Advice from a Relative on Selecting a Nursing Home
This article was written to guide relatives during normal times but has been amended to take the current pandemic situation into account. At Level 5, visits to nursing homes are not recommended and you are likely to be nervous and encounter difficulties placing loved ones in nursing home care during this period. It is hard to accept that a loved one needs nursing home care. You are likely to feel guilty that you can no longer care for them. Focus your energy on finding the best centre possible and remaining actively involved in their care, with regular visits. When I was faced with this challenge, I did not know the right questions to ask. The list below is not exhaustive but is based on my experiences plus that of other friends and relatives
Research the Nursing Homes
Start with a short list of the facilities closest to your home. Ask your GP and friends for recommendations. A list of nursing homes in Ireland is available here at: https://data.gov.ie/dataset/list-of-nursing-homes-in-ireland. Go to the HIQA website: https://www.hiqa.ie/reports-and-publications/inspection-reports. Read the reports on the nursing homes in question. Check how the home has addressed any areas where HIQA has sought improvement. Check the record of the nursing home – have they previously had COVID-19 cases? If yes, how have they fared? This will all provide valuable background information. If you plan to ask for Fair Deal support, check the details out here: https://www2.hse.ie/services/fair-deal-scheme/about-the-fair-deal-scheme.html
Review the location of the building — is it located in a town or a more rural setting? Location affects the residents’ access to green space, their general quality of life and their safety. If the facility is located on a busy street, it may not be a safe place for someone who has dementia or Alzheimer’s. On the other hand, an urban location may provide more visual stimulation and facilitate visits from neighbours and the broader community. What is the garden like? Is there a wheelchair accessible area outside to sit or walk in?
If circumstances permit, do visit to the nursing home in person. If this is not possible, ask for a virtual tour. Think about the length of the journey from your home. Many people stress proximity when choosing a nursing home for the simple reason that a shorter car journey or easy public transport links will facilitate more frequent visits but you do have to weigh that against where you feel your loved one will receive the greatest level of care and enjoy the highest quality of life. Perhaps your loved one would be happier in a nursing home close to the community where he/she grew up versus where you now live. Remember that your pre-entry discussion with the nursing home is important in shaping your future relationship with the home. So, take notes and be firm. For example, what is the home’s attitude towards a relative wishing to remain involved in the resident’s care? Some relatives have told me that their nursing home has excluded them from involvement in the ongoing care of their loved ones. This can be detrimental to both the resident’s comfort and wellbeing as well as causing a relative to feel excluded. Some examples given include hand and nail care, help with feeding and personal hygiene, including washing and showering.
How big is the nursing home? How many residents can it accommodate? How many trained nurses are available? How often are their skills refreshed? What is the staffing level like at night? In terms of the care assistants, what training do they receive?
If you can visit, observe the residents. Note the effort that was put into their appearance – do they look neat and coordinated or are they wearing mismatched clothes? Is there flexibility in what they can wear? I had to face a lot of pressure to stop my mother being dressed in a track suit for the staff’s convenience, when I knew she hated that style of clothing. Is their hair combed? Are their nails clean? If circumstances permit, chat with the residents. Ask them how long they have been residing there, what the food is like, is there a good range of activities, and if they are happy living there. If you cannot visit, speak if you can to some of the residents by phone and ask their relatives and friends.
Infection Control and Contingency Plans
Are staff and residents being tested regularly for COVID-19? Has the nursing home received a sufficient stock of personal protective equipment (PPE)? What infection control measures are in place in the event of a pandemic outbreak? Are the staff washing their hands, using masks and applying sanitiser? Are they maintaining social distancing? Is there a crisis continency plan in place? What is their policy if your loved one suddenly becomes seriously ill? Will they allow compassionate visits during the pandemic if your loved one is terminally ill or close to dying?
The smell of a nursing home is only an issue if you detect one, which you should not. Is there an emphasis placed on the oral hygiene of residents? Do staff remove dentures and hearing aids at night? What is the toileting policy? Do the staff encourage residents to go to the bathroom or is there a policy particularly at night to depend on hygiene pads? Hygiene pads work as a backup but they should not ideally be the first port of call.
Ask to see a sample care plan. Does the nursing home allow the resident to continue access to their own GP? Can you remain involved in your relative’s care, for example, will you be advised if a GP is to be called or if your relative is prescribed any new medications, including laxatives or sleeping tablets? If your loved one has diabetes, how often is the blood sugar level recorded? I found out when I looked at my mother’s care plan, it had been taken twice over the course of a year
What equipment do they have – for example can they administer oxygen or provide IV therapy? People complain about elderly people being admitted to hospital but many nursing homes, particularly private ones, are very constrained in the level of nursing care they can provide. Does your relative have dementia or any special needs? Does the nursing home have a special focus on dementia care? If so, ask them to provide details.
Quality of Life
What is the nursing home’s policy on restraints? My mother hated bars around her bed at night as it made her claustrophobic. The solution was a lower bed and a crash mat with an automatic bell alert, which I was happy to purchase. Is there flexibility about when to get up and go to bed? I remember being horrified to find my mother in bed at 530pm on a beautiful summer’s evening. It was done simply to accommodate staff but what about how my mother felt? During normal non COVID times, can your loved one have visits at any time, just as they would if they still lived at home? Can they bring a pet or are pets allowed to visit?
Are there any sources of entertainment other than television available, for example, puzzles or a current daily newspaper? Is there a daily activities board – if so, check that the activities actually take place? Look out for ‘institutional ‘ seating arrangements in day rooms, landings or corridors and loud TV with not a wireless to be seen/heard. The availability of cable, satellite TV or Wi-Fi access may be important for sports enthusiasts or for residents keen to stay in touch with family abroad. During normal times, does the home host community activities, for example, visits from local school? Likewise, are you encouraged to bring your loved one home or out for drives regularly? Does a physiotherapist and occupational therapist regularly? Is there a hair dressing service? How often do religious services take place?
Is there an option to have a personal phone in the room? What is the situation with laundry? Does the centre handle clothes labelling in a sensitive way, i.e. use the resident’s name versus a number? How is washing done? Is everything boil washed en masse or do they take into account instructions on the washing labels? A beautiful wool rug my mother loved was destroyed as it had been washed at too high a temperature.
Nutrition and Hydration
Is there a daily menu available? What do other residents say about the standard of the food? Is there variety and choice? Are drinks always available in the day room to ensure residents remain hydrated? Are special diets available for people with diabetes and swallow problems? When my mother developed a swallow problem, I was asked to research the situation myself!
Is there an effort made to make the common spaces homely? Plants, paintings and lamps all help. Look for comfy chairs that will encourage residents to use the space. Is there sufficient wardrobe space and shelves for pictures and books? Some homes wallpaper the bedrooms or put up different borders to personalise the space. Some give each room its own colour scheme and encourage residents to bring personal belongings, even pictures and furniture from home. These little touches make the difference between a hospital room and a bedroom. Do the bedrooms have adjustable electric beds? Are the sinks and location of mirrors at the right height for people in wheelchairs? Can a resident sit close to the window? Is there a pleasant view?
If you can visit, note the way people are interacting around you. Observe if your tour guide says “hello” by name to residents. If a resident is calling out for assistance or holding out a hand, note how your tour guide or the other staff members handle it. No nursing home staff member, regardless of who they are, should ignore a resident. The staff should not be shouting at residents who are hard of hearing, but rather enunciating in a slightly louder tone. Do staff members knock before entering residents’ rooms?
If you are not able to visit, ask friends and neighbours who are familiar with the nursing home and what their experience has been. Is there general respect for the residents? One a visit to an uncle, I was horrified to see that the staff had served him his supper on a table in the room on which his urine bottle had also been left.
During Level 5 lockdown, no visits are permitted to ensure the safety of residents and staff but ask what the visiting arrangement are like during the other levels. Are window visits permitted? How many visits are permitted weekly and for how long? Where will the visits take place? What precautions are in place? In the event of lockdown, does the nursing home have an active way of keeping residents engaged? For example, will they permit daily newspapers to be delivered? Will they facilitate videocalls to allow your loved one to stay in touch with you?
Focus on Autonomy
If your relative is independent, ask about how their autonomy will be supported. Do you see staff helping a resident walk and stay mobile or is everyone confined to bed or wheelchairs? Is it easy for the residents to get around? Are there handrails lining the hallways?
Some homes have ways for residents to take part in the running of the facility, such as a residents’ committee with regular meetings. Others have small kitchens or snack areas that are open all day so that residents can have more control over their food and fluid intake. My mother loved a late night snack but the nursing home she was in was unable to accommodate her.
Some nursing homes allow the residents to garden and care for small farm animals, like chickens. Some facilities have their own newsletter written by residents, or a resident-run convenient shop. Intergenerational programmes allow residents to have contact with children. All of these are ways to give residents a sense of purpose and autonomy and to enhance their quality of life. Nobody wants to feel that they live in an institution.
Is there a family council or an advocate in place (a champion who will speak on behalf of residents?
A Final Word
Be sure to ask for a copy of the contract to understand what is included in the monthly charge versus extras. Before you decide on a nursing home, ask yourself, would you stay in the home yourself? Say if you broke a leg, would you be happy to be placed there for recuperation? What is good enough for your loved one should be good enough for you. Older people want to continue to live good lives. Above all else, visit regularly at different times, stay involved and observe.
You will hopefully experience plenty of good practice – I know that I did for the most part, despite the issues outlined above. Be sure to recognise and acknowledge good practice but If you see something wrong or have questions, do not be afraid to speak up. Good nursing homes are open to constructive feedback and will want to improve.