Five-Star Hotel, Five-Star Care? Part 4: Conclusion

New Year 2016: with mum thankfully recovering from an emergency admission from her care home to hospital just before Christmas (and another acute episode at the beginning of January), I made a formal complaint to the General Manager about a number of issues that had led up to this crisis.  I was shocked to find myself in this situation, as prior to summer 2015 I had had nothing but praise for the home.

I did not blame the staff, who were clearly doing their best as before, but with ever-greater demands on their time since a new wing had opened in mum’s unit, doubling capacity.  As the complaints process progressed through the subsequent months and indeed years, it also became evident that most of the problems could not be solved unilaterally by the manager, but had their roots in corporate culture and finance.

The company, which still trades on the person-centred ethos of its founder, had changed its structure and aims: it was now run by a corporate board with City objectives. These structural and strategic changes occurred back in 2013, but were never communicated to the residents and families dependent on its extensive network of homes.  It took a couple of years for their effect to filter down.

In the last decade, a number of new operators have entered the market – many from a background of “hospitality”, rather than nursing or social-care. In short, hotels.  They have looked at the demographics and seen that there is a burgeoning demand for retirement apartments and care homes, but may not appreciate the difference between them.  We know about accommodation, they think; we can do that.  And if we make it glossy and build in richer parts of the country, we can charge premium rates.

And yes, active and affluent retirees in their sixties and seventies may well enjoy a cinema, swimming pool, café bar, and the kind of cool minimalist décor they have grown used to at home or in upmarket hotels and restaurants.  These are lovely facilities, if money is no object and you are fit and well.  Even so, I would argue that the qualities you seek for a short break in a luxury hotel or time-share complex are not the same as your own home comforts. 

And if you are over eighty, frail, confused, living with dementia or other degenerative disease, and looking for a home with intensive practical support, they are not the most important factors.  What you need is people.  This cannot be said enough.  People can give care.  Fancy curtains can’t hold your hand when you’re dying.

The much-vaunted “person-centred care”, touted on every website and brochure, needs two essential ingredients: staff and time.  Enough well-trained, well-paid, kind, empathetic staff; and enough time for those staff to spend with their residents outside practical care tasks, to engage with them as people, not room numbers.

So it frustrates and depresses me to see care home companies all hurtling sheep-like down the road of spa hotel one-upmanship, at the expense of investment in the basics.  And it breaks my heart that mum’s provider, that once led the field in genuine person-centred care, now feels the need to compete on these terms – offering a staff/resident ratio just a little bit better than its competitors (but significantly worse than its own prior to 2015), and achieving that “little bit better” by making stealthy cuts to service elsewhere (catering, housekeeping, maintenance) and by keeping staff on minimum wage.

It’s well-known that the National Living Wage has placed greater financial strain on both care providers and funding bodies.  Good care isn’t cheap, it never will be, and should not depend on the exploitation of workers.  But if there is a crisis in funding and priorities have to be chosen, that’s a conversation providers should be having with residents and families, not a unilateral decision to be deployed by sleight of hand to maintain profit.

In my view, there’s a moral imperative for transparency; but if commercial arguments are all that count, I would point out that at the time of mum’s crisis in December 2015, we had personally paid over £200,000 to that company.  That represents the sale of our family home, our collective lifetime assets.  Surely that buys us some rights of consultation? 

(The annual residents and families survey had quietly been dropped around the time of the corporate changes, and communications from the company were minimal; the one meeting with the new manager was held on a weekday afternoon when most relatives could not attend.)

While there was apparently scant budget for daily running costs, money was available in relative abundance for cosmetic improvements and gimmicks. Focusing on kerb appeal to attract new business in this way, to the detriment of basic daily care and humanity, is a pernicious economy.  I suspect a cynical calculation that, as the average stay in care is two-and-a-half years, some providers concentrate on point of sale, rather than providing an ongoing standard of service, because their “customers” have a natural shelf life and won’t be around to complain. Please prove me wrong.

So what happened to my complaint?  (For details, see previous posts, Problems, and Crisis.) After many months of extensive correspondence, meetings, and stress that escalated the case to Divisional Manager level (three stages up; a saga in itself), at one point it appeared to be resolved to relative satisfaction, but after another change of senior management, the main issues persisted*.  Early on, I had accepted that the hospital admission was necessary in the circumstances, and that night staff, faced with a life-threatening emergency, acted in good faith, to the best of their ability. I had no complaint against them.

My main concern was to address the issue of staffing levels on mum’s unit (which had fallen 40% between July and December 2015, from 1:3 to 1:5/6), a general fall in service provision throughout the home, and the circumstances that led to mum’s sudden deterioration in the latter half of 2015. 

With improved monitoring in 2016, she rallied from this crisis, and by summer had improved enough to be able to sit out in the garden on some days. By that summer of 2016, there was a staff/resident ratio of 1:4/5 in daytime – although at times this slipped back down to 1:6 - but there were no plans to restore the original ratio of 1:3 or the proportion of nursing cover within that, which remained half that of pre-2015.   

(Staffing ratios overall need to be higher in dementia nursing units than in purely residential care, because residents’ physical dependency becomes intense, with help needed for eating, drinking, continence, and two care-workers required to lift a person and sometimes to manage distressed behaviour.)

The squash dispenser was restored (but with cheap and very diluted squash, not fresh juice); whiteboards in both lounges and some of the dementia-friendly design features were reinstated, but application of these was patchy. The atmosphere on the new wing became more homely; but although decorations on the old wing were finally completed, that lounge remained less used and less welcoming in character.

The residents and families survey resumed in October 2016, with a new staff survey supposedly to follow.  One of the nursing stations was allocated a computer and a unit email address, but the latter still did not allow care staff and families to communicate directly, only via the deputy manager or receptionist as before – the company reneged on a short-lived commitment to provide direct access. 

I lobbied hard on all these issues, but of course it’s difficult to say if the few gains were a direct result of my complaint.  One thing I did count as a significant achievement was a new protocol for emergency transfers of residents to hospital, which the home introduced in April 2016.  

This aimed to ensure that no resident is ever sent to hospital unaccompanied in emergency (as mum was in December 2015), through a rota of off-duty staff to be summoned as cover, and sets out a checklist of personal effects, contacts, and documents to support any such transfer. I'd be surprised if this protocol has survived in the face of further cuts and staff shortages... 

(I canvassed other major care providers for their policy on emergency admissions to hospital; shockingly none was willing to guarantee that residents would always be escorted - because that requires a degree of slack in their staffing levels above bare minimum cover, the standard for their budgets.  Ask yourself, would it be acceptable for a terminally ill child to be sent alone to ED?  No?  Then why do providers - charging up to £2,000 per week - believe it to be so for a frail elderly person with severe cognitive impairment or for an adult with learning disability?  You won't find that in any glossy sales brochure.)

One key question remains unanswered: were the actions of mum’s care provider (in downgrading its service) motivated by need or greed?  Did they make cuts simply to survive, or rather to maximise profit?  The latter being negotiable, the former, not.

The spectre looming over all of this is that of care companies, such as Southern Cross, suddenly going bust.  The regulator, the Care Quality Commission, now has a scheme called Market Oversight that monitors the financial viability of key providers and aims to warn local authorities if services they purchase are vulnerable to collapse.  As far as I know, there is no equivalent protection for self-funders, who remain entirely reliant on providers themselves (and their own independent research) for information.

The financial background of providers is notoriously labyrinthine and hard to interpret for the layman. I would like to see residents and families entitled to receive the same annual reports as shareholders – we are indeed the principal stakeholders in that business.

Throughout the UK, there is a known shortage of nurses in general, let alone specialist dementia nurses (and Brexit threatens to exacerbate this situation).  The appointment and retention of suitably qualified staff is undoubtedly a challenge for providers in a competitive market, and the Divisional Manager of mum’s company argued that they offer structured training, promotion, and bonuses to provide opportunities for career progression; but while these may look attractive on paper, from my observations I would suggest that staff retention is less about long-term corporate incentives  (that take staff away from hands-on care) than decent daily working conditions: 

Listen to the staff, value their opinions and expertise, and act on it; give them proper meal breaks and meals; pay them a good basic rate for very hard work (13-hour shifts in some cases); subsidise child-care or at least try to accommodate staff with fixed rosters; treat them with as much kindness and respect as is due to residents and families.

Above all, value the bond between residents and care-workers who know them well; see it as an asset, not a threat.  (Don’t, for instance, deliberately roster staff away from their accustomed units to render them interchangeable for corporate efficiencies; “personal” care should be just that.)

Finally, whatever the financial challenges, never forget that residents are not inanimate “units of business”, but people - whose lives depend on you.   If a genuine desire to provide care is not your prime motivation, look elsewhere to make your profits.  A home is not a hotel.  This is what it's about: 

*Updated @November 2016, August 2017, May 2018, April 2019, April 2020 (see postscript below).

NB: During 2017 and 2018, this situation escalated further to crisis for the home as a whole (not just my complaint), with it being rated "Requires Improvement" in all categories by the CQC in 2018, where it had formerly been "Good" or above.  In May 2018, regretfully I felt I had to move mum out of this once excellent home; it was a huge decision, but thankfully she settled well into her new home in the same area, due in no small part to some familiar staff who had preceded her there. Continuity of care is paramount for those with dementia and I was grateful that she had that once more. However, I am also aware of our good fortune as self-funders in being able to make this move; others were not so lucky, and many of the issues described here persisted in the original home for some time after she left. 

Update: as per summer 2019, I was pleased to find that the original home had received a good rating once more, but in her state of advanced age and frailty I didn't feel mum had time in 2018 to wait for this improvement. Crucially, I now know no provider is immune to these issues; they are part of the overall landscape of the sector, due to funding models that remain contentious.

Update: In January 2020, my mum died.  I'm thankful it was peaceful, before the COVID19 outbreak, and I was able to spend the whole time with her in the weeks preceding her eventual demise, holding her hand until the last; eternally grateful for the wonderful care she received in her final home and to kind and dedicated staff in both homes who supported us throughout her more than eight years in care.  

Sadly, I hear that the original home, having received a good CQC report in 2019, "promoted" the new manager to an executive post overseeing a group of regional homes (a familiar pattern), leaving that home once more under temporary leadership - and once more spending lavish sums on cosmetic refurbishments, when extensive redecorations had been completed barely a year earlier, at a time when staffing across the whole sector continues to be the top operational issue.  Desperately disappointing, the more so when care homes are suffering so much from government funding neglect in the face of COVID19.

Meanwhile, a report into privatised adult social care by Professor Bob Hudson indicates that the detrimental changes I have witnessed in mum's home are common symptoms of the drive among providers to maximise profit by cutting down on their major expense and main budget variable: staff.  (See in particular points 12 & 13 on page 9 of the report...)

[NB: This post was written in 2016, pre-COVID-19. Coronavirus has placed further strains on the care sector, and restrictions on visiting care homes may now apply; please check with the provider.] 

Part 1: a Good Home

Part 2: Problems

Part 3: Crisis

Five-Star Hotel, Five-Star Care? Part 3: Crisis

Mum had been in care for four years, and for the vast majority of that time I had been more than happy with the home.  I knew how fortunate we were to be able to afford good care in pleasant surroundings.

In summer 2015, however, a number of changes began that altered the character of the place and made me uneasy.  Chiefly, a new wing had opened in mum’s dementia nursing unit, which doubled capacity, without double the staff.  Resources overall appeared to be stretched more thinly, while an extensive programme of cosmetic refurbishments continued.

Throughout the autumn I was increasingly concerned that mum and other bed-bound residents in the old wing were being left unattended for long periods of the day, while staff were fully occupied in care tasks or supervising the new lounge at the other end of the unit.  The old lounge outside mum’s room and the nursing station next door were now empty.

I usually visit each Saturday, but one Friday in December, with bad weather forecast the next day, I decided to postpone my weekly visit until the following Wednesday, to attend the Christmas party on the unit.  I phoned to check that all was well meanwhile - and was taken aback to learn that mum had been moved into a new room a couple of days earlier.  I had been there the previous Saturday and am always available by phone and email, but no-one had spoken to me about any plans to move her or otherwise consulted me.

Given mum’s extreme frailty, I had misgivings about such a hasty and inexplicably furtive move, but reasoned that perhaps it was the manager’s way of addressing my concerns about her spending too much time alone; the new room, I was told, was next door to the nursing station in the new wing.  Having been assured that she was OK and “beginning to settle”, I decided to give benefit of the doubt until I had seen the room on Wednesday. 

With hindsight, I should have heeded my instinct.  Because at 7.00am on that Wednesday, I received a call from night staff – paramedics were in attendance, and were about to take mum to hospital.

This was a complete shock, as there had been no prior suggestion of acute illness.  She is mildly asthmatic and prone to low-level chest infections, but medication was routinely in place to treat these, there had been nothing untoward when I had last seen her, and no concern had since been expressed to me by staff; furthermore, I had signed an advance care plan which stated that mum should not be taken out of the home, except in life-threatening circumstances that could not otherwise be managed – and never unaccompanied. 

(Her dementia symptoms were such that she had not been out of the home since 2012, or even out of her old room in the home for over a year; changes of environment caused her too much distress.)  Was there anyone to go with her?  No. It was the last hour of night shift and no staff could leave the premises. 

I spoke to a paramedic, who insisted that mum had “severe breathing difficulties” and unless they took her immediately, she could die. It was their job to keep her alive; the advance care plan was irrelevant.  (I have since learned that there is a difference between an advance care plan and advance decision.  The former is merely an expression of wishes agreed between a person - or their representative, if they have already lost mental capacity - and a private care provider; the latter has legal force, but can only be drawn up by the patient themselves while still having capacity, and pertains to NHS services.  The advance care plan can be overridden by doctors or paramedics in what they consider to be the patient's "best interest" in an emergency, and has no force outside the premises of the private care provider, ie. in an ambulance or hospital.)

All I could do was get straight into the car and race the 100 miles in morning rush-hour traffic to join her. (What if that hadn’t been possible?)  I knew it would take me up to three hours to get there – in which time my beloved mum, a vulnerable 89-year-old with severe cognitive disability, could die alone and terrified in the back of an ambulance or in a strange Emergency Department, with no-one who knew her to comfort her.  This was not meant to happen.  Everything I had done in the preceding decade or more to care for her was aimed at avoiding such an undignified and desolate end.

En route, I spoke to the day nurse, who was trying to find someone to go ahead of me to the hospital, as I had begged, but reiterated that there was no-one available from shift.  They simply did not have any slack in the system. (Mum’s local friends are now also very elderly and could not attend such a distressing emergency.)  At my request, the nurse called a particular care-worker who knew mum well, and she agreed to go – on her day off, using her bus pass.  She was there when I arrived, a kindness for which I’m eternally grateful.

I’ll discuss the hospital experience in another post.  Suffice it to say, by the time I got there (and indeed before the care-worker had arrived), mum had been treated with IV fluids and antibiotics.  No medical records had been sent with her, so doctors had no drug history; they only obtained this by phone after I arrived. 

The diagnosis was aspiration pneumonia - a prime cause of death in people with dementia.  This occurs when a person inhales a piece of food or fluid and develops an infection on the lung.  Symptoms can look like choking (and choking may have caused the inhalation), but the mechanism is different; suction equipment, available at the home for choking emergencies, can only remove an obstruction in the throat, not the lung. 

People with dementia often develop problems with chewing, swallowing, and inhalation – three subtly different processes in the mouth – due to both diminished motor skills and cognitive malfunction.  Supervision with meals is therefore vitally important in the latter stages of the disease.

I had seen mum only 10 days earlier, but I was shocked at her changed appearance.  Her weight had already been very low (about 5 stone), but in the interim her face had become skull-like and one of her eyes was gummed shut with infection.  She had evidently lost weight in that week.

As far as medics were concerned, her treatment was over.  She was admitted overnight for observation, mainly in order to arrange transport back to the home, and to ensure that she was strong enough to withstand it.  A social worker from the Older Adult Liaison team intimated that I had to seize the right moment, as elderly people transferred in such circumstances often do not survive the trauma: where would I rather she died?  Here in hospital, or back in the home?  

While mum was being prepared for discharge the next day, I went to the home to fetch a clean nightie (she had not been sent with any personal effects or change of clothes).  This was my first opportunity to see the new room – and again I was shocked at what I found.  Yes, I was pleased that it was next to the manned nursing station and close to the new lounge; but it was a smaller room with less storage space than her old room – and it had been left in a terrible state of disarray. 

This was not a result of the paramedic attendance, but of the room move a week earlier.  Mum’s belongings had been dumped willy-nilly on any available surface, including the bathroom; a number of things had gone missing (some never to be recovered, with no explanation).  Everything was covered in dust.  The wardrobe was more than half full of other people’s clothes.  The toilet flush was broken; and in the bathroom there was no paper towel dispenser, but a mirror – a real no-no in a dementia unit.  It all spoke of haste and lack of time even to make good after the event.  What was so urgent that she had had to be moved in this insensitive way, without my knowledge? 

I had experienced possibly the worst 36 hours of my life, desperate to ensure that my dear mum, whom I had sought to protect for so many years, would not die alone in sordid conditions.  Now I stood in this room – for which we were paying over £1,200 per week – and struggled to understand how all this could have happened in a previously exemplary home, for which I had written glowing reviews and even editorial in praise of the wonderful staff. 

Over the next four months, as I pursued a complaint against the provider, I began to find some answers…

Part 4: Conclusion

Part 1: a Good Home

Part 2: Problems