Selecting a rest home for an aged parent is a difficult, often emotional matter. Martin Johnston and Geoff Cumming discover there is little information available to let families know whether a home is safe.
When Lois Madden set out to find a rest home with hospital-level care for her chronically ill mother, she found it hard to tell which one was better than any other.
The first place she visited looked in need of a lick of paint. The second smelled of urine - a sure sign of problems, as health agencies warn.
So she went on the recommendation of a friend whose relative had, 18 months previously, had no complaints about a Whangarei home owned by the Radius Residential Care chain. It looked clean and modern and the staff were friendly.
"I felt it was the best of the lot by the look of it ..."
But within four days of 84-year-old Gladys McKinnon's arrival at Lester Heights rest home, she was rushed to hospital, where she subsequently died.
"Mum had acute renal failure, on top of her chronic renal condition, as a result of dehydration from four days in the care of Lester Heights. They didn't notice she had an infection and wasn't drinking and they kept on giving her a diuretic [causing her to urinate more]."
This was despite Madden noticing, on her daily visits, that her mother was not right - and getting worse - and raising concerns with the nursing staff.
"She was refusing a cup of tea, which was unheard of. She was not eating and she was cold and shaking - all things which should have sent alarm bells ringing. But it was as if I was in some sort of Kafka play - the message just didn't seem to get through.
"Because of their neglect, she went through terrible pain and distress. I can't forgive them for that. She didn't have to go that way."
The rest home's system failures and those of the clinical nurse manager in charge are exposed in a Health and Disability Commissioner's report, which takes the unusual step of naming Radius, operator of 19 residential care facilities around the country.
The Ministry of Health says it received 14 complaints about Radius facilities last year and seven in each of the two preceding years. Nationally the ministry received around 150 complaints about rest homes in each of the past three years. High-risk problems were found at a Radius home in Hamilton last year.
But in most cases problem homes are not widely identified - so how are consumers expected to know if a home is safe?
The Lester Heights report, by deputy commissioner Tania Thomas, found Mrs McKinnon was not properly assessed on arrival; there were gaps in documentation and other communication failures; and she was not properly monitored to check she was taking fluids and food. A fluid balance chart (indicating fluid intake and urine output) was not started.
Though Radius' systems were at fault, much of the blame lay with the clinical nurse manager who had oversight of nursing staff and responsibility for Mrs McKinnon's care - and who resigned soon after the episode. It later emerged there were ongoing concerns about her performance, including lack of knowledge of clinical, medication and health and safety standards and not taking responsibility for poor documentation.
"This was a system that was in failure and they failed to recognise it," says Madden. "Clearly the problems at Lester had been going on for some time."
Madden has felt guilt over her mother's death ever since: "I was feeling personally responsible for not having found a [safe] place.
"You hear about places but you have to take your best shot - it's like Russian roulette. I chose a place that, despite recommendations and appearances, basically failed her - that's a hell of a legacy to live with. But how are you supposed to know?"
Madden takes strong offence at Radius' take on the episode, with managing director Brien Cree this week claiming Mrs McKinnon went to Lester Heights for end-of-life care and was very ill when she arrived.
Madden says her mother was moved only because her deteriorating arthritis meant she needed more hands-on care than her previous rest home could provide.
"She had only one kidney and it was diseased. We always knew that one day it would give out. But she had a strong heart and could have gone on for a long time. There had been no dramatic decline in kidney function."
Most homes these days are profit-driven and have business managers overseeing nursing managers. "They aren't going to know what's missing, what's not happening, unless they have a nursing background."
Madden believes there should be more regular monitoring of homes by district health board staff. "I don't think spot audits are enough - there needs to be regular inspection."
She supports calls for a league table or star system to be introduced for rest homes, so people can go online and read assessments by locally based people with medical expertise.
The Government has been under pressure to reduce the level of secrecy on its checks of suspect rest homes since the 2008 scandal in which Auckland's Belhaven was closed down after it was revealed a female resident's mouth had been taped shut to keep her quiet.
The ministry began posting summaries of rest home audits on its website, naming homes and their failings, and introducing spot audits.
Publicly identifying poor performers may seem a big concession to the affected operators, but the audits are of limited value to the family trying to find a safe, comfortable, compassionate home for Mum or Dad.
Their official-speak, which often buries details about problems among pages of bureaucratic waffle, will deter many who need this information.
One summary says on the cover page that an Auckland rest home was, in January, making "good progress" on addressing earlier areas of non-compliance. But turn to page 5 and a 2010 audit contains the alarming statement that there have been "no complaint investigations by the Health and Disability Commissioner, Police, ACC or Coroner since the previous audit".
The previous audit isn't there, so you're left wondering what kind of history, including possible dealings with these agencies, the place is making "good progress" in leaving behind. The owner denied any such history to the Weekend Herald.
Such ambiguity strengthens Consumer NZ magazine's call - echoing the 2010 Labour-Greens-Grey Power inquiry, and now supported by the Human Rights Commission - for star-rating. This could be an easily-digested ranking of rest homes on points like staff/patient ratios, staff training, complaints and rates of residents' pressure sores, infection and falls.
But Associate Health Minister Jo Goodhew says the Government has no plan to introduce such a system.
"The traffic light system already in place [the ministry's on-line reports] publicly shows an assessment of how a residential care facility is rating."
In the absence of an easier-to-use system, Consumer has campaigned for the release more information about poor performers. It pushed the ministry to publish the full findings of unannounced inspections, which can be much more revealing than the standard summaries.
A Consumer research writer, Jessica Wilson, said that when ombudsman David McGee told the ministry to release the full findings, he criticised the summary reports as being inadequate for consumers.
McGee said: "They do not contain the detail ... which would enable consumers to be more confident that they are making a decision about the suitability of a particular facility for themselves or a family member with as much information as possible."
Deputy commissioner Thomas, in her Lester Heights opinion, criticised Radius' failure to maintain a staff culture of compliance with its policies, although she concluded the company had fixed its problems.
Radius' Cree highlighted Thomas' conclusion and said: "We have made significant changes to our systems since that event to ensure that care plans are peer reviewed and adequately checked by other staff members."
Cree led a management buy-out of the company from Kuwait Finance House in 2010.
He has said an aim of the buy-out was "to bring some good old-fashioned Kiwi values and standards back into the aged care sector".
Radius Care is a mid-sized corporate operator in the rest home and geriatric hospitals market, serving more than 1400 residents, but has fewer than half the facilities of Bupa, which operates more than 40 care homes and hospitals.
Radius has had other troubles, both before and after the injection of "Kiwi values".
Lester Heights' certification audit in March, the most recent report on the ministry's HealthCERT site, says: "there are improvements required around documentation of care and support in care plans, including the use of short-term care plans".
Shortfalls also needed to be addressed in medication documentation and documenting that family members were informed of incidents and accidents.
Consumer in 2009 highlighted earlier failings of three Radius facilities in Whangarei. It said the ministry found "serious deficits in service delivery" at Oakhaven, and lesser problems at Lester Heights, including outdated care plans, and at Potter Home. In the latest audit, last year, Radius' Rimu Park in Whangarei had shortfalls of at least medium risk in areas including care plan documentation.
Complaints were made last year about Radius' Hamilton facility, Maeroa Lodge, on matters including staff/resident ratios and wound care. The ministry said residents' safety was not at immediate risk. An unannounced inspection found "recurring issues" following an earlier spot audit.
A later spot audit found improvements but said more were needeed, such as in short-term care plans. Some issues were of at least medium risk, but the website doesn't say which ones.
The ministry explained to the newspaper that of 15 improvements required following the unannounced inspection, six - in management, care planning, medicine administration and nutrition - were considered high risk.
Cree said a number of the Maeroa complaints were from one family. They were proven unfounded but Radius instigated audits - substantiated by a ministry audit - which produced some corrective action requirements. These, and extra staff training, were implemented.
Another provider to come under close scrutiny at more than one site is the Cressida group, which has six facilities in Auckland, Taranaki and Otago.
The Taranaki District Health Board appointed a manager at the Renaissance rest home and hospital in New Plymouth after failings were found, including in medicine reconciliation and medicine competencies of some staff.
The DHB and Renaissance were "working towards ensuring all audit requirements are met," said a DHB manager, Sandra Boardman. The appointment of a temporary manager - a serious step for a DHB to take - is not mentioned in the audit report summary.
Cressida's 36-bed North Shore hospital, Eversleigh, in Belmont, is the subject of one of the most frank reports released by HealthCERT, following complaints which were substantiated.
In a section on residents' safety, it says: "The facility is staffed by new graduate registered nurses - RNs - with no senior clinical oversight and risk management in place regarding abuse and neglect.
"There have been confirmed issues of abuse and bullying in respect of two staff members who have now resigned, related to the complaint.
"However there has been no support and education of staff."
Other findings were:
A high number of complaints were made.
Seven months passed without a permanent clinical manager.
One healthcare assistant was observed trying to feed lunch to seven residents.
A registered nurse was working 60 hours a week.
Care plans were not changed when a resident's condition changed.
Fire exits were blocked by equipment.
Kitchen cleanliness was "poor".Asked about the problems at Eversleigh and Renaissance, Cressida co-owner Graeme Kirkland, a former property developer, replied: "All the audit requirements are being met."
Were Eversleigh's problems being rectified? "They are in process."
A Waitemata DHB manager, Debbie Holdsworth, said Eversleigh had hired a nurse consultant and a facility manager to ensure a satisfactory level of care to residents.
Auckland DHB, which had to sort out the Belhaven mess, has another poor performer under watch.
It won't name the rest home but said a temporary manager had taken over and the clinical manager was on paid leave while "concerns regarding clinical competence" were investigated. This action arose from a complaint over clinical care to the Health and Disability Commissioner's office, which referred the case to the ministry.
Goodhew defended the secrecy.
"There is no intent for this to drag on unduly or to hinder the public. ... When that investigation is complete, information such as the name of the facility can be released."
She also defended Government spending in the sector. Despite tight finances, she said, the Government has boosted aged-care spending - which included homes - by 16 per cent since 2008, to more than $1.4 billion this year.
"Adding another $140 million, as recommended by the HRC [Human Rights Commission], on top of the $895 million we already spend on aged residential care each year is simply unaffordable at present."
The commission, after a wide-ranging inquiry, which included Equal Opportunities Commissioner Judy McGregor going under-cover as an unpaid trainee carer, called for carers in home support and residential facilities to be paid on par with their DHB counterparts, on average around $3 more an hour than typical rates of about $14.
It also reiterated others' calls for improved training of carers.
Goodhew said carers in state-subsidised aged residential care were already required to do foundation skills training within six months of their appointment.
Theo Baker, deputy health and disability commissioner responsible for complaints resolution, says staffing and competency are valid issues but a consistent finding in investigations is lack of adequate care planning and procedures which ensure monitoring, evaluation and response.
But in the absence of a star-rating system, these are things that people choosing a rest home - like Lois Madden when she placed her mother in Lester Heights - will largely take on trust.
"What really guts me," said Madden, "is that you put your most precious relatives in the care of strangers. You can only really rely on the system in place."