Worse than hell?

When a resident of a care home for older people says she would
rather be in hell most people on the outside world can only imagine
the sense of hopelessness.

Yet that abject desire to escape “down under”, so to speak, is
symptomatic of abuse uncovered by North Essex Advocacy Teams for
Older People (Neat).

Since Neat was formed in 1993, the nature of referrals has changed
dramatically as cases have become more complex. With Neat’s work
increasingly focusing on elder abuse, the group tried to measure
the extent of the problem in research called Behind Closed
Doors. The findings were disturbing.

This was a qualitative research project, based on 67 in-depth
interviews with older people, 40 of whom lived in residential and
nursing homes, nine in sheltered accommodation and 18 in their own
homes. Also interviewed were 40 care staff from residential and
nursing homes, together with a sample of professional
workers.

Particularly significant was the fact that, of 83 residential and
nursing homes contacted in the Tendring and Colchester area, only
20 would agree to take part in the research. Twenty-two per cent of
care staff interviewed said they had to deal with cases of abuse in
their work, with a further 12 per cent having to “sometimes”.
Thirty-five per cent of care staff had witnessed a form of abuse,
and responses included “sexual abuse”, “punching and kicking” and
“being rough with a client”. When those who had witnessed abuse
were asked what they had done about it, five said “nothing, it
comes with the job”. Other responses included “kept quiet – I
didn’t want any trouble, I needed my job”.

One of the main issues is a lack of training. It emerged that 77.5
per cent of care staff interviewed had never received any official
training to deal with abuse. It is evident that there is a huge
need for homes to offer staff training, but also to perpetuate an
ethos where staff feel able to “whistle-blow” and be commended for
this, rather than fear it will lead to peer animosity or loss of
their job.

Much of the abuse in the homes was subtle, and could be termed
“institutional abuse”. Fifty-two per cent of older people said they
had been given no choice about entering a home, with 20 per cent
saying direct pressure had been put on them. Answers included: “I
was told I was going on a holiday”, “the family decided” and “I was
just told I was going into a home”.

Of the 40 residents interviewed, 25 per cent said they felt the
management or owners did not know how the home was being run, with
one saying: “They are never here”. Access to cash proved another
problem with 65.2 per cent of residents reporting having no control
over their own money. When asked whether they were happy with this
situation, the most cited replies were along the lines of ” have to
be”, or “how can you make a complaint when you have nowhere to
go?”.

Residents were asked to name three things they did not like about
living in the homes, and some of the major themes to come out of
this were: the routine, no control over their own life, no
independence, sharing a room and – the most frequent – being made
to have a bath at regular times. Two of the most poignant replies
were given to the question: “Given the opportunity, where would you
like to move to?” One person replied “heaven or hell”, while
another said, “someone else would decide for me”.

From the sample, it would seem that sheltered accommodation –
perceived by many as a place of safety – might offer more
opportunity for abuse than any other setting. On the surface, the
housing complex used to conduct the interviews seemed excellent,
with happy, content residents and good management. Indeed,
initially, all residents interviewed said they were happy living in
the scheme.

Subsequently, it emerged that incidents had been occurring at the
complex over some years, which could be defined as
resident-to-resident abuse. There has been much verbal abuse,
including intimidation, but there is also physical abuse, including
pushing and knocking people out of the way when getting on
transport. Reports from the warden to her superiors pointing out
the gravity of the situation date to November 2000 but, at the time
of the research (May 2002), the local authority had done nothing to
rectify this situation.

There are many letters of complaint on record from individual
tenants, but all have been ignored. A typical extract reads: “Of
40-odd flats here, I don’t think anyone has escaped this
abusivenessÉ I have never been bullied before in my life until
about five months ago. This was for the second or third time. I was
so upset, I was ill for three weeks and had to see the doctor who
said I was suffering from stress due to this particular episode.”
This is probably the clearest example there could be of the “behind
closed doors” syndrome.

Interviews with professionals were enlightening. Of the two GPs
interviewed, neither had received training on elder abuse, with one
saying he “would not know what to do about it”, but that he would
discuss it with a colleague.

Three of the district nurses interviewed had received no official
training at all, and one had “non-specific training from the police
protection officer”. Three of the nurses had witnessed abuse. When
asked what they had done about it, one said “made the GP aware”,
one had spoken to their co-ordinator and the other said she was
“unclear how to act”.

GPs and district nurses are often the first point of contact for an
abused older person. But when the district nurses were asked about
the consequences of their actions in reporting the abuse, the
replies were “nothing changed at the time”, “assume nothing
changed” and “don’t know”.

Only one solicitor would agree to an interview. He had never
received any training on abuse, but said that sometimes older
clients did try to tell him their sons or daughters were trying to
take their money, but “there are two sides to every story, and it
always needs investigation – sometimes they are ga-ga and making
everything up”.

Recommendations from the research (see panel) include a call for
adequate training for staff in residential and nursing homes and
mandatory training for professional workers, particularly those who
may be the first contact likely to pick up the danger signs. This
is particularly vital for district nurses, GPs and solicitors.
There is also a vital need for clear policies and procedures for
dealing with abuse in sheltered accommodation.

Susan Greaves is project manager at Neat. Behind Closed
Doors is available from her free on 01206 251516.

Action on abuse  

Among the report’s conclusions… 

• There is more opportunity for abuse in sheltered accommodation
  than in any other residential setting due to lack of staff
  supervision and often off-site management. 
• People able to live in their own homes are open to abuse
  through door-to-door pressure selling.  
• What professionals understand as abuse and what older people
  perceive as abuse can be different. An example is being forced to
  have a bath when they don’t want to. 
• Care staff in homes generally treat abuse as something that
  “goes with the job”.  
• Care staff are reluctant to report incidents due to the lack of
  a confidential support system. 
• Many older people in care have a “stiff upper lip
  mentality”.  

Recommendations include: 

• Staff in care homes should receive regular training. 
• Homes should strive to perpetuate an ethos where staff feel
  able to whistle-blow. 
• “Absentee” care home owners and managers should make more
  effort to know what is going on in the home day to day. 
• Consideration should be given to the issue of mentally able
  residents being surrounded by dementia sufferers, as this can
  create an environment of frustration. 
• Consideration given to issues such as staff knocking on room
  doors before entering. 
• Councils should draw up procedures for dealing with abuse
  within sheltered housing schemes. 
• More support should be available for sheltered housing
  managers  dealing with problems. 
• Training should be offered to workers outside the care home,
  such as Meals on Wheels staff. 

Source: North Essex Advocacy Teams for Older People