You've got to look, listen - and sniff - when choosing a rest home for yourself or your elderly mother or father, experts advise.
"One of your first and maybe defining impressions of a facility could hit you as soon as you enter - the smell!" say retired aged-care nurses Jenny Moloney and Heather Johnston in Decision Time, their guidebook on choosing an aged residential care facility.
"If the smell is an issue, don't waste your time - you don't need any further information about this facility - leave immediately."
Choosing a rest home or long-stay hospital is as important, and complex, as picking a house to buy or rent, although there may be much greater urgency to find a place if an old person's health deteriorates quickly or they are being discharged from an acute hospital.
And the choice may be constrained further in small towns or by the need to stay in the suburb where the person had been living independently.
The first step into the bureaucratic world of aged residential care will typically be a referral from a public hospital or GP to a needs assessment and service co-ordination (NASC) team via the local district health board, although individuals can approach the service directly. The NASC will decide if the old person is sick or dependent enough to need either home support or residential care. The latter is at one of four levels, depending on need: rest home, dementia unit, residential hospital or psychogeriatric unit.
Step two is to apply to Work and Income for the residential care subsidy. You don't qualify if you own assets, including a house, worth over $215,132 (there is an annual adjustment).
Below that level, you must still pay your full income, with certain exceptions but including superannuation, towards the cost of residential care, except for a personal allowance of $42.64 a week and an annual clothing allowance of $267.43.
DHBs top up your contribution to the full price set under their contract with rest homes, which is $900 including GST a week in central Auckland, and less in other areas. The higher levels of care cost more, but the rest home rate - in each area - is the maximum that can be charged to private-paying residents in any level of care.
People are free to choose which home they want to live in.
The Moloney/Johnston book urges rest home shoppers to remember their first impressions of visiting a home - do the staff respond to residents in a warm, caring manner, are the residents animated and content and what are they doing: watching television, interacting with a pet animal, sitting alone in their room?
Check the audits on the Health Ministry website - the ministry has started posting full audits this week for this first time. On a second visit, ask about any fees, such as for a bigger room, en-suite, view, internet or health services.
On staffing, the "critical question" to ask is the numbers of registered nurses, enrolled nurses and caregivers on duty at different times of the day and week, and the total number of residents. "What is the staff turnover - if you find it is frequent, be alarmed!"
Staffing levels can be hard to evaluate, but comparisons can be made against the DHB contract, available on the ministry website.
The book urges choosers to ask rest homes what percentage of caregivers have NZ Qualifications Authority certificates and what training or education sessions were given in the previous month. Is there a diversional therapist, how frequent are outings, what percentage of residents are routinely on antipsychotic, sedative or antidepressant medication, and is there a residents' committee?
Mrs Johnston said the hallmarks of good aged care were maintaining residents' independence and mobility, and ensuring a safe environment and their constant well-being.
She said two to three baths or showers a week had become the norm in care homes, while the book recommended at least four.
"We're saying the ideal would be every day, particularly for those who are incontinent."
Pressure injuries are a particular concern and the book notes a 2010 Whanganui DHB survey of 336 rest home residents found 6 per cent had one on the day of the survey. At the worst-affected home, 23 per cent had a pressure injury, also called a pressure ulcer.
The survey also found 23 per cent of residents were malnourished, 14 per cent had had a fall in the preceding two weeks, and 55 per cent had incontinence.
An article in the journal Kai Tiaki Nursing NZ this month says pressure injuries are "a sign of neglect, particularly in relation to nursing care. While the majority of experts consider pressure injuries to be preventable, a small proportion may be unavoidable".
There is no requirement for aged care facilities to report publicly on their rates of pressure-injuries and quality-related outcomes - unlike DHBs, whose emergency department performances, numbers of surgical errors and various other quality measures are regularly published.
Bupa, New Zealand's largest rest-home provider, has started its own public reporting on quality measures, but by type of care nationally - "hospitals" for instance - rather than by each individual home.
Experts consider this an important advance in transparency and the pursuit of quality. In October, Bupa's rate of pressure injuries was 0.03 per cent in rest homes.
A new system of nursing assessments for all residents in aged care homes, called interRAI, will be made compulsory in 2015.
It is intended to improve outcomes for individuals based on checks on numerous aspects of health and well-being including dehydration, pressure ulcers and falls.
The mass of data would allow public star-rating comparisons of homes.
Associate Health Minister Jo Goodhew said the Government had no plans to use interRAI in this way. Instead, the ministry's revamped residential care website now provided "huge transparency".
The website's listing for each rest home now states the length of the facility's ministry certification, from a year or less, which is mainly for new or altered homes, and up to four years. Longer is better.
Where to get advice
• Age Concern - visit local office, contact details on website
• Needs Assessment and Service Coordination team at each district health board - decides if someone needs home help or residential care, contact details online
• Eldernet - directory of aged residential care facilities
• Health Ministry - directory, full audits, summary audit reports, how the system works
• Consumer NZ - checklist of what to ask and look for, list of rest homes that have been investigated
• nzherald.co.nz - comprehensive guide on how to choose a rest home
• findaresthome.co.nz - directory, how the system works
• Decision Time - book available at some public libraries and for sale at bookshops
Bored, hungry man pleaded to be taken out of home
David Airey's overwhelming memory of his years in a Northcote rest home is that it was boring.
"You can't go out for a walk. You're sitting inside watching TV. It's very boring," he says.
Mr Airey, now 66, spent three-and-a-half years in Anne Maree Court from 2008 to 2011 because of an intellectual disability and increasing physical frailty, even though he was under 65.
His sister, Robyn Airey, says the family moved him there after his mother died. He had been in a Devonport rest home close to his mother, and two of the nurses from there had moved to Anne Maree.
She says his room there was small - "like a little dog box" - but Anne Maree promised him a bigger room when one became vacant. When that happened, they wanted to charge him extra.
"They took him hardly anywhere at all," says Robyn's partner, Dave Moore. "He would join in with the rest of the patients, who were mostly in their 80s, watching TV. We'd go there and he'd be asleep."
Mr Airey says the food was cold and there wasn't enough, so he was often hungry. "I got sick and tired of soup." He couldn't even make a cup of tea because the kitchen was often locked.
His sister recalls: "Sometimes he'd say, 'Get me out of here, I'm going mad'." She kept a note he wrote pleading: "Not this place. I hate it. I am lost."
The family was angry when the home expected them to take him to Auckland hospital for regular radiation treatment for prostate cancer.
"I said, 'He's in your care'," Mr Moore says. "They put him in a taxi and dropped him off at the hospital. He's intellectually disabled, has difficulty walking, he had no caregiver with him. It's criminal. I did my nut." The home sent a caregiver with him after that.
Mr Airey now flats with others in a house run by Spectrum Care and has regained the weight he lost at the rest home. Anne Maree Court director Sheryl Samuel wouldn't comment on individual cases, but said: "We constantly look for quality improvements to care of our residents. This includes an organised programme of activities which runs eight hours a day, seven days a week.
"The recent Ministry of Health audit completed at our facility concluded all audited areas are fully compliant."