APPENDIX 7
Memorandum by the Relatives and Residents
Association (EA7)
1. ABOUT THE
RELATIVES AND
RESIDENTS ASSOCIATION
1.1 The Relatives and Residents Association
(RRA) exists to provide a consumer voice to promote the well-being
and represent the interests of older people in residential care
settings. It does this by employing the unique perspectives of
relatives and residents to help improve services and standards
for older people, and to influence policy and practice for those
in residential care homes, nursing homes and non-acute hospital
settings.
1.2 The RRA provides support and information;
builds positive relationships; and carries out research on matters
associated with the care of older people and the functioning of
care services.
1.3 The RRA runs an advice line which largely
brings us into contact with relatives of older people living in
care homes or contemplating their options in relation to taking
up a place in a home. They call us on a range of themes, chief
among them being issues connected with choosing a home, paying
the fees, problems in exercising choice and the standards they
encounter having become a resident.
2. THE SETTINGS
OF ELDER
ABUSE
2.1 There are undoubted differences in the
abuse an older person may experience, based on the setting in
which they live and whether or not family carers reside with them.
The comments contained in this note relate wholly to the situation
of older people living in residential care and nursing homes.
2.2 Care homes vary enormously as a result
of their size, or more accurately the number of residents; the
number of staff; the level and types of training required to secure
a job in the home, or provided to enable staff to perform better
in their role; the policies and procedures of the organisation
or individual managing/owning the home. It may be argued that
the larger the establishment the more likely it is that institutional
practices will flourish, putting resident welfare second to "smooth"
functioning. But such a possibility may be countered by larger
homes being able to benefit from economies of scale enabling more
training, better supervision or a wider mix of skills.
2.3 On balance we would suggest that larger
homes might create more scope for things to go wrong, and not
be noticed immediately or at all. The Committee may wish to consider
whether there should be an upper limit on the size of homes.
2.4 In our experience who owns the home—private/voluntary/public
organisation—is less important than whether the home has
aims and values that respect and protect the dignity and welfare
of each individual resident. We have heard reports of good quality
care from small homes, run by sole traders and some of the worst
excesses have emerged from public authorities where the existence
of an infrastructure of support, training and quality assurance
ought to have militated against poor performance. So, in our view
ownership may be a "red herring" when it comes to identifying
key factors influencing whether or not residents are at risk of
abuse.
2.5 Practices which members or enquirers
call us to discuss and seek views on, or support to challenge
individual staff or managers, may seem relatively minor when considered
against serious physical or sexual assaults but we would suggest
that such routine and daily infringements of life and liberty
offend against a frail and dependent person in a major way. Locating
furniture in such a way as to restrict an individual's movements
may not even be obvious to the casual visitor and yet it will
undoubtedly substantially affect the resident's lifestyle. And
if unchallenged may result in more worrying and inhumane treatment
such as that visited on a resident who was tied to a chair by
a dog lead (NCSC annual report 2002-03).
2.6 Relatives frequently comment on the
unkempt appearance of a loved one, mentioning either dirty clothes
or the fact that s/he seems to be wearing an unfamiliar garment,
or something that has been badly laundered or had not been ironed.
A survey drawing on the views of around 1,500 relatives of residents
in homes in one part of Northern Ireland produced consistent messages
on this theme (Eastern Health and Social Services Board and Health
Council, 2001). Such issues would not be so obvious nor so worrying
in the context of people living independently and serve as a useful
reminder of the point made in Para 2.1.
2.7 Routines—to give structure to
staff tasks; rules—governing staff performance; and regimes—devised
to ensure that complex logistics function efficiently all conspire
against respecting the needs of individuals and may collectively
be responsible in varying degrees for institutional abuse (Chapter
8, Elder Abuse—Critical Issues in Policy and Practice
1999).
2.8 We are aware of other aspects of abuse
such as the unauthorised use of residents' personal expenses allowance,
to meet the cost of services that had hitherto been free eg music
and movement sessions, or to bridge the gap between the fees charged
by the home and the amount a local authority is prepared to pay.
This is another type of institutional abuse with the local or
national state being seen by some as the abuser, by reason of
the inadequacy of budgets available to meet the cost of older
people's care.
3. WHAT CAN
BE DONE
ABOUT IT?
3.1 Set high standards, monitor performance
against the standards, reward those homes that comply, penalise
those that fail and regularly review standards with a view to
continuing improvement being made by all parties.
3.2 Central to the performance of a home
is the staff group and the leadership offered to them. Investing
in staffing by providing more training that starts from a value
base of respect for the individual, the protection of privacy,
and the promotion of dignity is vital. But training without supervision
and support will be less effective and so there is a good case
for investing in more and better management too.
3.3 There is a real concern that the organisational
changes of the last few years relating to the inspection of care
services have deflected energy and attention away from basic oversight
of homes. We are worried that the impending changes to the structures
of care inspection may have the same deleterious effect in the
short and medium term even if we believe that in the longer term
there will be significant improvements.
3.4 Lay people had previously played a part
in the inspection process in many parts of the country and this
seems to have been lost during the early life of the NCSC. We
believe that there is a sound case for introducing more—not
less—community involvement in this way. The focus of lay
assessors had been on talking to residents and collecting their
experiences as part of the inspection process adding to the intelligence
gathered by professional inspectors.
3.5 A combination of standard setting, staff
supervision and training, coupled with attempts to further strengthen
inspection by reintroducing an element of lay involvement, would
seem to be realistic and meaningful ways of responding to the
concerns which led to this inquiry.
3.6 It was disappointing to learn that the
introduction of the POVA list was to be delayed, and when this
was further compounded by the poor performance of the CRB, leading
to a dilution of the requirements on providers to seek such checks
on new and existing staff, it seemed that a pattern of disregard
for the welfare and safety of older people was emerging as another
form of institutional abuse—even if that was not intended.
In this sense this pattern might be described as mirroring daily
routines that are not designed to institutionalise residents but
do so nevertheless as an unintended consequence.
4. RECOMMENDATIONS
FOR ACTION
4.1 Additional resources must be provided
to make training more available and accessible to staff at all
levels, addressing basic awareness of abuse: What is it? What
part do I (unwittingly) play in it? How can I contribute to eliminating,
or at least reducing, institutional practices?
4.2 Standards should be subject to regular
and systematic review with resources being made available to enforce
better care and higher standards.
4.3 A system of incentives needs to be devised
to reward those homes that fully comply, alongside a set of penalties
for those homes that, for example, fail to offer adequate induction
and in-service training to staff.
4.4 Ways of involving lay people in the
inspection process need to be devised to enable more residents
to contribute their views.
4.5 Recognising that people hold back from
expressing dissatisfaction for fear of retribution, there is a
need for more advocates/advocacy services to be available to support
people in asserting their needs and expressing their worries or
concerns.
November 2003
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