The rising demand for senior care facilities, including retirement homes, assisted living spaces, skilled nursing homes, and dementia care homes, is a global phenomenon. India, too, is witnessing the growth of these facilities as people live longer lives. With increasing longevity, the need for such care homes continues to rise steadily. The letter from Kirtana to Sowmya that we cited underscores the grim reality of care standards. The letter is self explanatory and points to the larger issue of sub standard care. The lack of consistent regulations and uniform standards is a significant concern in this regard.
When individuals like Kirtana, whether they are relatives or friends, visit their loved ones, they should experience the feeling of entering their loved one’s home, rather to a shabby, depressed place. To achieve this, a well-managed care facility should mirror a family home: warm, personalised, comfortable, and inviting. This article provides insights into what individuals can look forward to in a well-established care facility.

  • Roshan J Mundapallil, Sowmya Lakshmi

Dear Sowmya,
I urge you to share my personal experience on your blog or website to shed light on the distressing conditions in our care facilities and the unfortunate situation faced by our elders receiving subpar care. While I could elaborate further, I will begin with my story about the last ‘Care’ home I encountered before meeting you. Our meeting completely transformed my perspective, prompting me to write this letter. I am truly impressed by your extensive knowledge and expertise in the field of aging and social gerontology.

I am not saying that everything in US is hunky-dory in elder care settings, there also there are a lot of shortcomings but there is a ‘system’ which routinely check for the quality of services. What I learnt is that here we don’t have any mandatory or independent body to oversee the expected and necessary standards.

When we arrived, no one there to receive us and we almost waited half an hour to get the gate opened. There was an overall atmosphere of a haunted place with unkempt grass and the building looks untidy. Ideally, their existence should not be necessary. This is the seventh ‘Care home’ that we visited past one week. An exploration to find the ‘right place’ to keep my mom and dad. It was a real sad experience to find how pathetic is the old age home (Care home) situation in India.

In brief these were the standards I was looking for :

  1. Dignity and respect to each inmate.
  2. A detailed involvement of the family in care and good communication.
  3. The right care, treatment and support that meets individual needs.
  4. A safe and hygienic environment.
  5. Staff to have the right skills and attitude to do their jobs properly.
  6. Adherence to protocols.
  7. Regular checks for the quality of the services.

It was obvious that many of these standards were in short supply at all the places, including the nutritious food and medication management. Many of the elders showed dramatic weight loss and most of them not bathed for may days together. I knew many conditions especially dementia itself can cause weight loss, on the contrary, in these cases, there was more than one cause. One lady had false teeth that whirled round her mouth alarmingly when she spoke and you can imagine how she can struggle with food. Many of them complained about the food.

Even though they objected to speak to the Inmates, in one, residents told me of strange food combinations and stale food. The portions seemed inadequate for some of the men and second helping is not provided. Food that should have been hot was often cold. Menus were often not compatible with what was served and much of the food was bought in, rather than home-cooked on site. Food that had not been eaten was often left on bedside tables with flies and ants swarming, when I visited in the mid-afternoon. As most of these facilities follow strictly vegetarian food, protein content of meals seemed low.

I could gather lot more information which are true concerns, such as no trained nursing staff being available at weekends other Holidays; night staff slept when supposedly on duty and most time spend on mobile phones! There appeared to be no regular assessment or monitoring of residents – a doctor was called when necessary. Because of the understaffing in almost all facilities, residents were left to empty their bowels and bladder in their beds, even though they could have walked the short distance to their en suite lavatory with help. I can smell urine in every bed ridden patient because no timely change of diapers. This is what one lady told me, when I popped my head round her open door and her helplessness made me cry thinking is this my future too. “I’ve had to pee on the pad every time – I complained the pad is not fitting properly and trickles down my leg and onto the bed – it’s wet and cold. No one bothers and this is what they tell me to do – I hate it – I just need help to get to the toilet, that’s all”.

As a visitor, though I am a stranger, I promised to get her help and found a carer, filling out paperwork.“I have to wait till the other carer has finished taking the tea round”, she responded. I said the lady was very upset. “ Madam,She’s a nagging patient and never listens. She will have to wait”, came the answer.Interaction between care staff and residents was often minimal and unfriendly. Having said that, in their defence, there were staff shortages. And the result is low level motivation.

I could go on. Management is not liking my way of finding answers and may not be used to this in-depth ‘probe’. In spite of this, I was subjected to a five-minute monologue about the medication management and emergency protocols – the message was clear – “mind your own business”!

Understandably, it was not very comfortable for them. But I was adamant to find appropriate answers because after all I was seeking admission for my Mom and Dad. So, why I rejected all the seven places? Poor management and lack of staff training were at the root of many of their deficiencies. I am sorry for the residents who were placed there and getting inferior care.”

In her letter, Kirtana Jagannathan expressed her disappointment with the conditions in long-term care settings and proposed numerous enhancements for the sector.

Even though she resides in the US, Kirtana, the long-distance caregiver, is remarkably certain about her preferences and requirements. Kirtana’s observations holds true. The deficiencies in the quality of care provided in elder care facilities are concerning, yet no one is taking the initiative to address the issue. These problems stem from inadequate or unsanitary infrastructure, a lack of skilled and motivated staff, insufficient nutrition, mismanagement of medications, non-compliance with evidence-based clinical practices, absence of emergency protocols, and poor documentation and information utilisation. Enhancing the quality of care and ensuring patient safety are crucial steps toward reducing morbidity and mortality rates. Quality care is not just a requirement for better health; it is also fundamental to ensuring equity and dignity for elders in their final stages of life. To achieve this, elder care services must be safe, effective, timely, efficient, equitable, and centered around the needs of the people.

This implies that every resident in a care home should receive personalized care and experiences, tailored to their individual needs and preferences. It’s crucial to acknowledge that no two individuals are exactly alike, even if they share the same birthdate, year, and diagnosis. When care facilities grasp the significance of this diversity and allow staff enough time to engage with residents, understanding their desires, needs, and aspirations, person-centered care can genuinely be implemented. While some wishes might be challenging to fulfil due to limitations such as disability, age, or budget constraints, a quality care home should endeavour to meet as many of these preferences as possible, no matter how unconventional they might appear.

In person-centred care, it’s important to recognise that not every desire or requirement is extravagant. Simple needs like knowing that one resident enjoys tea with milk and three sugars, while another prefers coffee with a splash of cold water and no milk, hold significant meaning. In institutionalised settings, where everyone is served tea with milk and sugar regardless of personal preference, it might not seem like a major issue. However, it essentially strips individuals of their uniqueness, conveying the message that their preferences and likes no longer hold importance.

For an elderly person, such situations can result in depression, aggression, lack of cooperation, disturbed sleep patterns, falls, anxiety, and the list continues. It appears to be an insignificant concern for you, but the reality it is not. In summary, how can we recognise a good care home with good practices? You can sense it! It’s evident in the genuine care from the staff, the laughter of the residents, the warmth and thoughtfulness in the home’s design, and the variety of enriching experiences accessible to everyone.

When you visit care homes, these are few questions you ask and if the answers are in the affirmative, then you can go ahead. We, suggest the following to a prospective buyer of institutional care:
1. Does the Owner/Director have formal geriatrics training and expertise. Better training naturally translates to a greater passion and oversight. How much is his or her involvement in the day to day affairs? Is it just another business opportunity for him? Is it well led?
2. What is the rate of turnover for staff and how long have the leaders ( Medical Director, Nursing Director, Nursing Staff, and Administers) been in the current position? The lower the turnover and higher the tenure says a lot about the quality of care.
3. What is the staff to patient ratio? Quality of care depends on this factor also. Overworked staffs will get exhausted and they tend to compromise on care. Prefer a better ratio than the mandatory rule demands.
4. How does the facility look and smell when you walk around? A foul smell or untidy appearance of the facility will tell a great deal about management attitude and quality of care provided.
5. Why not ask questions because you have a right to know even the minute details. Are they responsive to your queries?
6. In conclusion, it’s advisable not to place excessive trust in Google reviews, as star ratings often do not accurately reflect the quality of care. Many of these reviews are unreliable and could be fake. It’s essential to discern the genuine feedback from the noise. Sieve the chaff. Old birds are not to be caught with chaff.