Eldery Care

[2023forme]

I don’t really know what the point of my post is but I am feeling quite upset by some things in my working life that I need to get it off my chest. It’s a long one so you have been warned.

I have been a nurse for 30 years.
The first half of my career was working in cancer and palliative care and the second was in nurse education, mainly supporting student nurses on clinical placement. Got offered voluntary early release from the university so took it – but I wasn’t ready (or financially able) to stop working completely so I took a job at a lovely care home just round the corner from me.
A friend’s mum was a resident not too long ago and she rated it highly plus it meant a short walk to work and no commute, so I was really looking forward to doing clinical care again. But OMG – what an eye opener it has been.

I just was not prepared for how bad staffing is in the care home sector, the lack of resources and the level of waste has appalled me.
I enjoy the job itself but it has really made me think about my own future and that I need to make an advance directive now as I don’t want to end up living in a care home and just existing.

Staffing levels are dire. On a good shift, we will have a ratio of one staff member to five residents. There is one nurse and one nursing assistant on a shift and the rest of the staff are carers. Out of 32 residents, 27 need two staff members for personal care, continence care and moving/transferring/mobilising. Only 2 residents can feed themselves/take a drink independently. There is at least one agency nurse or carer per shift – often more. This means they don’t know the residents well and don’t understand their needs and preferences. There are also a high percentage of male carers who do agency and most of the female residents have specified in their care plans for only females to provide personal care. Given that women live longer than men, the residents are about 70% female to male. This means that often the male agency carers have very little to do whilst the female staff are run ragged. It also means that residents have to wait longer for care because the female staff are tied up meeting other residents’ needs. Sometimes we have no option but to ask the male carers to attend to a female resident’s care if the resident has dementia and is unable to say no to the male carer input, which feels really wrong to me. We are in the middle of a huge debate about trans women getting access to female spaces yet the issues of males having ‘access’ to some of our most vulnerable female members of society is not really considered.

The level of waste is truly shocking. An example is that last week we received a 3 month supply of high fluoride toothpaste – around 120 tubes. Since the toothpaste is prescribed, it is labelled with an individual resident’s name, meaning it cannot be given to another resident and if it is not used, it will be returned to the pharmacy and destroyed. I would estimate that about 90% of the residents who are prescribed this toothpaste cannot have their teeth brushed because they don’t consent to it (evidenced through spitting at you, hitting you and spitting it out) they choke when you try to do it or they are simply too weak to have it done to them/ can’t open their mouth etc.

The amount of medicines the residents are on is also eye opening. We have 95 year olds who are very frail and have less than 6 months to live still getting anti-cholesterol medications, folic acid and iron supplements and the like. A lot of the time, and I mean a lot, the medications are not tolerated by the residents (tablets too big even when halved and if effervescent is available, too big a volume to drink). Those with dementia just spit the tablets out. Last week we returned about 200 high protein drinks to the pharmacy for destruction as they hadn’t been used and were out of date.

But you cannot get a GP to stop prescribing as they don’t want to look like they are not treating the resident well. No one seems brave enough to say ….”look, this person is not going to benefit from cholesterol lowering drugs so lets just stop them”. In my palliative care practice, someone at the end of life had their medications stopped and were only on end of life meds to palliate symptoms.
I’m not talking about meds that help such as pain killers – but those that are just not going to add anything to the quality of the resident’s life. So we have all this money being spent on meds, high energy drinks, toothpaste etc but we can’t buy enough pressure relieving mattresses or employ more staff, both of which would do more to help provide better care.

We have one lady at the moment (aged 98) who is very frail and cognitively impaired. She has contractures, her skin is like tissue paper and is constantly tearing, she is doubly incontinent, unable to swallow much and is in a lot of pain.
But the GP won’t prescribe her morphine as he feels it is too strong for her frail state – if she had terminal cancer, no-one would think twice. She screams out all night, asking to be ‘put to sleep’, upsetting other residents and keeping them awake. We cannot sedate her – she is prescribed a medication for agitation, but she refuses to swallow it. In her lucid moments, she describes how her life is a living hell, she feels trapped in a decaying body and just wants to die.

I truly think we have lost our way when it comes to care of the elderly. People aren’t allowed to just get old and die anymore – its like we want to keep them living but for what? I’m not talking about treating reversible things which cause distress like urine infections – but really, what is the point in giving vitamin D tablets or iron supplements to someone who will likely die in a few weeks.

I don’t know what to do with regards to my employment – I want to remain and do the best I can for the residents but I am getting more depressed and frustrated at work. I spend around two hours of a 12 hour shift writing about care rather than actually providing the care. This is how long it takes to update the residents daily care plans – so I will be writing things like “Betty enjoys sitting in the garden and reminiscing about her time as a teacher” – but I can’t actually find the time to sit and talk with her and we can’t spare anyone to take her to the garden.

So AIBU to leave my job because I am finding it upsetting?
YABU – you have taken a role with vulnerable people and you need to stay and help provide care for them.
YANBU – you need to protect your own mental health and leave the work to those who can cope better with it.

I'm guessing that there wasn't someone in the room with him all the time so he wasn't assessed as being safe due to him moving a lot.
It doesn't help you now, but please be reassured that a lot of care provided (I work in the community) is holistic and client centred, with no blanket bans.

Hi OP

Thank you for writing this, it reminds me of the care home I worked in during lockdown (I'm wondering if it is actually the same one), I lasted 1 year and it was the worst job I have ever had and I constantly felt like I was letting the residents down. By the time I left I was physically and mentally broken.
I complained to management constantly, they were hostile and dismissive and I felt they hated me because I kept complaining and a colleague was a whistle-blower but nothing changed and when they had their inspection shortly after (which I suspect they knew about in advance) they still got an excellent report, though I can't remember if anyone spoke to the carers who were complaining, they definitely didn't speak to me (I was off that day) and my colleague. There were so many residents who complained daily too so I wonder if they kept them away from the inspectors.
It seems they are getting away with fudging the numbers, so for example they included the nurse, senior and kitchen carer (who plated up food and assisted) in the total numbers which meant that the real ratio was 1 to 8 as the nurse, senior and kitchen person were already doing their own important jobs and couldn't assist with personal care.
Having 1 nurse for over 30 residents with senior assisting some meds meant they were run ragged, especially when an emergency occurred.
It's not right that they can get away with this. I know there is a staffing crisis but I think it's made worse by allowing companies to get away with this, as it means the job is harder and care is poorer. The night shift was the same ratios as you describe, it is unbelievable.
Do you feel like management will listen if you complained?

We have these battles a lot with learning disability work as well - we've currently got multiple referrals open for challenging behaviour at a home where about 90% of the staff are agency or have just started that month, and there's NO structure or activity to the day. We're trying to get the importance of routine, choice, structure, control, interaction through - but the staff are run ragged just keeping people alive pretty much. It's a nightmare.

I think so. Because the alternative is wait until it’s something much worse isn’t it? Or the comorbidities just pile up. It would have to be a blanket rule because otherwise it’s tempting to say ‘just one more course of antibiotics’ until they go down the slippery slope.

I'm a care home cook, you've pretty much described exactly what's going on here too.
It's awful, some days only 3 care staff turn up & we're just expected to get on with it (40+ residents)
Management might as well be sat in their office with their fingers in their ears singing lalalala.
To top it all we are now expected to do all training (20 hours) online in our own time unpaid.
It's infuriating, sad & so dangerous & unfair to the vulnerable people we're doing our best to care for.

Only you know whether you can mentally cope with this role but I urge you to write to your mp, the department of health and the cqc because you are exactly the kind of person who has the background to understand the problems and could help get proposals for change together.

When dgm was in a care home with advanced dementia, psychosis and delirium i described the situation like having an animal you sponsor and visit at the zoo, they didn't really know you were there or cared but you feel good about visiting. It's crude but it felt cruel to keep her alive, finally covid took away her misery.

@Cuppasoupmonster

"pingopango
You can't have that as a blanket rule, it's just not appropriate. Look at David Attenborough. He's 96. If he developed a chest infection or pneumonia and it was treatable would you refuse and just offer pain meds?

I think so. Because the alternative is wait until it’s something much worse isn’t it? Or the comorbidities just pile up. It would have to be a blanket rule because otherwise it’s tempting to say ‘just one more course of antibiotics’ until they go down the slippery slope."

All decisions about care should be made by considering what is in that individual's best interests, taking their wishes into account (if known, that's why advanced directives are so important). So thankfully a blanket rule for over 90s will never come into effect!

All decisions about care should be made by considering what is in that individual's best interests, taking their wishes into account (if known, that's why advanced directives are so important). So thankfully a blanket rule for over 90s will never come into effect!

I know, just saying that I would like it to. The issue with ‘individuality’ here is that where one doctor might decide somebody should live, another might decide they should die. Any way of coming to a decision using a matrix or formula would be crude. I think it’s fair to be honest. By 90 you’ve had a long life.

Thanks for all the replies - too many to tag individually but there's a few points I'd like to respond to.

The cot sides issue - in our home, the 'solution' was to put nails in the runs for the cot sides so they couldn't be pulled up. We use beds at the lowest level and mattresses on the floor. Residents do fall out - for example, one lady who is immobilised with multiple strokes had to be nursed at 30 degrees due to her chest being moist - she somehow managed to lunge herself forward and ended up on the floor, head first. No resident can be monitored 24 hours a day - unless they have family members willing to do a rota and that really only happens when they are in the last days of life. Of course the real solution would be to invent beds with safe cotsides but elderly care is not sexy and doesn't attract research/innovation funding.

Even with 30 years experience, I have been 'assigned' nearly 70 (yes 70) online 'mandatory' modules to do in my own time. Some of these are way too basic for a nurse with my experience - questions like what are the main food groups - but I still need to do them. Their is no assessment of my existing skills and knowledge or option for me to say 'these are the courses I think I need'. For example, the food and fluids course was great as I was inexperienced in thickening foods/modified diets etc. But I really don't need to spend my own time doing a course on 'what are the different routes of medication' when I've been administering meds (or teaching it) for 30 years!! (FYI I'm not going to do them unless they give me training days and if they force it, I will resign on the spot). It's another tick box exercise so that if something goes wrong, the organisation can say 'well we gave you training in x, y and z.'

An MDT approach which assessed each individual and then made informed decisions regarding what meds were appropriate would be immense. As it stands, I'm convinced our pharmacy providers (a major chain which ryhmes with soots) are being kept afloat by care homes. If a resident needs paracetamol, it is always their most expensive caplets which cost about £1.99 rather than the generic 40p a packet jobs which do the same job. My friend in procurement was telling me that care homes are paying for dressing packs at a rate which is at least 10 times what the NHS would pay using their procurement system.

re learning disability - there was a heart breaking thread on here last night started by a poor mum at her absoulte wits end with her disabled son. Lots of replies saying 'say you can't care for him anymore and social services will need to get involved' etc - but the reality being there are no placements for him and likely he would end up in a locked psychiatric unit/borderline prison and she would lose all her parental rights.

In Scotland, the Care Inspectorate inspect the homes. Our home always gets excellent reviews, even with unannounced visits. The cynic in me thinks this is because the CI know that they would be opening a can of worms which couldn't then be closed if they truely did act on some of the issues. I used to say when I was supporting students, if you shut down every care home due to not meeting standards of care, you'd have barely any left open and what would you do with all the residents in the homes that were closed?

I am sorry for those who have had poor/difficult experiences and it is good to hear that some people have had better experiences. I do think it helps if the person has 'informed' relatives to stand up for them.

At the end of the day, care homes are businesses and are there for their shareholders no matter how much they bang on about the importance of quality care. Our manager gets bonuses on how much they save/cut costs - so go figure. It helps fund their brand new luxury car every year and frequent trips to Thailand! Thanks Thatcher for effectively privatising care the of elderly and letting people buy their council houses so that they then had an asset to sell to pay for it in later life!

I have been inspired by your responses and I think I will write to my MP. I know for a fact that my experiences are not unusuall in Scotland as I know a fair few nurses working in the sector. It probably won't change anything, but at least I will feel like I have done something.

@2023forme Sadly, that's the reality of life even in good well run homes. DMIL is delivered from it now, but her last couple of years were horrible. She was 93, with dementia, doubly incontinent, with polymyalgia and scoliosis. Fortunately, the care manager was an absolute tiger and made sure the GP took her off all the unnecessary tablets. But her last few weeks were traumatic because she fell and needed hospitalisation on an acute orthopaedic trauma ward in the high needs bay, with five other elderly ladies, several of whom screamed all night, every night.

DMIL was a nurse, and was utterly convinced of the need for a change in the law on assisted dying.

My friend's mum was in a care home with advanced dementia and about the only thing she was able to enjoy was sucking the cream out of a chocolate eclair. She was 94 and completely dependant wiht multiple comorbidities. My friend went up one day with her box of eclairs and was told her mum couldn't have them (or butter) as she had high cholesterol. Lucky my friend is a nurse and very assertive so safe to say, her wee mum continued to enjoy the cream from her eclairs until her dying day (which was only a couple of weeks later).

You sound amazing OP, what an utterly depressing situation this all is

Yeah, it's unpopular with me! I do a lot if cruises and I see people in their 90s being quite active. More active than quite a few 60yos, tbh. If they had a heart attack, why would you just leave them to die? It sounds monstrous to me.
My friends mum had heart stents put in at 89, she'd have died or have had a much diminished life otherwise. She's 92, shopping and cooking for herself, and still living an fairly independent life.

Everyone on here seems to know a 94 year old still living an independent life. In reality very few do, and most have a low quality of life.

This is why the vaccine mandate for care workers was insanity.

You can contact the CQC yourself and tell them your concerns. I wish you would. It's a nightmare trying to work out which is a good home or not so it would be appreciated by everyone if you did.

@Cuppasoupmonster how do you know that? Certainly if you go into a care home most of the residents that are over 90 will have multiple health issues. But that's why they are in the care home.
In truth you have no idea what percentage of people over 90 living in the UK have a poor quality of life. Because why would you?

Shes not 94, she's 92. She cooks and shops. She has help with cleaning. Her husband died last year and she arranged his funeral on her own. She is selling up and moving to come be near her two daughters and she's looking for an independent living apartment.
My mum is 87 and physically fit. But she has dementia otherwise she'd be fine at home. She has a DNR but if she, as someone said upthread, got pneumonia, I'd expect her to be treated. Despite her dementia, she still enjoys her life.

And to add, my sister plays bridge and she knows ladies in their 90s who still have their own home, go to bridge and enjoy their life.

But my point is, should people be entitled to die before they reach a point of pain and desperation? I say yes. There’s also the issue of cost to the state (although nobody wants to acknowledge this part).

@Cuppasoupmonster putting an argument forward for assisted dying, or just stopping active treatment, in line with an individual's wishes, is quite different to saying "pain relief only to the over 90s"!

Sorry can only write a short post. Definately feel your pain - I working the community.

With regards to your lovely 96 year old lady - can she not have burpenoprhine patches to help with the pain - alot off our eldery patients with contracted limbs have this and cutimed sorbat to prevent pressue sores.

Nobody wants to acknowledge the damage the vaccine mandate did to the care sector either. Coupled with the fact that care workers were treated like shit already its hardly surprising they prefer to work in Asda

You sound amazing OP!
The care home I worked for was part of a huge company and we also had those modules to do, which we were told we would have time to do on shift but that rarely happened. We would regularly get told we had to do them at home (unpaid) as being so short staffed meant there wasn't time. I did them and as soon as they were finished more were added. I felt it wasn't good enough, I learned more from 1 colleague than I did from the modules. What shocked me the most was I had no experience at all in any care but only had 2 days shadowing an experienced carer then I was on my own and I hadn't even met most of the residents, it was so difficult. I honestly don't know how agency staff manage to assist so many people with different needs without knowing them. Also the tight time frame we had to assist with personal care did not take in to account residents different needs, so for example someone could walk, very slowly, which was encouraged and that would take 10 minutes to get to the bathroom (there and back) but there was only 20 minuites total to wash, dress, clean teeth, cut nails change bedding, collect and deliver breakfast, some bedrooms were 5 minutes walk from the kitchen. Some people had daily showers too (which is their right and should be provided) which meant they needed hair dried which always took extra time and there would be less time for other residents. It was always such a rush and I felt so bad.
I was also told in the interview that I would be working towards qualifications but that never happed due to the pandemic and I left after 1 year but there were colleagues waiting 2 years pre pandemic to be put forward for qualification training. It's just not good enough.

Relatives of the elderly in care homes end up burnt out themselves. After the ordeal is over you're so stunned and frustrated by what went on, guilt about whether the right choices were made, stress and exhaustion from travelling miles to visit etc. It's only now, 4 years later that I could put up a fight for anyone else going through the nightmare. And I really do want to because it's so incredibly inhumane and something's got to change.