The reality on the rest home floor

Frontline staff say it’s just luck there hasn’t been another catastrophe like at Rosewood rest home. David Williams reports

For Sue*, to care is to fear, right now.

She’s close to the residents in her central North Island rest home, a locally owned business with less than 30 rooms. The residents are like members of her extended family – extremely vulnerable ones.

But at the moment the caregiver’s smile is forced, so they can’t tell she’s scared.

Like thousands of frontline healthcare workers she’s paralysed by a series of weighty questions. What if Covid-19 gets in there? What can be done to stop it spreading if it does? What if she’s the one who brings the virus in?

The answers to those questions could mean the difference between life or death, as has been seen at Christchurch’s Rosewood rest home.

“Yes, we wash our hands, and, yes, we wear gloves and aprons,” Sue says. “But there is still a huge risk that we’re going from one person to another, and one place to another, and, worst case scenario, that’s a catastrophe waiting to happen.”

Covid-19 is an added burden Sue and her colleagues don’t need. For many, the pressure of care work has pushed them to breaking point. Many are leaving, not for other rest homes but out of the industry altogether, because they feel unsafe and unappreciated.

“We’re stressed, we’re anxious, we’re burnt out, we’ve got staff ringing in sick, we have got trouble covering shifts because staff are sick, and then they need to have a stand-down period.”

Concerns over access to PPE by frontline healthcare workers has prompted an Auditor-General investigation. Photo: David Williams

Despite Covid-19 deaths in rest homes, and clusters of infections at six facilities, reassuring messages emanate from Wellington and the aged care industry.

New admissions to residential care homes are now being isolated for 14 days, the public is told. Stockpiled protective equipment (PPE) is being distributed by Ministry of Health to district health boards, and, there was plenty to go around, apparently.

Newsroom spoke to Sue and three of her colleagues in different parts of the country to check their experiences.

They admit there have been improvements at their rest homes. Procedures have been tightened, management are more often on the floor, and cleaning has been stepped up. Lounge furniture has been moved apart.

But the quartet of workers spoken to by Newsroom say isolation is impossible in some facilities, especially those with dementia units, and some facilities don’t even have a formal way of telling staff if a resident or colleague has been tested for Covid-19.

Access to PPE is patchy, they say. On that point, Aged Care Association chief executive Simon Wallace told Parliament’s Epidemic Response Committee on Wednesday: “Even now, nearly two months on, there are still some issues in our members being able to access the PPE that they need.”

The Auditor-General is reviewing the Ministry of Health’s PPE management.

Twenty residents of Rosewood rest home's dementia unit were transferred to Burwood Hospital on April 6. Photo: David Williams

Quinn* works at a rest home, owned by a big chain, with more than 30 beds in the Southern district health board (DHB) region. She says newly arrived dementia patients aren’t being isolated.

“It’s crazy,” she says. “Everybody’s sitting together, there’s no separation.”

(Wallace mentioned the 14-day isolation policy to the Epidemic Response Committee on Wednesday, but none of the MPs asked about its efficacy.)

Pat* also works in a rest home in the Southern DHB area, owned by a big national company. She says it would be near impossible to isolate new arrivals with dementia. “We have so many wanderers, you couldn’t keep them in their room.”

PPE at Pat’s facility is under strict control. “You almost get the feeling they’re more interested in preparing for maintaining it when it’s here than they are in preventing it.”

Anxiety is infectious. Now, Pat says, some care workers are being pressured by their families to leave – “because of how poorly they feel we’re being protected”.

Central North Island worker Ruth* says staff at her facility, owned by a big chain, are being bullied if they ask for PPE gear beyond what’s being issued. Staff haven’t been trained how to use PPE, she says – “not even how to dispose of it”.

Her colleagues are saying “I feel in danger” and “I’m terrified”. But they’re not leaving because of loyalty to their residents.

A positive case in her facility would be “absolutely disastrous”, Ruth says. “We would be in the same situation as Rosewood and the other facilities that have been affected.”

The argument’s been made that the aged care sector’s doing a fine job, given only half a dozen out of more than 650 facilities have clusters.

But these frontline workers say that’s mainly down to luck.

“The ones that it’s about good management are the minority,” Sam Jones, a national director of union E tū, says. “We’re deeply concerned for the safety of the residents and the workers.”

“The level of care these residents are needing is insane. You’re absolutely rushed off your feet.” – “Pat”

Caregiving is intense, skilled work. It’s physically demanding and mentally draining.

With the elderly being admitted to rest homes later in life, now, their needs are more complex.

Many residents aren’t mobile. They can’t walk anymore so slings are used to move them around. That increases the time and effort required for their daily “cares”.

“It’s easy to just stand someone up and walk them over to the toilet,” Pat says. “But it’s a lot harder if you’ve got to put a sling on them, and then hook them up to the sling, lift them up, put them on the sling, and then transfer them back as well.”

Some residents are deemed two-assist – it takes two caregivers to do their cares. That takes two people off the floor, in an industry where the staff-to-resident ratio is a huge concern.

Then there’s the mental side. While caregivers explain their tasks to residents, they’re often challenged. That might mean spending five minutes to convince a resident to hand over their dentures, Pat says.

“The level of care these residents are needing is insane. You’re absolutely rushed off your feet. A lot of it takes a mental toll on you.”

Compounding the intensity are staffing issues.

Quinn says: “Sometimes the roster’s got huge gaps in it.”

When they’re short-staffed, caregivers might have to pick up twice as many people. And these might be staff who have worked five days already that week, but are pressured to pull extra shifts.

“And they wonder why there’s mistakes sometimes?” Quinn says. “I wish we had a bigger workforce. Sometimes it’s far too tight.”

Another Christchurch rest home with a Covid-19 cluster. Photo: David Williams

To protect residents, some facilities are telling staff to go home if they turn up sick. Quinn says if they are forced to go home “for any little thing” then “we are screwed, pretty much”. “Who doesn’t come to work if they’ve got a sore throat or a headache, and just battle their way through the day?”

(That’s where regular Covid-19 testing of workers might help.)

This is where the economic frailties of rest homes, and their poorly paid workers, are exposed. If staff unable to work don’t have sick leave, and it’s not Covid-19 related, they might not get paid. Or if they do, it might be 80 percent of their wage. “It’s going to be really, really tough on those staff,” Quinn says.

Ruth says at her facility, short-staffing means caregivers with no qualification are often placed in the dementia wing.

Quinn, Pat and Ruth say they’d not recommend their rest home to a friend looking for work. Sue says she might have done before, but not now, under Covid-19 conditions. “There’s just so many things to worry about. There’s such a big workload. It’s just crazy.”

E tū and NZNO, the union representing nurses, have argued for years that minimum staffing levels – such as one on-duty staffer and one on-call for up to 29 residents – are unsafe. A joint report they put out last year, In Safe Hands, says stretched staff are having to choose who gets help – so-called care rationing that is compromising safety.

Staffing standards are out-of-date, voluntary, and don’t work, the report said. And that was before Covid-19.

“It’s not just about this moment,” E tū’s Jones says. “This moment just highlights how bad it is.”

Industry response

Newsroom asked three big care providers – Metlifecare, Bupa and Ryman – to respond, and state how they’re protecting residents and staff. The first two responded, while Ryman left the response to the Aged Care Association.

Wallace couldn’t be reached for comment yesterday, but has previously noted many rest homes acted quickly by banning visitors before the national lockdown. The association is now calling for mandatory Covid-19 testing of new arrivals to rest homes, something only some DHBs are doing.

Bupa’s media and external communications manager Robert Walker says it’s maintaining strict infection prevention and control measures. “These include restricting visitor access, enforcing the 14-day isolation policy, good hand hygiene and physical distancing where practicable. We continue to follow the Ministry of Health guidelines and advice.

“We are not aware of any issues at any Bupa sites, but encourage all of our people to speak up if they have any concerns. Our absolute priority is the health, safety and wellbeing of our residents and our people who care for them.”

(Speaking out doesn’t always happen, of course, especially by migrant workers whose visas are tied to certain facilities.)

Staffing, pay rates

Metlifecare’s chief executive Glen Sowry says the NZX-listed company developed a Covid-19 plan for its 11 care homes. Its homes aren’t under-staffed, he says, because it proactively recruited more registered nurses, caregivers and home support workers and increased the pay of frontline staff in care homes during alert level 4.

(Bupa has also temporarily bumped up pay rates, by $2 an hour. E tū’s Jones was curious some employers magically found extra money to increase pay “when they’ve continually said that they don’t have money to afford it”.)

Metlifecare care home staff have been instructed not to come to work if they’re sick, Sowry says, and to remain off work until they’ve had no symptoms for 48 hours. It has adequate PPE, he says, and is “strictly enforcing” the 14-day isolation policy for new residents.

Care home staff who are over 70, or have underlying health conditions, have been given the option of standing down on full pay, undertaking home-based roles, or continuing to work, Sowry says. “If there were an outbreak, at-risk staff would immediately be stood down on full pay.”

Pat, Quinn, and Ruth confirm their off-work colleagues are on 80 percent of their wage – a substantial drop for those on minimum wage – while others are forced to eat into their leave.

Jones, of E tū, says residential aged care providers are, almost across the board, refusing to pay staff 100 percent of their pay on special leave if they’re stood down, sick, or staying away from their rest home because of the risks to them or residents. “The worker should know that they’re not going to be financially disadvantaged by doing the right thing.”

Broken model needs fixed

Unions aren’t the only ones saying the sector’s broken. For years, the Aged Care Association has argued Government payments are inadequate.

Residential aged care is a strange blend of private and public, community care mixed with private gain. DHBs pay about $1.1 billion a year to rest homes, run by private companies, through contracted bed rates.

On Saturday, Health Minister David Clark announced the Government will provide up to $26 million of Covid-19 related costs to the aged care sector. But, like E tū, rest home owners and operators will be hoping the Government’s focus on their costs isn’t just about this moment.

Residential care facilities are under pressure and scrutiny.

Nine of the country’s 16 deaths from Covid-19 have come from one rest home, Christchurch’s Rosewood, which is now associated with 50 confirmed or probable cases.

Director general of health Ashley Bloomfield ordered a review of the six residential care facilities with confirmed cases, and DHBs are auditing rest homes for infection control procedures and processes. Chief Ombudsman Peter Boshier has also ordered urgent inspections of secure dementia units.

E tū’s Jones says people nearing the end of their life should be safe, well-supported, and looked after. “Rest homes really shouldn’t be about business, they should be about respecting those vulnerable people in our society.”

Part of that picture, he says, is income protection for the workers who are putting themselves at risk to keep rest homes going during the pandemic. He hopes to raise the issue at a meeting with DHBs and the Ministry this coming Tuesday.

The aged care industry has been painting a picture of measures being taken putting a veritable shield over society’s most vulnerable. However, according to its frontline workers, in some cases at least, for a variety of reasons, including insufficient funding, it is failing to do so.

The industry is so fragmented that it’s applying best practice inconsistently, not just between organisations but within them. Two of the rest home workers spoken to by Newsroom say they hope the official reviews and audits reveal deficiencies at their facilities so they can be fixed.

North Island worker Sue says rest homes might be meeting the official staff-to-resident ratio guidelines, but that doesn’t mean the elderly are getting the care they need, or deserve. More staff are needed to make rest homes safe, she says – and that means more money from the Ministry and DHBs.

“It wasn’t working before, it’s definitely a struggle now.”

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