Inspection reports on private nursing homes obtained under the Freedom of Information Act reveal a litany of failures by some homes to maintain basicstandards. Kitty Holland and Carl O'Brien investigate.
It broke Sandra Smaul's heart to have to put her mother, Maureen (78), into a nursing home. She adored her Mam, who suffered from Alzheimer's, but three years ago she had broken her hip and was in need of 24-hour care.
"I was thrilled when I found the place," says Sandra now, "it was not too far from home, which meant I could spend less time travelling and more time with her. And it was recommended by the health board."
A year later, shocked at the standards of care, she took her mother out of the home and back to live with her family in a Dublin suburb.
On one occasion Sandra had arrived to find her mother tied into her bed. On another, a member of the unqualified catering staff was administering her mother's medication.
She found other residents being ignored as they called out for assistance in their rooms and once found a woman in her 80s strapped into a chair, naked from the waist down and shivering.
"I put a blanket over her but I just thought it was appalling," she says.
When a care assistant told her she had found Sandra's mother lying face-down on the floor of her room, with the chair she had been strapped into on top of her, Sandra chose to bring her mother home, where she nursed her until she died eight months later.
Still open and under the same management, the home has 26 residents, each paying €750 a week for shared rooms. Contacted by The Irish Times, the proprietor of the nursing home says he is "sorry Sandra was unhappy with some aspects of the home when her mother was with us" but adds: "The rest of the residents and their families are very pleased with the care and facilities we provide." He says the home has been inspected on several occasions by the health board and "everything was in order".
About 25,000 older people are cared for in public and private nursing homes across the State. This number is set to grow dramatically, with official estimates suggesting the number of people aged 65 and over will double within the next 30 years.
The shift in the population's age profile, described by doom merchants as a demographic timebomb, will inevitably place huge strain on an already creaking health service.
However, an investigation by The Irish Times reveals that the elderly care system is already failing many vulnerable members of the community in hundreds of nursing homes across the State, despite reports of abuse and neglect.
Physical conditions in some public institutions are so poor that senior health-board officials admit that half of them should be closed down immediately. Official inspection reports of some private nursing homes also illustrate a failure to address serious issues such as poor hygiene standards, inappropriate storage of medicines and inadequate heating in winter.
Laid bare along this faultline is a service without any minimum standard of care, where most staff do not need any qualifications, and where the issue of abuse is being whispered about, but not always taken seriously by authorities.
Most older people never need to enter a nursing home. The vast majority live at home or with relatives and are cared for by family members or health workers. The 5 per cent of elderly people who end up in institutional care are resident in either public or private nursing homes or institutions.
"For anyone, be it a spouse or a child, to see their loved one unable to care for themselves can be very upsetting," says Mairead Hayes of the Irish Senior Citizens' Parliament. "We have people who ring up here crying over it. It's a highly emotive issue. People wonder if they're doing the right thing."
The vast majority of nursing homes offer satisfactory standards of care, say groups representing older people, but a study commissioned by the Government estimates that between 3 and 5 per cent of older people in care, at home or in institutions, suffer abuse at any one time.
"We are fortunate that most care is good," says Prof Des O'Neill, consultant geriatrician at Tallaght Hospital, "but abuse in institutions occurs where people are overstretched, under-resourced, where there aren't quality markers and where staff aren't trained."
Abuse isn't necessarily physical or sexual abuse. It may be verbal or psychological. It may be an act of neglect or an omission to act. Or it may occur when a vulnerable person is persuaded to enter into a financial transaction they did not consent to.
Acknowledgment of the scale of abuse of older people has many parallels with that of child abuse, in terms of denial, underestimation and then final realisation.
Older people are less likely to speak out about low standards of care, while families are often fearful that criticism will result in their relative losing their much sought-after nursing home bed.
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.
In Ireland, however, no such measures have been taken. And all indications are that while the issue is being whispered about, it isn't being seriously acted upon at the highest levels of Government.
Ann Quinlan still wells up with anger when she remembers the treatment her husband received in a public nursing home just days hours before he died. Her husband Mickey (72) had been admitted to Tralee General Hospital after suffering an asthma attack. Two weeks later, when his condition deteriorated, he was transferred to Killarney Community Hospital.
When she came to see him the night before he died, she found him without any clothes from his waist down and lying on a rubber sheet. He was given a sleeping tablet that night which it was clear he didn't want, Ann says.
"I'll never know if he wanted to say anything to me. I went to his grave in Limerick last month. It's still in me [the frustration]. It's there all the time," she says. Ann, who is 77 years old and still lives in Killarney, wasn't the only person unhappy with patient care at the Killarney Community Hospital.
An inquiry commissioned by the Southern Health Board followed on foot of a series of complaints about the hospital. While Ann's complaints could not be fully investigated due to an absence of medical records, on a wider level, the report revealed shocking lapses in the administration of drugs and inadequate nursing cover. The controversy at the State-run hospital, which was not subject to any inspections, highlights what patients' groups, social workers and carers see as gaping holes in the legislation governing the area of nursing home care.
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, there is no specific legislation dealing with the quality of the 500 publicly-run nursing homes or institutions which care for about 10,000 people, and these facilities are not subject to any external inspections.
Meanwhile, the regulations on inspections and standards of care for private hospitals, according to social workers, are highly ambiguous, undefined and non-specific.
The regulations made under the 1990 legislation make general requirements about "appropriate", "adequate" and "reasonable" standards and do not contain any nurse-patient ratios.
As one Midlands nursing home operator put it: "If an inspector gives out you can turn round and say you're still complying with the regulations."
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.
One of the few specific requirements is that one qualified nurse must be on the premises of a nursing home at all times, regardless of how many residents the home accommodates. Officials admit they are forced to refer to standards set out in British legislation because requirements in Ireland are so vague.
The repercussions of this are serious. Health authorities, fearful of fighting a legal battle they could easily lose without legislative back-up, are highly reluctant to prosecute a nursing home owner with poor standards.
A survey of health board areas shows just one nursing home has been closed down over the last five years.
"The health boards just can't get their act together," says one senior inspection official. "I know in one area we saw gross problems, and reported it right up the line, but it was sat upon. Nothing was done."
The inspection teams themselves are not independent, admit health board officials, given that in many cases they are providing education and health promotion services to homes which they are then asked to inspect.
"It should be an independent task and needs to be carried out by people of the highest calibre," says Anne O'Loughlin of the Irish Association of Social Workers. "It's given to people who are already overworked and are involved in several other areas of work. I wonder what that says about the value of the job."
St Mary's Hospital in the Phoenix Park is Dublin's biggest public long-stay institution for older people. Built in 1769 as the Royal Hibernian Military School, it retains its original large rooms, high ceilings and tall windows.
Today it is home to 327 patients and residents who range from older people with dementia, those receiving rehabilitation and the physically disabled.
While health professionals say older people should have their own room and toilet facilities where possible, one of St Mary's wards accommodates up to 36 patients, although it is divided into six cubicles.
The Eastern Health Board - now the Eastern Regional Health Authority - acknowledged in 1999 that it was proving increasingly difficult to meet modern-day standards at the hospital and announced plans to replace it. Four years later, the old building is still bustling with activity.
It also recommended that two other old institutions in Dublin be replaced, Brú Chaoimhín on Cork Street and St Brigid's Home, Crooksling, both of which are still operating.
While standards of care provided at these facilities are very good, according to health professionals, they are battling to provide care in outdated and unsuitable accommodation.
One senior health-board official working in elderly care in the east of the country, when asked why the public institutions were not inspected said, "Because they'd have to close half of them in the morning if they did."
Staff at many publicly run facilities are unhappy at the physical conditions of the buildings, but say they are doing their best in the circumstances.
"We'd like to have more space," says Dr Dermot Power, a consultant geriatrician in St Mary's. "We'd like to have more therapists, we've like to have more of everything . . . but we provide the best we can with our budget and I know we've pretty good care here."
Despite shrinking health budgets, staff have helped generate three imaginative schemes this year including a unit for stroke sufferers, a clinic which acts as an alternative to visiting casualty for older people, and a specialised ward for people with dementia. Staff at the hospital also say they would welcome external inspections and insist it would even strengthen their case to improve facilities.
Unlike most private hospitals, which provide basic care, there is also a multidisciplinary team on the site including a physiotherapist, occupational therapist, a dentist and chiropodist. All staff are trained, whether they be nurses or care assistants, which is not the case with the majority of private nursing homes.
Noel Traynor, former staff nurse in a public nursing home in Co Monaghan, says "lack of staff is a perennial issue" and a lack of trained staff compounds this. Few care-assistants in private nursing homes have received formal training.
"There is a perception that it's just a matter of bodies on the ground, that for example anyone can bath an elderly person. But it takes a professional nurse to be able to judge skin integrity, judge how things are developing," says Traynor, who is also industrial relations officer with the Irish Nurses' Organisation. "You see nurses and care staff flying around all day. The interaction they can give patients is based on the amount of time they can give. It is common they \ get little stimulation from staff and those staff are relying on good families to provide that."
The following is an extract of a recent letter to the Irish Association of Social Workers from the wife of a resident in a private nursing home in the east coast area, pleading for her husband to be relocated to another home.
"Since his transfer he has deteriorated an awful lot. He seems very withdrawn and disorientated and he has had several bad falls. He often looks quite dirty, unshaven and smells of urine . . . He is continually strapped into a wheelchair and gets no exercise. Each time I visit him I find it very distressing and become quite upset thinking about him."
While extreme, it's by no means an isolated case. Nursing home inspection reports for private homes, obtained under the Freedom of Information Act, reveal a litany of failures by homes to maintain hygienic kitchens, store medicines properly, or keep homes heated adequately in winter.
Records also show that many nursing homes are dragging their feet in responding to the criticisms outlined in inspection reports. For example, it took a nursing home in the northeast area more than 12 months to deal adequately with criticism that some residents were wearing winter clothes in bed to keep warm.
In one Dublin nursing home, inspection officials suspected that patients were not being washed regularly as, during an early morning spot-check, residents were already up and dressed. Fine Gael TD Fergus O'Dowd, who has been campaigning to improve standards of nursing homes, says more needs to be done to improve the enforcement of standards.
"A minimum period of, say, two weeks should be given to put it right," he says. "If not, there should be immediate prosecution and the health board should take over the running of a home until it is right," he says. "It is totally unacceptable to find, as I did, a patient in a nursing home bed wearing two jumpers and day clothes while in bed to keep warm. It is an indication of low standards in some places."
There are also serious concerns over what activities private nursing homes provide for their patients.
In one private home in the Midlands, visited by The Irish Times in the past fortnight, no activities were on offer. When asked about this the proprietor said, "Sure they don't want that kind of thing."
When the residents were asked by The Irish Times if they got bored, none complained, saying, "We have lovely views to look out at" and "We pray together. What more would we want? We've no interest in things like that [other activities] getting ready for the next world."
While regulations made in 1993 under the 1990 legislation require homes to provide "facilities for the occupation and recreation of persons", most offer little more than bingo and cards. Service agreements with private operators do not require other services such as physiotherapy, occupational therapy or chiropody.
Only the more expensive private operators provide physio, occupational and speech therapy as a matter of course.
Sean Collins, chairman of the Irish Nursing Home Operators, says these services are available in "high end" nursing homes but accepts that more could be done to improve access to services overall.
"It could probably be improved upon across the board, but it also depends on residents, and some aren't interested and others simply can't partake in activities."
Overall, Collins says that standards in private homes are high and that homes that failed to provide adequate standards would not survive.
"Overall we feel the standards are high. As in any industry, standards are improving year on year. If a home isn't up to required standard, they won't survive in the long term."
The way forward in improving monitoring and standards may be to follow Britain's example. There, the Care Standards Act (2000), which involves establishing minimum standards and independent inspections of all private and voluntary nursing homes and residential institutions, is being implemented. 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 nursing or personal care for older people.
A report by the Dublin-based 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.
Whistleblowing protection for staff who alert authorities to the failures of the health system is vital, says Anne O'Loughlin, if careworkers are to be encouraged to speak out without fear of putting their job at risk.
Health experts, such as Prof Des O'Neill, also say the issue of the lack of adequately trained staff could be solved by providing courses for nurses and careworkers which would centre on the specialist care of older people.
Most of these recommendations have been made and submitted to the Department of Health in numerous reports, yet no official action has been taken.
The Minister with responsibility for older people, Ivor Callelly, accepts many of these points. He says he would "love to bulldoze" many of the public hospitals for the elderly. "I have visited many and I am not satisfied with the structures of them though the care is tremendous."
He says he has undertaken a personal national inspection of public geriatric services throughout the State and is confident of getting necessary funds over the next four years to address deficiencies in the public system. He adds that he plans to establish a formal inspectorate of public nursing homes, saying it is "a case of finding the right mechanism to ensure meaningful inspections". He can not, however, give a time frame for the introduction of an inspectorate.
The Government wants to move as much as possible from the nursing-home option when considering the long-term needs of elderly people in need of care, he says. A key aspect of this is the development of "personal care packages", where an older person could receive services at home. Schemes like this are being piloted in the eastern, north-eastern and north-western regions.
"All the studies show people thrive better and for longer in their own homes," Callely says.
This does not address the issues Sandra Smaul faced in the home her mother spent most of the last 18 months of her life. And she says she is still unhappy at how her complaints were handled. The proprietor of the nursing home rejects Smaul's criticisms, pointing out that health board officials have inspected it on several occasions finding everything in order.
"We talk about what happened to children in institutions years ago. But what these places are doing to old people, who are just as vulnerable and unable to speak out for themselves, is as bad," Smaul says. "Maybe, unless they've seen it being done to their mam or dad, most people don't care either."