APPENDIX 28
Memorandum by the Registered Nursing Home
Association (EA36)
1. INTRODUCTION
The Registered Nursing Home Association is a
not for profit trade association representing the interests of
individuals or companies owning nursing homes, now called Care
Homes providing Nursing, throughout the whole of the United Kingdom.
The Registered Nursing Home Association is a company limited by
guarantee, which was formed in 1968. Its members own a total of
1,200 nursing homes, which equates to approximately 25% of the
5,000 or so nursing homes in the United Kingdom.
It is controlled by a National Management Committee
formed from within its membership, all of whom are nursing home
owners. Its head office is in Birmingham and is managed by the
Chief Executive Officer, Frank Ursell, who is also a nursing home
owner.
2. HOW PREVALENT
IS ELDER
ABUSE?
2.1 "Abuse may be found in homes in
the public, private and voluntary sectors, and problems are as
likely in small homes run by sole traders, as in large homes run
by big national companies. It would be much easier if we could
say that the problem of abuse arises only in certain specified
circumstances, for example in homes with more than 40 residents,
managed by employees of national organisations with share holders,
or conversely in homes run on a quasi-family basis by couples
with few hired staff. Would that it were so easy. We could then
move our attention away from looking at the sector as a whole
onto a focused approach to that significantly small group of potentially
offending homes and their staff.
Ideologues of left or right will assert, with
equal single-mindedness, that only the public sector or only the
private sector can look after people. Neither of these positions
reflects activity in the field, and each ignores the role of voluntary
organisations, which between them continue to be responsible for
around 15% of all places in homes, about 70,000 in total. Nevertheless,
voluntary organisations, founded on notions of good will, charity
and benevolence, can also not present a record wholly free of
scandals" (Harm's Way, Les Bright, Counsel & Care).
2.2 "We simply do not have enough hard
evidence from any source to give a reasonably coherent picture
of the extent, nature and dynamics of abuse in residential care"
(Behind Closed Doors, Susan Greaves—North Essex Advocacy
Teams for Older People making Reference to Macreadies' Comprehensive
review of elder abuse research).
2.3 The definition used by the Health Select
Committee for this enquiry is well known to the Registered Nursing
Home Association. We would, however, wish to identify that this
all embracing definition does not adequately differentiate between
abuse which is intentional, or caused by deliberate omission,
and those "acts or lack of appropriate action" which
are more appropriately called bad practice.
2.4 We believe that this differentiation
is particularly pertinent when looking at what can be done about
elder abuse, which will be addressed later.
2.5 Anecdoctal evidence indicates that abuse
of older people which occurs in a residential setting, either
a residential home or nursing home is in the order of around 6%.
The reporting of abuse which occurs in a residential setting,
however, is around 25-30% of all reports and reflects the increased
publicity which this subject has received in recent years following
Government initiatives such as "No Secrets"
and the increase in regulatory attention.
2.6 The Registered Nursing Home Association
does not have any personal evidence on the prevalence of abuse,
but has been working for many years with organisations such as
Action on Elder Abuse and shares their concerns wherever abuse
is identified. We have regularly cooperated over the years with
Action on Elder Abuse and were involved in the creation and publication
of guidance for providers of nursing home care and their staff,
and we will continue to work relentlessly in the future to eliminate
elder abuse.
3. WHAT ARE
THE CAUSES
OF ELDER
ABUSE?
3.1 Our response to this question is limited
to abuse within the residential home or nursing home setting.
3.2 Firstly, it is necessary to expand on
an early statement in relation to differentiating between poor
practice and examples of genuine abuse, and to endorse that whatever
the cause of the adverse incident, it is never justified.
3.3 Where, for whatever reason, be it lack
of training, ignorance or actions driven by overwork, an adverse
incident occurs, anecdotal evidence seems to indicate that it
might be for one of two particular reasons, either poor care on
the part of the care worker with no causation effect of the patient,
or actions (or inactions) on the part of the patient which causes
a frustration in the care worker and a hasty action or reaction.
3.4 It is not possible to draw any firm
conclusions from such evidence as there is, but there is little
support for suggestions that any one group of people are more
liable to be abused than any other, whether by age, illness, race
or gender. However, it would be right to identify that the various
degrees of dementia are more likely to lead to abuse from frustration
than is the case in relation to patients who are suffering from
a physical, rather than a mental, illness.
3.5 On some rare occasions there are examples
of financial abuse, but in a care setting these amount to criminal
actions in their own right and are usually dealt with by recourse
to the Police service and the Courts. Such action is always dealt
with promptly by care home/nursing home providers wherever it
is discovered.
4. THE SETTINGS
OF ELDER
ABUSE
4.1 This response has been limited to the
potential for elder abuse in a collective living situation.
4.2 In respect of examples of abuse which
relate to a reaction to mental impairment there are two factors
which help to minimise abuse in a care home/nursing home setting,
compared to a home environment. Firstly there are, invariably,
other staff involved who would be in a position to observe any
change in the physical appearance of the patient. Secondly, regular
shift changes mean that an individual does not have sole responsibility
for the care of a patient and the build up of any frustration
can be dissipated more easily.
4.3 In the case of nursing homes there is
a qualified nurse on duty 24 hours per day which offers a double
benefit. The professional eye of the nurse brings an additional
element in the care of older people and should give additional
protection, whilst the professional accountability to the Nursing
& Midwifery Council should also reduce the risk of abuse occurring.
5. WHAT CAN
BE DONE
ABOUT IT?
5.1 It is important to state that a key
aspect of preventing abuse in a care home/nursing home setting
is the operation of a an effective "whistle blowing"
policy. Whilst the care home/nursing home manger/provider is often
engaged in other activities which might take him/her away from
the day to day activities of care staff, other staff members are
in a position to witness any untoward incident. Confidence that
they can report such action through the management system is crucial.
5.2 A different term to differentiate between
abuse which is intentional, or caused by deliberate omission,
and those "acts or lack of appropriate action" which
are simply bad practice would help to reduce elements of abuse.
Whenever such an emotive term as "abuse" is used it
triggers a defence response which seeks to minimise or justify
any action, rather than a willingness to remedy the incident at
the first opportunity. There is often a greater willingness to
recognise that poor practice has occurred and, as a consequence,
to take preventative and/or curative action.
5.3 There are a number of factors which
directly affect actions which can be taken to prevent abuse which
are constrained by the lack of financial resources. These include
the rates of pay for care assistants, training and other conditions
of employment. It cannot be emphasised too strongly that there
cannot be the increase in status, credibility and work ethos of
social care staff without some significant increase in the funding
available for collective care so that staff can be paid a more
rewarding salary.
5.4 Whilst it is acknowledged that increased
salary alone will not bring about immediate and real change, at
the same it must be accepted that a more responsible and more
appropriate social care worker cannot be secured from a group
of people who are prepared to work for £4.50 per hour. Adequate
pay is the starting point for reducing the risk of abuse. Research
in America entitled "Maltreatment of patients in nursing
homes" by Karl Pillener, reported in the Journal of Health
& Social Behaviour also addresses this issue. Further explanation
can be found in the memorandum from Action on Elder Abuse at section
12.5.
5.6 The prevention of abuse in a collective
care setting needs to built on a strong base. A robust recruitment
policy, adequate checks on previous history and any police record
together with taking adequate references, particularly from a
previous employer.
5.7 There must then follow adequate training,
starting with Induction and Foundation training and awareness
training in elder abuse. Specific training in the needs of patients
which the homes sets out to meet, as specified in the Statement
of Purpose and a thorough understanding of the home's whistle
blowing policy, together with all of the other policies and procedures
in use within the home. Supervision and monitoring of staff must
be an ongoing activity.
5.8 External agencies, both formal—the
National Care Standards Commission in its inspection role, and
commissioners of care—and informal—visiting professionals,
advocates, etc all have a part to play in ensuring that any risk
of abuse does appear. The more open the approach of the home the
less opportunity there is for abuse to occur.
6. RECOMMENDATIONS
FOR NATIONAL
AND LOCAL
STRATEGY
6.1 The "No Secrets" publication
has had a marked effect in raising awareness of abuse, however,
in many parts of the country this has been imposed upon providers
rather than being a shared event, working in true partnership.
Further action should be undertaken as equal partners in a commitment
to prevent abuse occurring.
6.2 Every provider who discovers abuse in
his/her care home will want to deal with that abuse immediately.
There is, however, at times a reluctance to report that occurrence
to the regulators or commissioners for fear of retribution. Care
should be taken to prevent an excessive action being taken by
the Commissioner. It is acknowledged that there is a fine balance
between taking responsible action and behaving in a responsible
manner. Training for commissioners in abuse investigation should
include sensitivity to the provider.
6.3 For example, a member nursing home owner
discovered that a male care assistant had physically assaulted
patients. This action had taken place during the night and was
reported to the home owner by other staff members. The offender
was suspended and the health authority (then the regulating body)
and the police were informed. The health authority informed the
local authority commissioner who instigated a full abuse enquiry,
including writing to all of the relatives advising them that an
incident of abuse had been reported. The member felt that the
actions of the local authority were excessive in the circumstances
and expressed the view that in future they would simply sack the
employee, telling nobody.
6.4 There are also previous examples of
over zealous reporting of allegations of abuse by the United Kingdom
Central Council for Nurses, Midwives and Health Visitors (UKCC)—now
the Nursing and Midwifery Council (NMC) which later proved to
be unfounded. Such actions do not endear practitioners to the
regulators and, therefore, have a negative result in relation
to reducing/minimising abuse.
6.5 There should be greater engagement between
providers of care, regulators and commissioners together with
experts such as Action on Elder Abuse on a regular basis. Guidance
produced by such engagement should be made freely available to
all providers and not simply published on websites.
December 2003
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