Working through a grey area

ANYONE looking for a care home for an elderly relative right now must be beside themselves with worry.

Between the Panorama expose of a home for autistic adults in England, the closure of the Elsie Inglis home in Edinburgh following the death of a resident and subsequent police investigations, the financial collapse of major operator Southern Cross and various concerns about how those with dementia are treated in hospitals, the whole sector appears to be in crisis.

All we have to help us select a suitable care home is a publicly-available report from the Inspectorate (formerly the Care Commission, now Social Care and Social Work Improvement Scotland or SCSWIS) whose job it is to drive up standards of care.

But there are two sides to every story, and all is not necessarily as it seems.

I'm the secretary of a very pushy, very active relatives group at the nursing home where my mother lives. It's a fine place run by fully-qualified and highly-experienced nurse-managers rather than pen-pushers. We meet with managers and care staff once a month, as well as having open access to them all the time, and no restrictions whatsoever on when we visit our relatives. We don't have any complaints, but we're quick to suggest any possible improvements, and the nursing home is just as quick to seize on any idea that will improve the experience of their residents or to report back to us when things have gone well or badly. We work together.

And after a great deal of effort, quizzing, advice and perseverance, I have come to understand a Care Commission report . . . just a little bit. They are so esoteric and jargon-based as to be incomprehensible, completely misleading and utterly useless to anyone who hasn't studied the convoluted methodology behind them.

Any reasonable person would think that a score going up means a home has improved, and a score going down means it has deteriorated since the last visit. This would be true if the inspections from one year to the next were based on the same? criteria, the same evidence and the same things. Unfortunately, a different focus or emphasis for each inspection makes a direct year-on-year comparison impossible.

It shouldn't come as a huge surprise that an organisation now calling itself SCSWIS relies heavily on bureaucracy . . . lots of it, generating reams of paperwork for nurses and activities people who we would all rather spent their time with residents.

I know of one highly-experienced nurse who used her clinical judgment to remove an air mattress from the bed of a resident who had suffered from a pressure ulcer. The sore was virtually healed and the mattress itself posed a higher risk of the lady sliding or falling out of bed. The nurse's decision was never questioned or criticised. Her mistake was forgetting, for once, to write it down . . . black mark. In the real world, that's no more than a minor glitch in administration.

If a report sternly states: "Best practice in pressure ulcer prevention must be implemented," it would lead any normal person to assume there must be a problem in preventing or treating ulcers. Wrong. At any given time a "best practice" is identified by the Inspectorate from among the many methods that have been used over decades. Best practices change. This statement means a home may have none, a few or many pressure ulcers (bed sores) and is therefore utterly meaningless to anyone outside the business who doesn't care which method is used as long as it works.

One home was chastised for insufficient "service-user feedback". This would be quite reasonable were it not for the fact that every resident suffers from dementia. Many don't recognise relatives, some can't converse meaningfully and few could remember eating lunch, let alone offer a culinary critique. When asked precisely how they suggested this be delivered, the Care Commission came up blank . . . but still wanted the feedback.

The message for care homes is, above all keep your paperwork up to date, even if it means less time for nursing and care. And always use best practice of the moment - even if you are an experienced nurse and favour another method or think your particular patient might respond better to another treatment. Don't rock the boat.

The message for the public is take these reports with a pinch of salt.

I've no reason to doubt that the Inspectorate's work drives up standards; the reports probably make sense to other people in SCSWIS; and those within the industry can at least understand them, even if they don't always agree with them.

But they are compiled and written in such a way that they are not fit for purpose as a guide for distressed lay people like us; we are not equipped to interpret them, and it is almost inevitable that we draw the wrong conclusions from them. As relatives, we may also have very different priorities from the inspectors.

If and until something more user-friendly is available, my advice (which I don't offer lightly) having walked in the moccasins, is to ignore the Inspectorate's reports. Conduct your own inspection, observe and ask direct questions. Take someone with you - all the better if they have some knowledge or experience.

Are the residents happy? Are they physically treated well, fed well, dressed well, occupied and entertained? Are all their medical needs met? Are the nursing and care staff experienced in caring for those with dementia/frailty or whatever? Are there enough nursing and care staff with a high level of professional knowledge and expertise? Do they appear to enjoy their work?

Are residents treated with dignity, respect, empathy and understanding? Are relatives welcome at all times? Is the place homely for an elderly person rather than too antiseptic, clinical or uniform? (It's a home, not a hospital or a prison - they could be there for years.)

Is the standard of hygiene good? Are the staff willing and able to talk to relatives and support them as well as residents? Have there been any serious complaints upheld?

Ask to be put in touch with the relatives' group or relatives of current residents to ask them for references.

And relax. There are some excellent homes out there. You just have to find them - but don't rely on the baffling SCSWIS report to help you do it.