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A growing public disquiet about the quality of care provided to older New Zealanders prompted the Labour Party, Greens and Grey Power to investigate rest-homes last year.
Their report described an unregulated, desperately short-staffed sector driven, in many areas, more by cost-cutting and the pursuit of profit than best-care practices.
The authors heard stories of residents being given anti-psychotic medication to sedate them and make them easier to manage, and not receiving proper medical treatment for common conditions, and of untrained caregivers routinely giving out medication.
With no regulations on minimum staffing levels or training, the care provided from facility to facility was "inconsistent", and with no transparency and inadequate monitoring, it was extremely difficult for the public to work out whether a facility provided good-quality care or not.
In late 2009, Auditor-General Lyn Provost also claimed the Ministry of Health had not responded quickly enough to problems it knew about with inconsistent, poor-quality auditing of rest-homes.
The Government later responded, saying criteria for rest-home auditors had been tightened, spot checks had been introduced and agencies had begun sharing information to identify "at risk" homes.
The Ministry of Health has also started publishing summaries of rest-home audits online.
New Zealand Nurses Organisation organiser Simone Montgomery says some minimum care delivery ratios are set out in the voluntary standards governing rest-homes but it is difficult to accurately assess residents and deliver safe care, as acuities change and often deteriorate quickly.
Employing a registered nurse as the facility manager and including their hours in the total RN hours allocated to a site is common practice, even though that manager may never be clinically involved face-to-face with a resident.
With registered nurses increasingly involved in documentation and auditing requirements, rest-home caregivers - called health care assistants, or HCAs - are delivering care with a clinical component more often.
The minimum staffing levels set out in the standards mean residents often are left in places - for example, forgotten in chairs - and have to wait to be toileted, she says.
Rushed caregivers have no time for quality conversations with residents, so often seem curt and take shortcuts when lifting them, sometimes injuring themselves in the process.
Often, there is no extra time allocated for staff orientation and new staff who have not finished the orientation programme are left on their own to give care they should not be providing.
Registered nurses are also constantly interrupted while dispensing medications, allowing errors to occur.
Ms Montgomery says funding for aged care needs to be prioritised and staff paid what they are worth - an HCA working for the district health board earns at least $2 an hour more than one working in aged care.
Nina Lunn, manager of the Redroofs Rest Home in Dunedin, says standards and audits introduced in recent years mean rest-homes are under watch at all times, and that has been successful in raising the standard of care.
However, those working in aged care get a "bad rap"much of the time and people rarely hear about the good homes.
"To get good staff, you have to look after them and part of that is recognising the risk they run just because they work in aged care.
"Registered nurses especially are becoming quite fearful of working [in the sector] because the risk is too high. Things will go wrong and the backing won't be there."
Even some hospital medical staff do not know what care rest-homes provide, she says.
Ms Lunn does not support mandatory staffing levels, saying numbers do not reflect the level of care residents receive, but does feel everyone in the sector is overworked and underpaid.
HCAs are responsible for everything from dealing with families, showering residents and making sure they eat well to minor wound care, making pill rounds and carrying out "observations" - the tests used to check a person's pulse, blood pressure and heart rate.
In some homes, they start on the minimum adult wage, $12.75 an hour, and in others they earn $14 to $15, while counterparts working in public hospitals with less responsibility start on about $16.
While retirement villages have apartments and townhouses to supplement the care part of their operations, rest-homes have no ability to bring in extra income.
"At times, it's hard to give the level of care expected and the level of care you'd like to give on the funding we receive... The elderly are worth more than what they get."
Malcolm Hendry, the Otago-Southland board member on the New Zealand Aged Care Association (representing 75% of the country's aged-care facilities), also claims the industry has been underfunded for some time.
National kept its election promise and provided a boost in funding but, given the recession, it is unlikely there will be any significant increase in the near future.
Labour and the Greens tried to suggest aged care in New Zealand is run by big profit-driven corporations, but that is not entirely the case, Mr Hendry says.
"There are a significant number of privately owned operators that are New Zealand-owned.
"It's a very attractive industry for investors to get into at the moment because the baby boomers are starting to hit retirement age and there will be significant demand for all sorts of things for the 65-plus age group for the next 30 years."
~ The steps to residential care ~
1. Get assessed
Telephone the Southern District Health Board needs assessment service co-ordinator to arrange a needs assessment. An assessor will determine the level of care required and can help with information about appropriate facilities in your area.
2. Subsidy check
Ask the assessor for the "residential care subsidy" application form. Complete the form and send it to Work and Income. Do this promptly because eligibility can only be backdated for up to 90 days before the date of application.
3. Means matters
To qualify for the subsidy, the value of your assets must be no more than the appropriate threshold for your circumstances, so there is a financial means assessment.
If you do not have a partner or if your partner is also in long-term residential care, the amount is $200,000, including your house and car. If your partner is not in care, you can choose a threshold of $200,000 including your house and car or $105,000 not including those assets.
Your house is exempt while your partner continues to live in it but is included in an assessment if he or she later moves into care.
Other assets that are counted include cash, savings, investments, loans made to other people and gifts of more than $5500 per year made in the previous five years, but not household furniture, clothing, jewellery, pre-paid funeral expenses and some debts.
4. Assets under
If your assets are below the threshold you qualify for the residential care subsidy. Work and Income will assess your income and tell you how much of this you need to pay towards the cost of your care. This will include most of your New Zealand Superannuation and any other income you receive.
5. Assets over
If your assets are above the threshold you do not qualify for the subsidy and pay the cost of care up to the maximum contribution for your area.
People whose assets are above the threshold, primarily because they own their home, may qualify for an interest-free loan which is secured by a caveat over the house and is payable back to the Government when they die or when the house is sold.
Any income you receive will be assessed to work out how much you contribute towards the cost of your care. Income includes New Zealand Superannuation, the veterans' pension or any other benefit, and 50% of private superannuation payments.
The maximum amount any resident pays varies by region and is adjusted annually. The figures are at present $804.51 a week (in Dunedin), $786.94 (Clutha and Waitaki districts), $790.44 (Central Otago) and $825.65 (Queenstown-Lakes).
You get to keep a personal allowance of $35.55 a week and will receive an annual clothing allowance of $251.75.
Read the Ministry of Health booklet, Long-term Residential Care for Older People: What You Need to Know, available on www.moh.govt.nz or phone (04) 496-2277 (quoting item HP5082).
Residential care subsidy: (0800) 999-727 or go to www.workandincome.govt.nz and click on "individuals", then "forms and brochures" at the left of the screen, then scroll down to the "residential care" section.
Age Concern: www.ageconcern.org.nz
~ Check list for choosing a rest-home ~
• Decide on the size of the rest-home you want to live in and whether it is important for you to be close to public transport, shops, family and friends.
• Don't wait until there is a crisis. Devote ample time to finding a suitable facility.
• Ask if you can stay for a while when the tour is over and take this opportunity to talk to residents about what they think of the home.
• Go back unannounced to what you thought were the best places (perhaps choosing a meal time) to see if your first impressions still hold true.
• Ask for a copy of the home's latest audit report and what has been done to rectify any problems that were identified. You can check how well your local rest-home meets Ministry of Health standards on www.moh.govt.nz/audits.
• Arrange to have a trial stay.
• Ask about the financial consequences if you are not satisfied and want to move out.
• Before signing a contract, always have it checked by a lawyer.
PRIORITIES WILL DIFFER FROM PERSON TO PERSON BUT HERE IS A 20-POINT CHECK LIST TO GET YOU STARTED:
• Is the home clean, warm and comfortable?
• Are toilets and showers easily accessible?
• Do the residents appear happy and well cared-for?
• Do staff treat them with respect?
• Do the meals look appetising?
• Are there regular outings and activities?
• What are the policies on private telephones, televisions, pets and alcohol?
• Can family and friends visit at any time?
• How many caregivers are there on each shift and what are their qualifications?
• Is there a formal schedule for ongoing training?
• How many hours a week is a registered nurse on the premises? (Hospitals have to have a registered nurse on duty at all times; rest-homes don't.)
• Does each resident have a care plan and how often is it reviewed?
• Do staff have specialist training in Parkinson's or dementia?
• What is the policy on sedation?
• What happens if the level of support you need changes?
• How does the home keep family members informed?
• How are complaints dealt with?
• Is there an evacuation plan and an adequate number of smoke alarms and sprinklers?
• Will the home give you a copy of its latest audit report?
• How much are the fees and what services incur extra expense?