The human rights abuses of NI's elderly

THE human rights implications of use of restraint and handling of medication in Northern Ireland’s nursing homes are laid bare in a new report out today.

A study commissioned by the Northern Ireland Human Rights Commission has critiqued the quality of care provided to Northern Ireland’s elderly population from the perspective of civil liberties. The report, entitled ‘In Defence of Dignity’, concentrated specifically on nursing homes which, unlike residential homes, provide 24-hour care.

Current regulations for oversight regime of care for the elderly, it concludes, have not integrated human rights standards.

“It is the Commission’s view that it is not enough that, in some cases, they deliver on an aspect of human rights by chance – instead, both good sense and the government’s international legal obligations require that the human rights standards become a much more explicit basis for the regulatory system.”

It has recommended:

• changes to nursing homes regulations and standards protocols to properly weave in human rights standards;

• that individual nursing homes are provided with guidance on how to apply human rights standards to everyday care;

• that external inspections by the healthcare watchdog, the Regulation and Quality Improvement Authority, are grounded within a clear human rights framework and that it amend its current standards to require a greater staff to residents ratio;

• that the Northern Ireland Executive brings forward a statutory definition of restraint, drawing on the international human rights standards;

• changes to the law to allow privately-funded residents have recourse to courts here under the Human Rights Act – as they currently fall outside it; and

• effective complaints procedures and remedies for residents, which take account of the fluctuating capacity of for example dementia patients, in the form of specialist advocacy services.

The report also recommends changes to legislation to make nursing homes set out clearly how residents can actively participate in;

• deciding how they spend their day;

• decisions on the physical layout of the home, including the grounds;

• decisions on personal care;

• devising menus and the times and locations of their meals;

• reviews and decisions around medication and treatment.

The investigation fieldwork was conducted through four anonymous nursing home case studies across Northern Ireland. This included interviews with staff, residents, and family members or friends.

In addition, the Commission invited members of the public to come forward with their experiences of nursing home care through a dedicated phone line or an on-line questionnaire. The Commission recorded 163 calls for the investigation and received 25 written submissions.

PERSONAL CARE

The report examined problems around the handling of the continence needs of residents. Numerous callers to the Commission reported that residents are not taken to use the toilet other than at set “toileting” times and that requests for help often go unanswered.

One caller explained how at times when she visited her mother she was “in tears” and “hammering” on the cupboard for someone to take her to the toilet. It was often reported that it could be up to 45 minutes before a resident’s calls for help were answered, by which time it was too late.

In addition, at least six callers stated that the resident’s alarm bell is switched off or placed out of reach so that they are unable to ‘buzz’ for help to go to the toilet. One caller explained how her mother used to call from a mobile phone in distress because she could not access the alarm bell.

ACCESS TO HEALTH CARE

A number of callers stated that GPs do visit residents when requested by nursing home staff. However, others reported that doctors never see residents face-to-face and instead, contact nursing home staff by telephone.

In a small number of cases, callers stated that nursing home staff contact the GP only if family members insist upon it. At least six callers stated that, on visiting, the GP diagnosed an illness that required further treatment. In three instances, it was reported that the resident required an antibiotic for a chest infection, and in two instances that the resident required hospital admission, in one case for pneumonia and the other because of a stroke.

REVIEW OF MEDICATION & HEALTH CARE

Under current regulations it is required that GPs undertake yearly reviews of medication. When providing care, doctors should prescribe drugs and treatment, including repeat prescriptions, only when they have adequate knowledge of a person’s health and are satisfied that the drugs and treatment serve their needs.

The report found that there was a distinct lack of evidence to show whether the mental health of residents with dementia had been reviewed by GPs. For residents with dementia, there was little evidence of a reassessment of mental capacity, which would help determine if dementia medications are still advisable and therefore should continue to be used.

For residents receiving anti-depressants, there was no evidence that their depression had been reassessed using recognised assessment methods. Lack of reassessment for depression may lead to unnecessary use of medication.

As previously reported by The Detail, Northern Ireland is still the only region within the UK without a Dementia Strategy.

Only four out of the 25 nursing records examined contained written evidence of the reasons why a GP had either prescribed or changed medication.

RESTRAINT

The report found that residents’ freedom of movement may at times be restricted in nursing homes due to physical measures of restraint, such as bedrails, or the use of medication with sedating effects.

During the Commission’s call for evidence, several callers reported that tables had been used to “barricade” residents or that measures such as reclining chairs were used beyond the time assessed necessary.

There is no statutory definition of restraint in Northern Ireland and little guidance within the Nursing Homes Minimum Standards explaining restraint. The findings of the investigation revealed that this difficulty translates into practice and at times staff are often uncertain about when a measure or action constitutes restraint.

A number of callers who provided evidence suspected that restraint was used in the absence of an assessment and more for the home’s convenience rather than for the safety of residents.

RECOMMENDATIONS

The report concluded that there remained serious legislative gaps in Northern Ireland around mental capacity and restraint. It recommended that nursing homes should maintain a register in which all instances of physical restraint are recorded and that methods of restraint must never be used to compensate for a lack of staff.

It also called on the Northern Ireland Executive to bring forward a statutory definition of restraint drawing on the international human rights standards and said that the use of medication causing sedation should be subject to compulsory review by a qualified medical practitioner at regular intervals and at least twice a year.

The findings from this investigation reveal that, in practice, there are significant barriers for older people and their families in raising complaints. It recommends that the Northern Ireland Executive ratifies the Revised European Social Charter without delay.