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Inappropriate placements in registered nursing homes - fact or fiction?

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VOL: 97, ISSUE: 10, PAGE NO: 37

Mandy Lloyd, RMN, RN, is a nursing homes registration and inspection officer

As a nursing homes registration and inspection officer in the south west of England, I have seen a number of smaller homes close or go into receivership. And the owners often say they have been forced to close because of financial difficulties.

As a nursing homes registration and inspection officer in the south west of England, I have seen a number of smaller homes close or go into receivership. And the owners often say they have been forced to close because of financial difficulties.

One of their main burdens is increasing wage bills as a result of the minimum wage regulations and the need to boost nurses' pay to compete with the NHS for a limited number of staff. Many homes face great difficulties in recruiting staff and have to use agency personnel, which adds to their costs.

Then there is the Care Standards Act 2000, which also has financial implications. Some nursing homes did not invest in the provision of single rooms for all their residents and their profit margins are now being squeezed because many social services departments will not place residents in shared accommodation.

Increases in the fees paid by local authorities have not generally kept pace with homes' increasing costs. This is a particular problem for dual-registered homes, registered under parts 1 and 2 of the Registered Homes Act 1984, which offer both residential and nursing care.

Under part 1 of the act, a home is able to care for those who have 'personal care' needs. The act defines this as 'care which includes assistance with bodily functions where such assistance is required' and, when a resident is ill, the kind of attention someone would receive in his or her own home from a caring relative under the guidance of a GP or nurse member of the primary health care team.

However, residential home staff are not expected to provide the kind of professional care that is properly the function of primary health care services. And district nurses are not obliged to provide care to people in nursing homes unless they specifically require it, which means that they have been referred by a GP.

Nursing homes are registered under part 2 of the act. They provide the kind of care that requires the skills or supervision of a nurse. This may well occur in circumstances such as the following:

- Someone in need of constant nursing care over a 24-hour period;

- A patient in need of medication by injection, complex dressings or artificial feeding;

- A highly dependent patient whose care requires basic nursing skills;

- A patient who needs frequent attention because of urinary or faecal continence problems;

- A patient needing help with a complex prosthesis or appliance.

These definitions were published in the National Association of Health Authorities' handbook for nursing homes after the promulgation of the 1984 act. Fifteen years on, some of them urgently need to be updated. This is the because of developments in community care and an increase in the range of conditions that can be managed at home, such as artificial feeding. If patients can be managed at home they can be managed in a residential home with the support of community nurses.

There is a dichotomy: we are bound by the Registered Homes Act 1984 yet current practices have changed and community nursing has developed to the extent that, with the right support, residents with multiple needs can be cared for in residential homes.

The owners of dual-registered homes, which can accept both categories of people, complain that social services departments take advantage of the developments in community care and increasingly classify older people as in need of residential care rather than nursing care, saving large amounts in their budgets. But, they say, many people are placed in dual-registered homes because there is always a nurse on duty.

In theory, NHS community nurse teams should reassess, plan, implement and deliver care to residents in dual-registered homes who have a 'nursing need'. Community nurses sometimes instruct home staff to carry out the care under their supervision, but in practice it is difficult for nurses working in dual-registered homes not to deliver care to residents.

Another issue is the placement of people with dementia who also have physical care needs. If their physical health needs outweigh their mental health needs a general nursing home placement is usually agreed. But there is a fine dividing line and such placements need to be monitored as these people may have mental health needs that can only be appropriately met by skilled mental health nurses.

So it is easy to see why some home owners feel they are providing nursing care on the cheap.

Nursing homes also care for much frailer patients with many nursing needs and potential problems, and their nurses work autonomously and have to ensure that they keep up to date with the latest clinical practices. It is not unusual for nurses in nursing homes to care for patients with multiple health problems and complex nursing needs. The number of staff needed to care for these patients properly often means that the homes' owners walk a tightrope between complying with the inspectorate and financial pressures.

Nursing home registration and inspection officers hear many anecdotes about inappropriate placements. We have asked owners to supply evidence so that we can raise the issue at a senior level. Social services inspectorate colleagues notify us if they see clients with unmet nursing needs in residential homes. If community services cannot provide the level of nursing care required, residents are moved and the owner could be prosecuted for running an unregistered nursing home. An alternative is for it to become dual registered.

One nursing home recently enquired about a request to accept a woman from hospital. She had lived in a residential care home before its staff decided that she had become too dependent. Hospital staff said that she needed nursing home care, but a district nurse felt that an appropriate residential home would be able to cope with her. The client's family lived close to the nursing home, which was willing to take her, but the social services department's funding panel would pay only high-dependency residential fees. A compromise was reached so that the nursing home could admit her as a 'nursing patient' at the residential fee rate. Such dilemmas underline the difficulties that can develop under the current system.

It is not difficult to predict the implications of inappropriate placements or insufficient funding: more nursing homes will close, meaning fewer choices for individuals. In turn, more people may be placed inappropriately or will have to go to homes far away from their relatives. Community nursing services also risk being overstretched by the nursing care needs of residents and there is a risk of hospital beds being blocked by frail people waiting for places in large corporate nursing homes - the ones that are more likely to survive in the long run.

The Department of Health's Fit For The Future? consultation document and the long-awaited Care Standards Act 2000 will establish a single independent body responsible for the regulation of the care sector, and probably compulsory qualifications for inspectors. But although the long-term care inquiry and The NHS Plan have stated that nursing care in nursing homes will be free, nursing and residential care still need to be nationally agreed and defined.

The draft of Fit For The Future? clarifies the standards expected of care homes. It also aims to achieve some consistency on what their owners can expect of regulators and what residents should expect to receive in a care home. There needs to be similar consistency on whether someone requires nursing or residential care, which should be applied regardless of local finances.

- Fit For The Future? National Required Standards for Residential and Nursing Homes for Older People is available on the internet at: http://www.doh.gov.uk/pub/docs/doh/fitfuture.pdf

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