Five-Star Hotel, Five-Star Care? Part 2: Problems

2015: Mum had been in residential care since 2011, becoming mostly bed-bound in the last eighteen months. We had progressed further along the dementia journey, which brought new emotional challenges at every stage; but during those four years, I never had cause for concern about the home or its staff, in whom I had complete faith.

That summer brought insidious change that would rock my former certainties. First came news in June that the long-standing manager would be leaving at the end of August.  A highly experienced nurse, she had established the home in the 1990s under the original person-centred ethos of the operating provider – pioneering at the time – and maintained those exemplary standards for the next twenty years of her tenure.  I had hoped she would remain at the helm throughout my mother’s time there, but knew that impending retirement might make that impossible; I was therefore disappointed, but not surprised, by her announced departure. 

What did surprise me, however, was that she was not retiring, but leaving to take up a post at a new home, rather than spend her final years in situ; and that she suddenly disappeared in mid July, more than a month before her notice period. There was no advance warning from the provider, only a somewhat perfunctory letter introducing her successor after the event.  I did not even receive this letter myself until I enquired some weeks later, mystified as to what had happened. The early departure was clearly unplanned, as it left the home without a manager for two weeks.

Around the same time, one of the two nurses in charge of mum’s unit also left, as did the housekeeper.  In the ensuing weeks and months, there followed a stream of other departures: the Deputy Manager (an award-winning nurse of long service); several other nurses from both day and night shifts; a number of care assistants; the chef; the long-standing receptionist and her replacement (who lasted only three months).  

Residents and families received no forewarning or explanation, which struck me as very odd, given that I knew these staff to be decent, caring, and considerate of the frail elderly people who depended on them and of whom they had been fond.  I later learned that the company had barred them from telling anyone (residents, families, or colleagues) more than twenty-four hours before their departure.

While such practices may be common in finance, law, retail, and the media, one might (perhaps naively) expect care to operate under different values – because residents are not “customers” who can exercise market choice on a daily basis, but extremely vulnerable people who have sold their own homes and given their life savings to fund a place in which to live out their final days, whose well-being hinges on trust and continuity, and for whom any upheaval poses a risk.  The contract between care provider and resident is more than financial, but this company evidently deemed its own commercial sensitivities more important than the security of its residents; and of course one may ask why so many good staff of long-standing and expert experience should suddenly wish to seek employment elsewhere…

The physical environment was also thrown into flux.  Refurbishments had indeed been due – but proved far more extensive than simply refreshing worn out furniture, curtains, carpet, and paintwork. Public areas downstairs (seldom used by residents or families) became palatial, with luxurious fabrics, expensive contemporary furniture and lighting. 

Upstairs, meanwhile, the dementia nursing unit was suddenly stripped of all familiar features and left in a state of bareness for several months thereafter, because there was no budget to hire outside contractors to complete the job – the two maintenance staff were expected to add these major refurbishments, including kitchen-fitting, to their routine duties (which also suffered as a result). 

I was dismayed to find that previously exemplary features of dementia-friendly design – brightly coloured doors, picture signage, contrast handrails, rummage materials and orientation aids – had been removed without consultation and replaced with cold, minimalist, all-white décor.  The whiteboard in the lounge, that signalled which staff were on duty (and how many) was taken down, as were residents' names from their room doors.  The effect was depersonalising for both parties. It seemed that the management was keen to erase anything that made this look like a care home.

Pets too were quietly phased out; the soft toys and live plants that had created a homely atmosphere in a small conservatory area (and initially sold the home to me) were disposed of with no explanation.  Even relatively new features, such as two charming seaside corners, were summarily ripped out to create a uniform look – that of a spa hotel.

Worst of all, mum’s unit was notably understaffed.  In 2014, when she had become frailer and mostly bed-bound, mum had been moved into a room next door to the nursing station and directly abutting the lounge, so that she could easily be monitored and have company close at hand.  But in the autumn of 2015 I was frequently disturbed to find both the lounge and the nursing station empty.  Mum, and several other bed-bound residents, was effectively alone in her bed.  Few staff were visible at all on the wing, and if I did glimpse them, they would be rushing down corridors en route to a task, with no time to talk. 

I had vaguely known that a formerly disused corridor at a right angle to mum’s unit had been refurbished to provide more accommodation, but I never had occasion to go there; it had previously been behind a key-pad door. Only belatedly did I learn that this was in fact a whole new wing, with a separate lounge, that doubled capacity of the nursing dementia unit – without a commensurate increase in staff. 

While a few new care assistants had been engaged, others had left or been seconded to other units, and, crucially, no second nurse per shift had been hired for the extended wing that now catered for up to twenty-four residents with advanced dementia, instead of the previous twelve.  A daytime staff/resident ratio of 1:3 (including a nurse) had by stealth become 1:5 (with the nursing element diluted by half), and 1:7 at night, instead of 1:6.  Furthermore, fewer of those staff knew the residents in depth (or indeed at all); by Christmas 2015, only one day-shift nurse on that wing had worked at the home for more than three months, and there was a marked increase in casual agency cover.

When the wing previously had only 12 residents and four day-staff, it felt like a family unit; staff knew everyone’s personal foibles.  Residents had a key worker, who would have primary responsibility for their wardrobe and personal care.  Even I, as a regular visitor, could tell you what style of dress each person wore and match up any stray laundry items; but in the months leading up to Christmas, racks of unidentified clothes began to appear in corridors, inviting staff to try and pick them out.  The laundry itself went badly awry, with much of mum’s nightwear being shrunk to child-size.

The new manager had been in post since the beginning of August, but her introductory meeting with families was not held until mid October – on a weekday afternoon, when most working relatives would not have been able to attend.  By then, I already had serious concerns, so made a special effort to be there (involving a 200-mile round trip ahead of my usual weekend visit to mum).  I raised the issue of staffing levels on the dementia nursing unit and the desolate atmosphere on the original wing.  The new lounge at the other end of the unit was much more cheerful, and this is where all the mobile residents and most of the staff spent the day.   

Of course this made sense, given that the old lounge and kitchen were in a continued state of disarray, and one nurse could not be in two places at the same time (she was now based in the second nursing station by the new lounge). If you have few staff to monitor an increased number of residents, you need to corral the majority in one place, in order to keep them in sight together.

But what of the bed-bound people in the old wing?  Staff did their best to ensure their basic needs were met, making the required scheduled checks and bringing meals across from the kitchen at the other end of the unit.  This was, however, a long walk away; and in between such task-based attendances, there was no ongoing company or activity on the wing. 

The manager said this was temporary, due to the refurbishments, and both lounges and nursing stations would be manned in due course.  No action was taken and the situation persisted into the New Year. 

I later discovered that she had been powerless to address the staff shortage, as the budget for daily running costs did not allow for any more personnel, and funds could not be diverted from the ongoing programme of lavish redecorations - that money was ring-fenced at source.  Thus it seemed the company had prioritised kerb appeal to “brand new customers” over practical care for existing residents.

As autumn turned to winter, my sense of unease grew.  Mum’s right hand had become severely contracted, meaning that she couldn’t use it to grip; she had taken to eating tiny portions of food with only her left hand and struggled to manage cutlery and china (ideally she needed a light, plastic, bright-coloured beaker, but these were scarce, while heavy new white china double-handled mugs were in plentiful supply).  If she did not have supervision, food and drink were more liable to spillage than consumption. 

One November afternoon, I had come to meet the NHS Continuing Healthcare Assessor to go through mum’s funding review (she had been turned down for CHC the previous year and continued to be self-funding, but I thought her needs had increased).  While we were in the empty old nursing station, looking at paperwork, a cup of coffee had been brought to mum in bed next door.  When we went in to see her, we found that she had spilled it all down herself and the bedclothes, and had been sitting for about an hour in her wet nightie.  There were no staff about.  If we had not been there, it might have been another couple of hours before she was changed.

I also noticed that the cold drink dispensers in both kitchens on mum’s unit were frequently empty or disconnected.  These had previously offered a continuous supply of squash, day and night, which passing staff could routinely take to residents every time they were monitored.  Now drinks appeared to be prepared “on demand” from bottled mix – but people with dementia are often unable to ask for what they need. 

When I raised this, again I was told it was temporary, while the refurb was in progress; but as time went on with no change, I concluded that it was more likely a catering economy.  The delicious cream cakes, trifle, meringues, and gateaux that had regularly appeared at mealtimes to tempt fragile appetites were now replaced with a limited choice of cheaper plain cake and bulk-buy biscuits. 

In the weeks up to Christmas, I continued to flag my concerns to staff, but heard nothing more from the manager.  There was no follow-up from the meeting.  And in December, concern suddenly turned into crisis…

Part 3: Crisis

Part 4: Conclusion

Part 1: a Good Home