fail to provide adequate standards would not survive.
The Department of Health, meanwhile, has avoided talk of introducing new legislation, although sources say they will examine the possibility of strengthening existing laws to help fast-track the closure of homes which clearly place their residents at risk.
In Britain, however, the Care Standards Act (2000), has transformed the sector by establishing minimum standards and introducing independent inspections of all private and voluntary nursing homes and residential institutions. It also sets targets on the proportion of carers who should be qualified and provides detailed core requirements which apply to all care homes providing care for older people.
A report by the Human Rights Commission this year called for similar measures here. It says legislation on basic quality of care is necessary to cover up-to-date public information on the standard of nursing homes, an improved complaints and appeals system, and independent inspections.
In Britain it took a series of serious abuse incidents before legislation was enacted last year which provided for greater control, higher quality and the standardisation of services across the whole home care sector.
Health sector workers and interest groups are hoping it will not take similar tragic incidents to prompt legislative reform here as well.