The death of rest home residents raises questions about how we treat our most vulnerable. David Williams reports
Questions over staff access to protective equipment are being raised in the wake of six Covid-19-related deaths from a single Christchurch rest home.
More broadly, for an industry that has existing procedures for controlling infectious diseases and commonly uses protective equipment, it’s fair to ask, how did things go so wrong? Indeed, is the aged care sector properly configured to adequately care for the frail, the elderly, the sick and the dying?
The Ministry of Health announced yesterday four more deaths from Covid-19, taking the national death toll from the virus to nine.
Six of those come from the Rosewood rest home and hospital. All are from the Linwood facility’s psycho-geriatric dementia unit of 20 people who, a week earlier, were moved to Burwood Hospital. Nurses from Burwood’s Ward GG tell Stuff, grimly, no-one is likely to come out alive.
Director-general of health Ashley Bloomfield, who yesterday launched a review of rest home facilities with confirmed Covid-19 cases, said aged care facilities had taken appropriate precautions, such as banning visitors before the national lockdown was announced, and were operating correctly in difficult circumstances.
He noted in some rest homes further transmission was stopped quickly, while in others it spread rapidly, showing “just how tricky this virus is”.
(Yesterday, Aged Care Association chief executive Simon Wallace said given there were about 35,000 aged care residents across the country “actually we’re not doing a bad job”. Only six of the country’s 662 rest homes have confirmed cases.)
But there are already suggestions of problems at Rosewood leading up to its first confirmed case, and in the maelstrom afterwards, when many staff were isolated.
Kerri Nuku, kaiwhakahaere of the nurses’ union NZNO, welcomes the Ministry of Health’s review. She says while the facts of what happened at Rosewood haven’t been established, early reports from union members indicated access to protective equipment (PPE), and associated training, was a concern.
Another source suggests PPE wasn’t readily available to staff at Rosewood until the rest home had its first confirmed case.
Rosewood’s owners, Christchurch couple Malcolm and Lynda Tucker, aren’t commenting. Their advocate, Mike Kyne, says they’re under instructions from the Canterbury District Health Board not to say anything.
Newsroom asked questions of the DHB yesterday morning, including how soon after the first confirmed case its staff visited Rosewood, and whether the actions taken by the facility were appropriate. The DHB didn’t respond by publication deadline.
On Monday, the DHB’s incident controller, Dr Sue Nightingale, said of Rosewood and fellow Christchurch rest home George Manning, which has 16 confirmed or probable cases, it would review all systems and processes at both facilities “as soon as it’s appropriate to do so”.
A Canterbury DHB spokesperson, talking about Rosewood specifically, told the NZ Herald yesterday: “In the demanding context of managing a cluster of frail elderly residents, a significant number of staff needed to be isolated because of exposure to Covid-19 and this contributed to a number of issues regarding safe practice, including the way PPE [personal protective equipment] was used.”
Bloomfield read out comments yesterday from the children of one former Rosewood resident, who said they couldn’t speak more highly of the care and staff at both Burwood and Rosewood.
Unions are calling for stricter measures to protect their members, aged care and home care workers, as well as their vulnerable clients.
“Workers are really scared in this sector about going to work, especially those with vulnerable people at home,” says Sam Jones, a national director of union E tū. He’s heard of a facility – he didn’t say where – at which 12 healthcare assistants, none of them E tū members, resigned last weekend. (Some home support workers, who are union members, have quit the industry because they weren’t paid, or were under-paid, by their employers.)
Reports from overseas might suggest why healthcare workers here are rattled.
More than 20 staff at the United Kingdom’s National Health Service have died. Last month, terrified workers told The Lancet the Covid-19 crisis was overwhelming London hospitals, and, amidst the “chaos”, “we are literally making it up as we go along”.
In the United States, more than 4000 cases of Covid-19 are associated with nursing homes or long-term care facilities, The New York Times reports, including one facility in Washington, which is linked to 43 deaths.
Meanwhile, back in New Zealand, there has been a spike in the number of healthcare workers contracting the virus.
Jones, of E tū, is calling for all new rest home residents to be screened, through a standard set of questions, and tested for Covid-19 before arrival. Until the results come through they should be isolated from other residents, he says. Community and residential aged care workers should also be tested, Jones says.
Testing of new residents and staff is also backed by the Aged Care Association, but director-general Bloomfield is resisting those calls. He said yesterday every new arrival into aged residential care homes will go into isolation for 14 days, there are no shared meals, and no visitors are allowed. There’s a low threshold of testing of residents, new arrivals, and staff, Bloomfield says.
“I’ve asked all our DHBs to work with each of the facilities in their region, to ensure they have good policies/procedures, that they have access to PPE that they need, and good supply lines, and to identify what other support those facilities may need.”
Aged residential care facilities will get extra state funding to help offset additional costs related to Covid-19.
E tū says it hasn’t been consulted on changes and the details aren’t clear. Jones is sceptical the isolation of new arrivals is water-tight.
“What we’re hearing is that they’ve not been given their own staff, so therefore the staff are working with other residents, and unless they’re able to pay for it, they’re not being given their own amenities – if you’re using common toilets, well, there’s clearly going to be a problem.”
Another South Island rest home source says the Ministry and DHBs don’t grasp the issues with dementia patients. “They are telling all facilities to isolate for 14 days. But it is impossible to isolate a dementia resident who does not understand the need to stay in their room.”
Nuku, of nurses’ union NZNO, says for years it has been concerned about over-worked staff and under-staffed residential care facilities, and has argued there is the wrong mix of staff, especially in high-needs dementia units.
During a crisis like the Covid-19 outbreak, there should be the ability for these facilities to increase their workforce, Nuku says.
“I’m not sure [the current model] allows that to happen, to respond to the changing needs of such an external environment and the needs of the patient.”
As Nuku suggests, there are wider concerns which strike at the heart of how the care industry’s structured.
Those requiring residental care are placed in private facilities, subsidised by public money, funded on a per-resident, per-night basis. Services are contracted and monitored by DHBs.
(You can pay more for upgrades, like having a room with an ensuite. As Jones noted earlier, he’s not sure such luxuries are extended to new arrivals who can’t afford it, forcing them to share toilet facilities.)
Alzheimers NZ chief executive Catherine Hall says about 70,000 people have dementia, with about 30 percent living in residential facilities and the balance living in the community. The number of people living with the condition is expected to rise to about 170,000 in the next 30 years, she says.
The vulnerable population supported by her organisation has, Hall says, been neglected for years. “Covid-19 hasn’t created that situation but it has certainly highlighted it.
“The numbers are going to increase significantly, there are nowhere near enough services, generally, in the community for people. We’re going to need more and we’re going to need to ramp those up fairly quickly once we get past this crisis situation that we’re in.”
Community-based services for dementia patients, their carers and supporters, is free. But Dementia NZ chief executive Paul Sullivan says his organisation, and Hall’s, could do much more if they were better funded.
“From what we’re seeing from research there’s a real benefit to people, for quality of life, from staying and living independently for longer.”
University of Auckland research into the city’s aged care statistics found that, in the 20 years to 2008, the proportion of the population aged over 85 in rest home care decreased from 27 percent to 16 percent. However, over the same period, those considered “high dependency”, having problems with mobility, continence and cognitive functions, increased from 36 percent of aged care residents to 56 percent.
Nuku, the nurses’ union kaiwhakahaere, says Ministry of Health staffing standards for aged and dementia care facilities are voluntary and haven’t been reviewed since 2005.
(The guidelines state in a facility with 10 or fewer subsidised residents there must be “a care staff member on duty at all times”. In facilities with more than 60 subsidised residents, there must be “at least three” staffers on duty at all times. Each rest home must have “at least one” registered nurse.)
“We’ve seen evidence for a long time now of short-staffing, the lack of time to care, and staff being overworked.” – Kerri Nuku
Research released by NZNO last year showed more than half of aged care providers delivered less registered nurse time than recommended for hospital and dementia-level patients.
Nuku says the Health Ministry’s just-announced review should re-think staff-to-resident ratios and make them mandatory, and ensure there are more regular rest home audits.
Staffing levels in residential aged care fall well below international recommended levels, she says. “We’ve seen evidence for a long time now of short-staffing, the lack of time to care, and staff being overworked. These shortfalls in care quality we often see as complaints coming through the Health and Disability Commissioner.”
Wallace, the boss of the Aged Care Association, couldn’t be reached for comment.
Two years ago, though, in response to the Herald’s investigation into rest home incidents, Wallace told INsite Magazine that more people will be entering residential care at an older age, with higher and more complex needs. “So yes, change is needed to address the limitations of New Zealand’s current aged care delivery model to better reflect its central role in caring for our elderly loved ones.”
He added: “The reality is that our system has not kept pace with the increased demands and costs of aged care, putting significant strain on individual facilities’ abilities to provide optimal staffing, technological advancements, an expensive array of equipment, and meet rising resident and family expectations.”
Last September, a report commissioned by the ministry and DHBs recommended changes to the sector’s funding model.
E tū’s Jones isn’t a fan of the industry’s private-public mix, saying there are lines in contracts with residential care providers the DHBs don’t dare cross. During the national lockdown, he’s been saying to the authorities, as often as possible: “Wouldn’t this be easier if you could just make a decision?”
Jones says: “What we need is, ideally, health workers to be employed by the state, would be a good start, and the Ministry to be in more control of what happens out there in what we call the privatised healthcare part of the world.”
It’s one thing to increase the pay packets of overworked care workers, as happened after the historic $2 billion pay equity settlement in 2017, in a claim taken by E tū on behalf of Kristine Bartlett. It’s another thing altogether, it seems, to address the industry’s well-known staffing problems or fix a funding model the aged care sector itself admits isn’t working.
It is said a nation can be judged on how it treats its weakest members; its most vulnerable. The Covid-19-related deaths, and questions over the protection of health workers and their clients, suggest there is more this country can do.