Simon Collins

Simon Collins is the Herald’s social issues reporter.

Inside our rest homes: Where should you go?

This page is a guide to choosing the best aged care for yourself or an elderly relative.

Photo / Thinkstock
Photo / Thinkstock

Seek advice

This guide is written by the New Zealand Herald health reporter Martin Johnston and social issues reporter Simon Collins in November 2013 after two months of research. But we strongly recommend that you make an appointment to go and see someone at your local office of Age Concern, who is likely to have spent a lifetime developing first-hand and up-to-date knowledge of the options in your area for both residential care and home care. Also ask around anyone you know who has had family experience of local rest homes, and make appointments to look around the homes that sound like the best options. Look, listen and smell what the place feels like, and talk to residents, any visiting family members, staff and volunteers as you look around. All this on-the-ground local knowledge is much more valuable than the official audits and other internet-based material which this page will guide you through.


How it works - home care

1. Hospital or general practitioner refers you to your local district health board (DHB)'s needs assessment and service coordination (NASC) service. You may also apply to NASC directly.

2. NASC assesses your need for "personal cares", such as help with showering and dressing, and for "household support", such as help with housework and shopping.

3. Help with "household support" is available only if you have a community service card. Most DHBs have cut household support in recent years to prioritise scarce funding for personal cares, and in many areas household support is now available only if you also need personal cares. If you cannot get publicly-funded household support, you can buy services at your own expense from a provider listed by the Home Health Association, Eldernet or, for Auckland and Northland, Seniorline.

4. Help with "personal cares" is provided free to any older person for as long as it is needed, up to a threshold at which the NASC judges that the person needs to be in residential care. The NASC may refer you to a particular provider to suit your needs, but you can choose a different provider if it has a contract with the DHB. Many DHBs have drastically reduced the number of contracted providers in recent years. Check with your NASC or pick up one of Eldernet's Where from here booklets free from Age Concern or for $5 online.

How it works - residential care

1. Hospital or general practitioner refers you to needs assessment and service coordination (NASC) service. You may also apply to NASC directly.

2. NASC assesses your need for residential care at one of four levels:

Rest-home care: unable to live safely at home but in stable condition not requiring 24-hour nursing.
Dementia care: as for rest-home care but locked in because of potential harm to yourself and/or others.
Hospital care: require 24-hour nursing.
Psychogeriatric care: require more intensive 24-hour nursing.

3. Apply to Work and Income for Residential Care Subsidy. No subsidy if assets (including house) worth over a threshold, currently (Nov 2013) $215,132. If assets below that, you must still pay your full income, with certain exceptions but including super, towards the cost of residential care, except for a personal allowance currently $42.64 a week and an annual clothing allowance currently $267.43 a year.

4. District health board tops up your contribution to full cost of between $820 a week ($117 a day) in Southland and $900 a week ($129 a day) in Auckland for rest-home care, or higher rates of $1173 to $1617 a week for dementia, hospital and psychogeriatric care. The rest-home rates are also the maximum that can be charged to the resident at all four care levels.

5. You are free to choose from competing providers at each care level.


How to choose - home care

Home care providers have been required, since September 1, 2013, to comply with the Home and Community Support Sector Standard NZS 8158:2012 available from Standards NZ at $62.10 including GST. A free version with additions by an Otara Maori provider, Whaiora Homecare Services, is available online.

All home care providers are now being audited against this Standard. The Ministry of Health holds copies of all audits and intends to publish summaries on the Ministry website at a date which has not yet been decided.

We are not aware of any independent assessments of home care services and can only recommend talking to your local Age Concern and to local family carer support groups listed by Carers NZ.

Read the full audit report here:

How to choose - residential care

Aged residential care facilities can be assessed against three separate documents:

1. The Health and Disability Services Standards NZS 8134:2008. Rest homes and hospitals must comply with these standards to be certified to operate and are audited regularly to ensure that they comply. However the standards are written in very general language to cover all healthcare and disability services.

2. The Age-Related Residential Care (ARRC) agreement. This is a detailed standard contract between each residential care provider and its local district health board (DHB) specifying the services the provider must provide in return for receiving the Residential Care Subsidy for qualifying residents. Since January 1, 2013, the regular audits assessing providers against the Health and Disability Services Standards have also assessed whether providers are complying with the ARRC contract.

3. A voluntary handbook produced by an expert committee convened by Standards NZ in 2005 called Indicators for Safe Aged-care and Dementia-care for Consumers. This specifies recommended safe rates of staffing, falls, weight loss, pressure sores, urinary tract infections and assessments for pain and depression in aged residential care facilities.

Audit reports on rest homes and hospitals are on the Ministry of Health website. Summary reports (about 5 pages) are available on all facilities. Full reports (about 100 pages), and previous reports showing any recent spot audits and investigations by the Ministry, DHBs and the Health and Disability Commissioner, are being posted on the Ministry website as they are received in batches from Nov 26, 2013, as a six-month trial. If you value these reports, we recommend that you download them direct from the Ministry website, because the Government has said that it will remove the full reports and stop publishing them after six months if no one bothers to read them.

Reports on all known investigations into complaints about aged care homes since 2007 are also available, for a fee, on the Consumer NZ website.



Rest-home audits: what to look for

Key issues to look for in audit reports are, in order of importance in our view:

1. Helping residents to do what they want

Why this matters:
Eden Alternative principles hold that person-centred care should "place the maximum possible decision-making authority into the hands of the elders or into the hands of those closest to them", and that "medical treatment should be the servant of genuine human caring, never its master". Nicola Turner of Presbyterian Support Central's Enliven service has said this "involves shifting staff from a task focus to supporting residents to be independent" - giving priority to helping each older person to do what s/he wants to do, rather than being fixated on daily schedules, medications and institutional policies.

What the documents require/recommend:
Health and Disability Services Standards: Many of these standards aim to ensure that residents are in control of their own lives, including most of the first block of standards on "consumer rights" (standards 1.1.1 to 1.1.13). The full standards included two standards directly focused on empowering residents:

* Standard 1.2.5 (Consumer Participation): "Consumers are involved in the planning, implementation and evaluation of the service to ensure services are responsive to the needs of the individual."

* Standard 1.2.6 (Family/Whanau Participation): "Family/whanau of choice are involved in the planning, implementation and evaluation of the service to ensure services are responsive to the needs of the individual."

However these two standards were removed when the 219 original standards were reduced to a shorter list of 101 "highly relevant criteria" in a new streamlined audit process introduced in January 2013 (new Part 11 of the Designated Auditing Agency Handbook).

Standard 1.3.3 (Service Provision Requirements) still requires that: "Consumers receive timely, competent and appropriate services in order to meet their assessed needs and desired outcome/goals."

ARRC contract: Section D3 (Service Philosophy) states that care providers must "ensure that the subsidised residents have access to a typical range of life experiences and choices" and "must: (a) be resident-centred; (b) promote the subsidised resident's independence and quality of life; (c) be comprehensive and multidisciplinary; (d) centrally involve subsidised residents in decisions that affect their lives; (e) actively encourage subsidised residents to maximise their potential for self-help and involvement in the wider community; (f) respect the rights of each subsidised resident; (g) ensure a culturally appropriate service; and (h) acknowledge, value and encourage the involvement of families/whanau in the provision of care."

Section D4.1(d) says providers must "provide the opportunity for each subsidised resident wherever possible, or the subsidised resident's representative, to be involved in decisions affecting the subsidised resident's life."

Section D16.3 (Care Planning) requires a "care plan" for every subsidised resident, developed with input from the resident and their family, which "addresses the subsidised resident's current abilities, level of independence, identified needs/deficits, and takes into account as far as practicable their personal preferences and individual habits, routines and idiosyncrasies."

Indicators for Safe Aged Care: do not address this issue.

Where to find information:
It's worth checking out the first block of standards on consumer rights, but in practice auditors appear to take pretty much a "tick the box" approach to this section.

In a full audit of Radius Maeroa Lodge in Hamilton in August 2013, the most useful information indicating the extent to which residents can control their own lives is under Standard 1.3.3, which describes the process of developing each resident's "care plan". "Tracer audits" (detailed inspections of the files of particularly vulnerable residents plus interviews with those residents and as many other relevant people as possible) must be reported under this standard. In the Maeroa Lodge audit, these show that care plans include the residents' goals. In one tracer audit of a younger woman, the woman's goals are based around "being as independent as possible" and writing her life story; "there is a volunteer to assist her with this activity." Another tracer audit of a hospital-level patient records a serious pressure sore and weight loss, but notes that the pressure sore has reduced from 4cm to 0.3cm with good care and that the weight loss has been stopped with high-protein supplements. These tracer audits are a good sign that, despite earlier problems, Maeroa Lodge is now trying hard to help residents do what they want to do and is taking good care of their health.

Care homes committed to the Eden Alternative aim to do even more to transfer power to the residents. Elizabeth Knox Home and Hospital in Epsom has a residents' committee and weekly residents' meetings, and includes residents on interview panels to select new staff.

2. Family and community involvement

Why this matters:
Eden Alternative principles hold that "the three plagues of loneliness, helplessness and boredom account for the bulk of suffering among our elders". They state that:

* Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship.
* An elder-centred community creates opportunity to give as well as receive care. This is the antidote to helplessness.
* An elder-centred community imbues daily life with variety and spontaneity by creating an environment in which unexpected and unpredictable interactions and happenings can take place. This is the antidote to boredom.

What the documents require/recommend:
Health and Disability Services Standards: Standard 1.1.12 states: "Consumers are able to maintain links with their family/whanau and their community."

ARRC contract: Section D16.5 (Support and Care Intervention) says care providers must provide for each resident a "social and recreational programme of activities planned to meet the identified interests, stated preferences and level of ability/disability" of the resident, and that this programme "shall include group and individual activities and involvement with the wider community".

Indicators for Safe Aged Care: do not address this issue.

Where to find information:
Check out Standard 1.1.12 in the full audits. The Maeroa Lodge audit says: "A number of residents are observed independently and/or being accompanied by visitors going out into the community and to facilities in the rest home. There are no set visiting hours and family/whanau are encouraged to visit.... Residents are supported and encouraged to access community services independently, with visitors or as part of the planned activities programme. The three activities coordinators report Catholic communion is available weekly with individual residents, and the service runs a church service fortnightly. A number of residents access their spiritual advisers individually or with family as required."

This is a fairly minimal commitment to community involvement. At the other extreme, Elizabeth Knox Home and Hospital has a close involvement with girls from St Cuthbert's College across the road and 200 volunteers, including many migrants and international students who need human companionship just as much as the Knox residents. It also encourages residents, families and staff to bring in animals which the residents can love, care for and enjoy.

3. Activities

Why this matters:
Organised activities are less important than empowering individual residents to do what they want and keep in touch with family and the outside world, but having a wide range of organised activities available is also important to avoid the plague of boredom.

What the documents require/recommend:
Health and Disability Services Standards: Standard 1.3.7 (Planned Activities) states: "Where specified as part of the service delivery plan for a consumer, activity requirements are appropriate to their needs, age, culture and the setting of the service."

ARRC contract: Section D16.5 (Support and Care Intervention) says care providers must have "a designated staff member who is skilled in and accountable for assessment, implementation and evaluation of social, diversional and motivational recreation programmes for each subsidised resident". As noted already, care homes must also provide for each resident a "social and recreational programme of activities planned to meet the identified interests, stated preferences and level of ability/disability" of the resident, and this programme "shall include group and individual activities and involvement with the wider community".

Indicators for Safe Aged Care: do not address this issue.

Where to find information:
Look at Standard 1.3.7 in the full audits. The Maeroa Lodge audit says each resident has "an activities assessment and diversional therapy plan with a resident-centred goal". Three activities coordinators were interviewed, a high number for 61 residents at the time. The audit mentions a men's group, a garden party and Christmas lunch, and again mentions weekly Catholic communion and fortnightly church services.

You can see the activities programme on a whiteboard or noticeboard in most rest homes when you visit. When we visited Maeroa Lodge in Nov 2013, there were two separate programmes running each day and residents could choose to attend any part of them. Activities included a current events discussion around the morning paper, a group jigsaw puzzle with morning tea, courtyard gardening, crosswords, quizzes and word games, physical activities, a ladies' group, a craft group, bingo, card games, church services, target bowls (bowling from your seat), a movie, a happy hour with entertainment, a touch-and-feel activity with coloured lights, and a weekly outing.

4. Staffing

Why this matters:
In our view, staffing is the main driver of the quality of care because nurses and caregivers at understaffed facilities are less likely to have time to check and respond to residents' needs, help them to stay in control of their own lives as far as possible, or even to interact with them as caring human beings for a meaningful amount of time. The Indicators for Safe Aged Care should be seen as an absolute minimum because of a trend for people to enter residential care later and at higher levels of need each year, so the average level of need has increased significantly since the indicators were drawn up in 2005. In practice NZ Aged Care Association chief executive Martin Taylor estimates that about half of all aged care providers follow the recommended indicators and half don't.

What the documents require/recommend:
Health and Disability Services Standards Standard 1.2.8: "Consumers receive timely, appropriate and safe service from suitably qualified/skilled and/or experienced service providers."

ARRC contract: (a) Rest homes and dementia units must employ at least one registered nurse (no hours specified), and must have caregivers at all times in the ratios of at least one on duty for up to 10 residents, one on duty and one on call for 11-30 residents, at least two on duty for 31-60 residents and at least three on duty for more than 60 residents; (b) Hospitals must have at least one registered nurse and one caregiver on duty at all times (D17: Human Resources).

Indicators for Safe Aged Care: (a) Rest homes should employ two hours of registered nurse time plus 12 hours of caregiver time per resident per week; (b) Dementia units should employ 3.5 hours of registered nurse time plus 14.5 hours of caregiver time per resident per week; (c) Hospitals should employ at least eight hours of registered nurse time (up to 14 hours for more acutely unwell patients) plus 16.5 hours of caregiver time per resident per week, with a registered nurse on duty at all times (Table 4, page 24).

Where to find information:
Check out Standard 1.2.8 in the full audit reports. For example, the Maeroa Lodge August 2013 audit found (page 54) that Radius staffing rates were: (a) Rest home: 0.25 registered nurse hours a day (1.75 per week) and 1.5 caregiver hours a day (10.5 hours a week) per resident; (b) Hospital: one registered nurse hour a day (seven hours a week) and 2.5 caregiver hours a day (17.5 hours a week) per resident. Thus Radius operated at 12.5% below the recommended indicators for rest-home staffing and for registered nurses at hospital level, but with 6% above the recommended indicator for caregiver hours at hospital level.

The Maeroa Lodge audit also reports on response times to call bells under this heading. In August 2013 it found that "the majority of calls" were answered within 4 minutes. Some calls took more than 10 minutes to answer but "some of these" were where staff forgot to turn the bell off or helped the resident to go to the toilet before turning the bell off.

5. Clinical indicators

Why this matters:
Old people end up in residential care only because they have physical and/or mental ailments that mean they can no longer look after themselves without help. Obviously a basic requirement for care homes is that they should provide the help required to keep residents as well as possible.

What the documents require/recommend:
Health and Disability Services Standards Standard 1.2.3: "The organisation has an established, documented and maintained quality and risk management system that reflects continuous quality improvement principles."

ARRC contract: Facilities must have documented policies relating to issues including infection control, fall prevention practices and a quality improvement programme (D19: Quality Focus and Risk Management).

Indicators for Safe Aged Care: (a) No more than 6.38 falls per 1000 occupied bed days in rest homes and hospitals and no more than 11.09 falls per 1000 occupied bed days in dementia units; (b) No residents with unintentional weight loss of more than 5% in 30 days or 10% in 180 days; (c) No pressure ulcers; (d) no more than 1.51 urinary tract infections per 1000 occupied bed days; (e) Comprehensive assessment of every resident's pain level within 48 hours of admission and then at least every six months; (f) Assessment for depression within 21 days of admission.

Where to find information:
The full audits report only fragmentary clinical indicators under Standard 1.2.3. For example, the Maeroa Lodge August 2013 audit reports "improved rate of falls with no injury" and "an improved performance in relation to the number of residents with grade one pressure areas", but gives no figures.

The country's biggest rest-home operator, Bupa, is the only one of the top 12 rest-home chains reporting any of these clinical indicators (three of them) on its website, all on a national basis broken down for rest homes, hospitals, dementia units and psychogeriatric units. Its monthly indicators for rest homes in the period Jan-Sept 2013 averaged:

(a) 6.7 falls per 1000 occupied bed days, slightly worse than the recommended indicator of 6.38.

(c) 0.2 pressure injuries per 1000 occupied bed days, slightly worse than the recommended indicator of none.

(d) 1.6 urinary tract infections per 1000 occupied bed days, slightly worse than the recommended indicator of 1.5.

Although Bupa fell slightly short of all three recommended indicators, you can at least be confident that this company is monitoring these indicators, and being transparent about them, which are good signs that it is trying hard to improve them.

See the result of the OIA request:

6. Overview - shortfalls

Why this matters:
The summary audits on the Ministry of Health website grade each care home on each of six blocks of standards using a five-colour "traffic light" system:

Blue: Commendable elements above requirements.
Green: No shortfalls; standards fully attained.
Yellow: Some minor shortfalls; some standards partially attained but low risk.
Orange: Moderate shortfalls; some standards unattained or partially attained and medium to high-risk.
Red: Major shortfalls; some standards unattained and medium to high-risk.

Where to find information:
These grades are easy to see in the summary audits. In the full audits, they are shown in the table headed "Summary of Attainment" which follows the Executive Summary of the report. The abbreviations are:

CI: Continuous Improvement (more than just fully attained).
FA: Fully Attained.
PA: Partially Attained.
UA: Unattained.
NA: Not Applicable.
Neg: Neglibible risk.
Low: Low risk.
Mod: Moderate risk.
High: High risk.
Crit: Critical risk.

Since January 2013, aged care facilities have been graded only on 101 "highly relevant criteria" in a new streamlined audit process (new Part 11 of the Designated Auditing Agency Handbook). The last column in these tables shows that these are only 101 out of 219 standards in the full Health and Disability Services Standards.

A July 2013 Consumer NZ review of audits of all 634 care homes found that:

* 9% had no shortfalls (only blue or green grades for all six blocks of standards).
* 28% had minor shortfalls (yellow on at least one block of standards).
* 61% had moderate shortfalls (orange on at least one block of standards).
* 3% had major shortfalls (red on at least one block of standards).

For example, Maeroa Lodge's August 2013 audit gave the home green lights for all blocks of standards except one, "Safe and Appropriate Environment", where it scored an orange light (moderate shortfall) in the summary audit, marked as "PA Moderate" against Standard 1.4.7 in the table in the full audit report. The detailed report on Standard 1.4.7 explains that this was because four residents could not reach their call bells. On Consumer's analysis, this places Maeroa Lodge in the middle 61% of care facilities, below the top 37%, at the time of the audit. This shortfall has since been fixed.

7. Certification period

Why this matters:
The Ministry of Health assesses all audit reports and certifies care homes to continue operating for six months or one, two, three or four years. Those with shorter certification periods are either new (or in new ownership) or where there have been major shortfalls requiring close monitoring; those with longer certification periods have had no major shortfalls and the ministry is confident that they are providing high quality care.

Indicators for safe aged care and dementia care for consumers:

Where to find information:
This is the easiest way to get a quick overview of a facility's performance because the certification period is shown on the Ministry of Health's audit home-page, in the extreme right-hand column.

Data supplied to us under the Official Information Act from Ministry of Health Acting Chief Medical Officer Dr John Crawshaw show that certification periods granted in the year to June 2013 were:

4 years: 9%
3 years: 66%
2 years: 19%
1 year or less: 6%.

Radius Maeroa Lodge's two-year certification places it in the bottom 25%. However Radius managing director Brien Cree told us the home had improved: "There was a period in its history a few years ago where it did have issues. From there, you have to look at the tremendous amount of work done to get it to where it is now. It has only got two years because they have a "continuous improvement" provision so you have to show continuous improvement over a period. Next time up, if we were to get one PA or two, it will probably get four years."

Elizabeth Knox Home and Hospital was granted three-year certification in March 2012, with one block of standards rating as a moderate shortfall (orange), four as minor shortfalls and only one with no shortfalls (green). Similarly, chief executive Jill Woodward predicts a much better result after her latest audit in Nov 2013.

8. Overview - standards attained

Why this matters:
The number of standards only partially attained ("PA's") or unattained ("UA's") is less significant than the degree of risk to residents from each shortfall, which is measured better by the "traffic light" system and certification period as above. However, care homes may quote their attainment results to you, so it is useful to understand them.

Where to find information:
As explained under "shortfalls" above, data on whether a care home has attained each of 101 standards fully, partially or not at all are shown in tables after the executive summary near the front of every full audit report. Aggregate Ministry of Health data on 148 audits conducted between January and June 2013, shown graphically below, shows that care homes have a median of 4 and an average of 4.9 "PA" or "UA" shortfalls. In percentage terms, the numbers of PA's and UA's are:

Nil: 13%
1: 12%
2: 15%
3: 9%
4: 8%
5: 6%
6: 6%
7: 5%
8: 5%
9: 3%
10: 7%
11: 3%
12: 2%
>12: 5%

On this basis, Maeroa Lodge scored only one PA and 100 "FA's" (fully attained) out of 101 standards, placing it in the top 25% of care homes for the period.

- NZ Herald

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