Older people are more likely to end up in retirement facilities in New Zealand than in any other country. In the first of a five-part investigation, Simon Collins and Martin Johnston examine the standard of our care for the aged.
Retired air force warrant officer Frank Bailey, MBE, has never been a complainer. But when he speaks of his late wife, Lilian, he chokes up.
Mrs Bailey died in January 2011, just before what would have been the couple's 60th wedding anniversary. Mr Bailey, now 87, still feels guilty that he ever let her stay in the Hamilton rest home where she spent the last four months of her life, Radius Maeroa Lodge.
Brien Cree, managing director of Maeroa Lodge operator Radius, says the facility has improved since Mrs Bailey's stay and an August audit put it in the top 20 per cent in the country.
Back in 2010, Waikato Hospital was pressing Mr Bailey to find a rest home in a hurry. Mrs Bailey had had some toes amputated, needed continuous oxygen and a nebuliser and had bags collecting urine and bowel motions; she needed 24-hour nursing care.
She struggled to get it at Maeroa Lodge. She was on multiple medications but had to press a call bell to get a nurse to give her pain relief when required.
"She had to press the emergency button sometimes because pressing the normal call bell used to strike times when the staff were having lunch or afternoon tea," Mr Bailey says. "Usually someone came within 10 or 15 minutes but sometimes she would have to wait up to 40 minutes."
Often on his daily visits, her bag was full and urine was backing up the tubing because no one had checked.
Their daughter Helen Bailey says: "Nine times out of 10 I would change her or empty her catheter, as she would ring for assistance and there was never anyone around."
Waikato Hospital had told her she needed regular physiotherapy to maintain her ability to walk with assistance, to help drain fluid from her lungs and help with a persistent painful pressure sore on her back.
But it was eight weeks before a physiotherapist came, and she was seen only three or four times during her four-month stay.
Mrs Bailey needed antibiotics for frequent lung and urine infections, but usually had to wait in pain and with difficulty breathing until a doctor came the next day and a pharmacy supplied medicines a few hours later.
When she finally caught pneumonia and was fighting to breathe, nurses could not get the doctor that evening. She was rushed to hospital in the morning and died the next day.
Mr Bailey says she got less attention at Maeroa Lodge than he did in a makeshift desert hospital when he served in Egypt more than 60 years ago.
Patricia Bett had a similar experience. She went into Maeroa Lodge in September 2011 needing 24-hour nursing care because of a rare disease which left her paralysed from the neck down, aged only 72.
She also needed physiotherapy to give her a chance of recovery. But her daughter, Jacqui Robinson, says the physiotherapist's hours were halved for financial reasons a few weeks after Mrs Bett moved in and the physiotherapy "didn't really happen".
The family paid for a masseuse to massage her hands, which were turning inwards. The masseuse offered to teach the care staff the technique, but they were too busy so Mrs Robinson says it happened only when she came from Auckland to do it herself.
Carers were also too busy to help Mrs Bett with her breathing. Mrs Robinson says: "They had a breathing thing that she could blow in to help her breathing, but to do it someone had to give it to her and everyone was always too busy."
Despite being paralysed, Mrs Bett was highly sensitive to pain. Some carers were "really good" with her, but others were not.
Sometimes carers were too busy to feed her, so she could not eat. Her daughter says: "Her food would be taken into her room and left; reason was that they were too busy." Sometimes she became dehydrated. Sometimes she was not helped out of bed, dressed or washed. Mrs Bett died of a chest infection in July last year after 10 months in Maeroa Lodge.
Health and Disability Commissioner Theo Baker found last month the home's nursing and caregiving staff failed to meet Mrs Bett's rehabilitation needs. She referred the case to the Waikato District Health Board and the Ministry of Health.
When the Herald visited Maeroa Lodge this month, the home was well lit and appointed, with paintings that could grace a flash hotel.
Its latest audit, in August, found only one fault - call bells that were out of reach of four bedridden residents. "This places the facility in the top 20 per cent in the country," says Mr Cree of Radius.
"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 to where it is now."
Mr Cree simply does not believe Mrs Bailey's family had to change her urine bag themselves nine times out of 10, or that Mrs Bett was sometimes not helped to eat meals or put to bed in her clothes.
"I haven't asked whether staff put her to bed in her clothes," he says. "I have an organisation to run."
The August audit of Maeroa Lodge found its staffing levels were below voluntary indicators for rest home care and registered nurse time at hospital level, although 6 per cent above for caregiver time at hospital level. That was enough to comply with the DHB contract.
The audit also found a majority of call bells at Maeroa Lodge were now answered within four minutes.
A two-month Herald investigation of rest homes around the country has found that many simply can't afford a level of care most New Zealanders would want for their loved ones.
"We're funded to provide a minimum level of care," Mr Cree says. "There isn't a lack of staffing, but there is a perception by the public there should be higher levels of staffing."
Old people are more likely to end up in rest homes here than in any other country. An Auckland University study last year found 38 per cent of New Zealanders aged 65 and over die in residential aged care, compared with 32 per cent in the next-highest country, Australia, and under 20 per cent in most developed European and Asian nations.
Also, almost a third of the 34 per cent who die in acute hospitals here come from aged care homes, so almost half of us (48 per cent) can expect to spend time in a rest home or aged-care hospital before we die.
The quality of care we can expect varies enormously. At the best place visited for this series, the 144-bed Elizabeth Knox charitable home in Auckland, two physiotherapists, three physio assistants and an occupational therapy team offer therapy to allcomers every day, with facilities rivalling a commercial gym.
But most places don't have the personal legacy that endowed the Knox home 105 years ago. Three-quarters of our rest home beds are owned by companies like Radius that struggle to earn a return on their capital under government-regulated fees.
In the worst places, Age Concern Auckland field worker Chris Frew says there are only minimal activities and residents just sit for most of the day in their rooms or in lounges.
"They are like chicken farms, some of these places; they plonk people down in front of TV and over-medicate," she says.
A 2010 review by consultants Grant Thornton found our aged care facilities' prescription rate for medications was 42 per cent above an international benchmark. In the same year, the country's largest aged care operator, Bupa, had 30 per cent of its residents on anti-psychotic drugs that curb problem behaviour but make people passive.
Bupa managing director Grainne Moss says the company has reduced that since then to 23 per cent.
The Occupational Therapists Association says problem behaviour, and hence the need for anti-psychotic drugs, can be reduced by encouraging residents to look after themselves, keep up leisure interests and contribute to the community. But the trend has been to "minimising registered staffing levels over the years".
"Many decline more rapidly because they're not given opportunities to do things for themselves," it says.
The standard rest-home contract of the DHBs requires a "social and recreational programme of activities planned to meet the identified interests, stated preferences and level of ability" of each resident.
It says owners "must provide the treatment programme prescribed by a medical practitioner or nurse practitioner to assist the subsidised resident to develop and maintain functional ability".
But at Maeroa Lodge the doctor was contracted by the home, and when Mrs Robinson tried to express concerns to him about her mother, she found he did not see patients at the home or speak to relatives unless a Radius manager asked him to.
"There is no requirement for a fulltime physiotherapist," says Radius operations manager Jane Smart. "We are not a rehabilitation unit."
Mr Cree adds: "We don't provide massage services; the service contract doesn't have that in it."
An Aged Care Association survey last year found only eight fulltime and 92 part-time physiotherapists working across 375 facilities with 20,841 beds, although that was up from four fulltime and 66 part-time in 2009. Occupational therapists increased in the same period from nine to 39 fulltime, and from 49 to 81 part-time.
A handbook of Indicators for Safe Aged Care approved by an expert group through Standards NZ in 2005 recommends two hours of registered nurse time and 12 hours of caregiver time for every rest home resident a week, and eight hours of registered nurse time and 16.5 hours of caregiver time for every patient at the lowest level of long-stay hospital care.
But Martin Taylor of the Aged Care Association estimates only half the country's 634 aged care facilities follow the voluntary indicators.
Are you or someone in your family thinking about moving into a rest-home? The Herald has compiled this guide for you to consider before you make your choice.
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