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STATES OF JERSEY
Health, Social Security and Housing Panel
Long Term Care of the Elderly
WEDNESDAY, 30th JULY 2008
Panel:
Deputy A. Breckon of St. Saviour (Chairman) Deputy R.G. Le Hérissier of St. Saviour
Mr. J. Forder (Adviser)
Witnesses:
Ms. C. Kennealey (Manager, Palm Springs Nursing Home)
Ms. M. Jewell (Managing Director, Palm Springs Nursing Home)
Deputy R.G. Le Hérissier of St. Saviour :
I would like to welcome you and we will introduce ourselves. Then I would be obliged if you could introduce yourselves and just say what your role is in the home. Then we will launch into questions. I think you have had an outline there of the questions. Just to say we give this normal little caution out every time. It is recorded but you do have legal privilege. That essentially means unless you say something which is malicious and also unfounded in terms of evidence you are free to say what you think; and indeed we hope you will be free to say and want to be free to say what you think because we need to hear that. I am Roy Le Hérissier.
Deputy A. Breckon of St. Saviour (Chairman): Alan Breckon.
Mr. J. Forder (Adviser): Julien Forder.
Deputy R.G. Le Hérissier:
Julien is the adviser to the panel from the University of Kent.
Mr. M. Orbell: Malcolm Orbell.
Ms. M. Jewell (Managing Director, Palm Springs Nursing Home):
I am Mary Jewell. I am the Managing Director and owner of Palm Springs Nursing Home.
Ms. C. Kennealey (Manager, Palm Springs Nursing Home): Cheryl Kennealey, Manager of Palm Springs.
Deputy R.G. Le Hérissier:
What we will do then - and we are going to rattle on, so to speak, until 1.00 p.m. or thereabouts. We will ask you a series of questions but whoever feels most competent or most knowledgeable just jump in and obviously the other person just add to the answer if that is what you think. I wonder if you could tell us a brief biography, so to speak, of the home, the number of residents, your particular role, how long the home has been open and the number of staff, for example.
Ms. M. Jewell:
The home has been there since 1969. I have been there in charge for 24 years. We are registered for 25 patients but to make everybody comfortable and because of staff logistics we take 20. We are registered for geriatric, post-operative, respite and medical, that is our complete registration. We specialise in the very elderly, very frail, physically and mentally. End of life, really, that is what we do. We have 40 staff. We are restrained and told what to do by the laws of the Nursing Home Act.
Deputy R.G. Le Hérissier:
Can you give us a breakdown of those 40 staff? What kind of staff are they?
Ms. C. Kennealey:
Obviously varying from staff nurses, we employ 6, and we also have a matron and myself, staff nurses' manager. Then we have nursing auxiliaries and domestic staff and then that is basically it.
Deputy R.G. Le Hérissier:
Can you tell us what your view is of the overall provision of dementia care services on the Island? What is your view?
Ms. M. Jewell:
I can only tell you dementia care as we see it. We are very well served, as I was saying to you, by Dr. Wilson and people from St. Saviour's. The 2 C.P.N.s (Community Psychiatric Nurse) we deal with are excellent. Instant call, instant there with any help that we require. We sort of sit on our mountain up Trinity Hill on our own and just deal with the people we are required to deal with. We find them excellent.
Deputy R.G. Le Hérissier:
Where do your referrals come from? Is it families? Is it St. Saviour 's Hospital?
Ms. C. Kennealey: All of those.
Deputy R.G. Le Hérissier: All of those?
Ms. C. Kennealey:
The dementia care that we really deal with are usually patients that have now become very frail with their dementia, as opposed to dementia that has been diagnosed early on. The dementia is not the main focus of our care, it is actually the physical care that they require.
Deputy R.G. Le Hérissier:
Does that mean, Cheryl, are some of them coming from other residential homes or nursing homes?
Ms. C. Kennealey:
They can come from being at home, they can come from residential homes, they can come from St. Saviour's, they can come from Beech Ward , Poplars, Overdale, referrals from the hospital, we take referrals from anywhere. From everywhere actually, we will take referrals from.
Ms. M. Jewell:
I was saying when I met you that we quite often have Aunty Rose and then a few years down the line we will have Aunty Jo or Aunty Kate, whatever, you know, send them to Mary. That sort of thing.
Mr. J. Forder:
The people that come from St. Saviour 's, do they go to St. Saviour 's to be assessed or ...?
Ms. C. Kennealey:
It depends. Sometimes they go to St. Saviour 's to Poplars or Beech Ward and they can be there for up to 6 months for assessment. But often they end up there because there is no other beds, anywhere else for them to go. They may or may not need that degree of psychiatric care. Hence they will often go there as a waiting period.
Mr. J. Forder:
As some kind of stop gap?
Ms. C. Kennealey: Unfortunately it can be a stop gap.
Deputy A. Breckon:
With your residents, how many would be privately funded and how many would be through ...?
Ms. M. Jewell:
At the moment I think we have 12 publicly funded and 8 privately funded. It differs. We have 4 contract beds with the States of Jersey, that is all. The others are pro rata as needed.
Deputy A. Breckon:
Is the funding issue a concern to residents and families depending on their state? For example, if they had to sell their home, has that been an issue for you?
Ms. M. Jewell:
We have had it once. Some people who lived in the Parish of St. Helier , they had not had to sell their home but there was a restraint put on the house at the end of life. That was a problem obviously for their children. People did not realise what was happening exactly.
Mr. J. Forder:
I was just going to follow that point. So the States spot purchase some of your places as well, is that right, and then there is 4 contract beds?
Ms. M. Jewell: Yes.
Deputy R.G. Le Hérissier:
You did mention, Mary, that people arrive in an advanced state of frailty and perhaps dementia. Notwithstanding that, are you able to develop programmes that provide a degree of stimulation that might enable you to bring in the community, for example?
Ms. C. Kennealey:
Bring in the community, as in ...?
Deputy R.G. Le Hérissier:
Say a local primary school or a W.I. (Women's Institute). Is it possible to have that involvement?
Ms. M. Jewell:
We tried it. We had children come in and sing carols at Christmas, but we do find, sadly, that children do not know what to deal with very old frail people. They are frightened of them, I think. They sort of look at them as though they are going -- do not quite know what to do. We do have choirs every Christmas and all that sort of thing but it is not a regular thing. We have pat dog comes in, we have had people who I employ just to play dominoes and painting and take them out for a drive, because it is very much one-on-one. Community.
Ms. C. Kennealey:
Most of our clients are not able to participate in a group, for example, we have tried having things like bingo sessions and that type of thing. We just cannot do it. Our patients are not able to participate but they are able to participate in a one-on-one. So bringing people in from the community, not really. It can be very daunting for little children to come in or even volunteers, for some patients that may not be speaking, are not able to communicate and a lot of them have dementia and behavioural issues and that can be a bit frightening for people that do not really know what they are getting into.
Deputy R.G. Le Hérissier:
I asked you about your staffing structure. One of the themes that is recurring in this evidence is the difficulty in recruiting staff. Have you got a difficulty?
Ms. C. Kennealey:
Very, yes. You try to recruit, especially staff nurses, and it is not attractive enough to come into the Island any more for staff nurses. It can be very, very challenging.
Deputy R.G. Le Hérissier:
Are you able to upgrade in terms of providing training or do you really have to bring people in with the requisite skills?
Ms. C. Kennealey:
You have to bring people in with the requisite skills, there has been a programme running at the hospital doing a nurse's programme; from what I can understand I do not believe it has been that successful. I do not think they have qualified yet, either. So they are not available for employ and they would also need a certain degree of experience. We could not take a newly qualified staff nurse in. They need to have a certain amount of experience and the staff -- the patients that we deal --
Ms. M. Jewell:
Cheryl has gone ahead. We have a nurse who we have to - because of registration problems - employ as an auxiliary. We found a way, Cheryl has found a way, that we can mentor her through her 6 months so that she can get her pin and work as a trained staff nurse. We are very much -- new area for us, new area for the Island. It has not been done before.
Ms. C. Kennealey:
There is an overseas nurses programme that all nurses that have qualified outside of the E.U. (European Union) have to go through in order to become a member of the N.M.C. (Nursing and Midwifery Council), and we are now putting one of our auxiliary nurses through that programme - as Mary said, the first place in the Island to do it - and through a 3 month membership programme she will be able to get her N.M.C. and qualify and get a registration as a staff nurse. Which we are hoping we can continue that in the future if -- it will be an interesting thing to do if there is obviously a need for it.
Deputy A. Breckon:
The age of your residents, are we all living older or are you dealing now with older residents than you did say, 5, 10 years ago?
Ms. M. Jewell:
People used to come into us a little earlier in their mid-70s, now it is mid-80s.
Deputy R.G. Le Hérissier:
So you are getting what they call a compression, are you?
Ms. M. Jewell: Yes, yes.
Deputy A. Breckon:
You mentioned before "end of life", your residents would come to you in their last 6 months, the last 9?
Ms. M. Jewell:
Some of them come and stay, one lady was here with me for 14 years. Generally it is a few years. People seem to, you know, it is constant care.
Ms. C. Kennealey:
We either have a very short turnover of, say, 6 months, or people are there for 3, 5, 6, 7, 8 years.
Deputy A. Breckon:
Is that, with respect, become a specialism for you, is it, because you have a level of fairly dedicated and intensive care that it is seen that you are the specialist there and you get those referrals?
Ms. M. Jewell: That is exactly it.
Ms. C. Kennealey:
All of our patients require a huge amount or have huge dependency levels, only 2 patients at the moment can actually walk. Most of them cannot move themselves. The level of dependency is very high and getting higher all the time.
Mr. J. Forder:
Is that almost everybody with quite severe levels of dementia now, or is it a mix of physical and mental?
Ms. C. Kennealey:
I think it is a mix of both. But I also think that there is age-related dementia as well that comes into it. Ninety per cent of our patients are well into their 90s.
Deputy R.G. Le Hérissier:
In terms of family support, how many receive what you might call positive and active family support?
Ms. C. Kennealey: The majority.
Ms. M. Jewell:
The majority. Some have nobody which is very sad. Everybody has gone out of their lives, so we try and put something in for them. Families are very good but we do encourage them to come and have afternoon tea in the garden and things like this. They are very good families, by and large. There is one thing though, I saw a programme about statins, they discovered that they might stop Alzheimer's or the early onset, which will be good for us all, as we get older.
Mr. J. Forder:
Although apparently - Dr. Wilson mentioned this yesterday - where she said there is also some conflicting evidence and evidence that statins actually worsen the ... at least in theory she thought that they could worsen the possibility of ... or the risks of developing Alzheimer's disease, these things never seem to be clear cut, that is the trouble. There is always a wonder cure for Alzheimer's just around the corner and it just stays around the corner forever.
Ms. C. Kennealey:
Then 10 years down the line they discover it is ...
Ms. M. Jewell:
One of the senior consultants at the hospital who smoked a lot used to say that that was the reason that she did not get Alzheimer's because she smoked a lot.
Mr. J. Forder:
Whereas now we know the opposite to be true.
Deputy A. Breckon:
You mentioned earlier about the regulations. What is your relationship with the inspection service? Are you comfortable with it or does it cause you grief or are you content?
Ms. M. Jewell:
No, we do not have any problems with it. It is very good.
Deputy A. Breckon:
You have a good working relationship?
Ms. M. Jewell: Yes, very good.
Ms. C. Kennealey:
Inspection is very good. I think it is ...
Ms. M. Jewell: Very necessary.
Ms. C. Kennealey:
It is important and we have a very good relationship with the inspectors, all of them.
Deputy A. Breckon:
If somebody is coming to you for care you would say: "We have had an inspection report." Or is it for your own purposes?
Ms. M. Jewell:
At the moment we feel it is for our own purposes. To help us along and make us provide more if it is required. I am not so sure about making it public. I think we would need to be shown the report and say: "That is wrong", prior to it being published because sometimes they do get it totally wrong. Not always, very rarely, but sometimes, very occasionally.
Ms. C. Kennealey:
I think if they are going to make a recommendation for a change or to alter a certain policy that you have, I think you need to be given the opportunity of rectifying that and meeting the recommendations, whereas if that was open to the public if there was a recommendation that was made, that could stand long term against you. But we have never had an issue like that.
Ms. M. Jewell:
No, never but I know from other people at the Care Federation discussions, you know, they have had problems.
Deputy R.G. Le Hérissier:
Building on that, Mary and Cheryl, when you get a report what kind of support are you looking for from the inspection team?
Ms. C. Kennealey:
Obviously within nursing things are always changing, regulations are always changing, standards are always -- the bar is always being raised. Through inspection you know whether you are meeting the criteria, you also know how you can improve your standards. That is what we are always looking to do. We are obviously striving to improve. So through inspection I think it does give -- you get a better quality of care, higher standard of care.
Deputy R.G. Le Hérissier:
One of the issues with inspections, a lot of these regulatory bodies, they are trying to cut back on enforcement and be a more educational advisory facilitating kind of body. Do you feel that that is a direction?
Ms. M. Jewell:
Mrs. Blackwood is very good.
Deputy R.G. Le Hérissier:
You feel that we are in that direction, do you?
Ms. M. Jewell:
She provides all sorts of educational assistance for people to go, she is very good.
Ms. C. Kennealey:
There has always been regulations in place for nursing homes, we have always adhered to those anyway, so, we have never really had the inspection, you know, Christine Blackwood being the enforcer of anything, because we are always adhering to it anyway. We have never really had that problem.
Ms. M. Jewell:
Residential homes is very high, wide and handsome at times, their regulations, where ours are quite specific.
Deputy R.G. Le Hérissier:
One of the arguments used, which is a bit of an old chestnut and it may be history, is that the small homes tend to suffer more from regulation because obviously you do not have the resources of these big U.K. (United Kingdom) operators that are now coming into the Island and they can really refurbish and put on the individual valves on the taps. Do you feel it hits you disproportionately?
Ms. M. Jewell:
Financially it can do because there is only me, you know, with the cheque book; at the end of it all there is only me. But the regulations are there to be adhered to, that is the business I got in to therefore.
Mr. J. Forder:
I am going to go back to funding, sorry. It is my preoccupation at the moment. You have got self-payers and State supported people. If you have a self-payer who is a nursing client, they would have done this, paid all the fee themselves, there is no State support, they do not get the sort of -- there is not a nursing component that ...?
Ms. M. Jewell:
They used to get an Attendance Allowance which I believe has stopped now. I do not understand that.
Mr. J. Forder:
Yes, I think it has. It is just something that triggered in my mind earlier on today because in the U.K. if you are a private payer in a nursing home you still nonetheless get a contribution towards your fee which covers the nursing element of your care.
No, that is not applicable to Jersey, is it, yet anyway? Is it £10 a week?
Mr. J. Forder:
No, it is about £80 a week.
Ms. M. Jewell: Is it really?
Mr. J. Forder: Yes.
Ms. C. Kennealey:
Before everything changed, I mean I know there was an Attendance Allowance, there was a Transport Allowance, and there was ... but that is not something we get involved in anyway.
Mr. J. Forder:
They still get an Attendance Allowance as well, in the U.K. but the argument is that if you were in a N.H.S. (National Health Service) continuing care ward then you get your nursing care provided for free, and it is also the same here, if you were in the Limes, for example, then you pay for your accommodation but the nursing care, the care element is picked up by the Health Department.
Deputy R.G. Le Hérissier:
That is how ... if you are in a States dementia unit, so to speak, the States will pick up the nursing element and you will be means tested on the hotel element. That is what they do. That is what they do at the moment.
Ms. M. Jewell:
We get paid for the States patients that we take. Similarly to the Limes, similar to everything else. So they pay absolutely nothing really, apart from personal care; hair and shampoos and stuff. Everything else is included in that fee.
Mr. J. Forder:
I mean the people who are States supported, as you say, even when they are in your home, they pay to the States the accommodation charge. I was just wondering about how purely private payers, whether they get any kind of support at all?
Ms. M. Jewell: Nothing at all.
Deputy A. Breckon:
When you say the States group, can you just define, does some come from Health or is it through Social Security, are they are all going the same way now?
Ms. M. Jewell:
We used to get one lady, we still do, who was paid by a mental health department and the rest were all paid by Overdale. I understand that has changed, but we are still getting money from Overdale as far as I can see, whereas it has been sorted out.
Deputy A. Breckon:
Did you used to get clients funded from Parishes before?
Ms. M. Jewell: Yes.
Deputy A. Breckon:
That has changed now, that has gone to Social Security, has it?
Ms. M. Jewell:
So I understand, because we do not have any at the moment.
Ms. C. Kennealey:
No, I do not know how it is all going to work, I know that we are still being paid the same way;, I am not too sure how they have brought it all together.
Deputy A. Breckon:
But these are clients that come from health referrals rather than income support?
Ms. C. Kennealey: Yes.
Deputy A. Breckon:
Is the system better or worse? But you will not know until you get clients through that method?
Ms. M. Jewell: No.
Deputy R.G. Le Hérissier:
I think the intention of moving it to Social Security is not only to get the money out of one pot, but it is to get proper assessment tools, as people say these days, working and they are trying to assess the different levels of support needed. Apparently they will pay according to how they assess that level of support. How many levels they are going to insert in the system is obviously going to be part of the ...
Ms. M. Jewell:
You have been involved in this, have you not?
Ms. C. Kennealey: Yes.
Deputy R.G. Le Hérissier:
You have been on a working party, have you?
Ms. C. Kennealey:
Yes, with Mark Littler and a number of people have been involved in it. We have not been called back with regard to the outcome of funding on that score, as far as I am aware it has not been decided.
Ms. M. Jewell:
One thing I would say though, a meeting I was at with Mark Littler, and he said that the States of Jersey had received a document with regards to payment in the U.K. and it showed up very well against payment in Jersey, it was going to be very similar. The point is, payment in the U.K., the wages are minimum wage, they are nothing like what they are paid here. All the other extras that come with living in Jersey they were not included in that, because I did ask. So it is not like for like, it is oranges and lemons, is it not?
Ms. C. Kennealey:
There is another dispute about the amount of the payment that has been attached to each of those different levels. There is dispute at the moment.
Deputy R.G. Le Hérissier:
It is interesting in the Guernsey scheme, and as I briefly described of social insurance, one of the criticisms that has been raised is that they pay out the money but they have got no indication necessarily of what the value for money is. What they do do, and I will float it in front of you and see what your reaction is, what they do - and in a way this is what I suppose you can do in a smaller society - every home receiving assistance from the States, receiving people who are on this, they will pay I think about two-thirds, the States contribution will end up at two-thirds, and the rest may be paid by the person or by Social Security. They have to open their books to the States and then the States obviously make a decision that the right level of profit that is being made. That is how they manage it in Guernsey at the moment. They do not manage it qualitatively, they manage it on a quick financial audit, as far as I can see. What would be your reaction to a scheme like this?
Ms. M. Jewell:
I cannot see a problem unless they are going to - I am aware of the U.K. saying: "Fine we will give you £1,000 a week, £500 a week", whatever, and then 2 years down say: "You are not getting any increase on that you know, because we cannot afford it." So people are getting less and less and less, and no repairs are done, staff are cut down, and the people who really have bad times are the patients, are they not? They are not getting looked after. There has to be some control over where money is going, the level it is going to be paid at, percentages and so on afterwards, before we can agree any amount.
Mr. J. Forder:
Do you have funded people referred from St. Saviour 's?
Ms. M. Jewell: Yes.
Ms. C. Kennealey: Regularly, yes.
Mr. J. Forder:
It is interesting though. Because we have this issue about bed blocking, that is a nasty phrase, delayed transfer of care is a more euphemistic term, but part of the problem is that if people were in the hospital and they paid, soon as they come into the care sector and they have a lot of money themselves or a home or something, then they pay and consequently, of course, some of them do not want to make that transition very rapidly. I just wondered if that might be an issue here?
Ms. M. Jewell:
My understanding is that the consultants start to stamp their feet and then the hospital empties, and until a consultant stamp their feet they are still in the beds. But that is a problem. Very big problem for people. I suppose they feel: "Why should we?"
Ms. C. Kennealey:
In a sense that does not really affect us because as soon as we have an empty bed, either private or State, we have had been at 100 per cent occupancy now for well over a year.
Deputy R.G. Le Hérissier:
But if somebody comes from a States facility on a medical recommendation, then they do not pay. Is that correct?
Ms. M. Jewell:
No, it does not work like that. It has to go through the assessment centre at Overdale, whether they come to us. They make the decision because wherever the funding comes from, they are still making the decisions at the moment, unless private people just come to us straightaway, but that has got to be decided by the right department.
Deputy R.G. Le Hérissier:
So the Overdale decision, that is a decision made on the basis of the medical need of the person?
Ms. M. Jewell:
That, as well as the financial set up of a person, whether they have sufficient funds to pay themselves or not.
Deputy A. Breckon:
Do you have a fixed fee for that or do you have a fee that would be based on the level of care required?
Ms. M. Jewell:
All our care is top level, we do not have any lesser care. Everything is total care. We get a fee which we have agreed with public health at that level. Each year it goes up by a percentage.
Deputy R.G. Le Hérissier:
We have covered an awful lot of ground, financial as well as your work in dementia. Are there any other points you wish to make? Are there any things you think we may not have covered properly or you wish to add?
Ms. C. Kennealey:
Not really. I think what we are doing is obviously very good, in a sense that we are looking forward to what is going to happen in the future because there is obviously going to be a lot of changes. We are quite pleased to be involved in that.
Ms. M. Jewell:
Just something I have a bit of a bee in my bonnet about is outside this Scrutiny Panel's remit. I think they should sell off the hospital and move it lock, stock and barrel to a centre of excellence at Overdale. The area, car parking, everything. No problems. I wrote to Senator Walker and Senator Ben Shenton and they wrote back to me.
Deputy R.G. Le Hérissier: Good. Did they agree to do it?
Ms. M. Jewell:
They said it is not financially viable but then when you hear we are spending how much on an incinerator, I would rather have a hospital.
Deputy R.G. Le Hérissier:
You have spoken quite encouragingly of the support you get from Government and -- because we have had quite a bleak picture, as I was telling you, of Government struggling to meet this need and struggling to make dementia a high priority issue. There are obviously massive financial implications, the more people go into care of course it ultimately is a massive bill for Government. From your experience are the numbers going into care really starting to increase or who need to go into care?
Ms. M. Jewell:
Yes, because families do not stay at home any more. I think that is going to have to be something -- people are going to have to be given a wage to stay at home. You cannot expect people to stay at home for nothing. But they are coming to us later, people are staying at home.
Ms. C. Kennealey: Staying at home longer.
Ms. M. Jewell:
Yes, much longer. Because of Family Nursing and things like that. All the things being pulled together. Everybody is not going to be demented, hopefully, at the end of it. So, it might not be such an enormous figure.
Ms. C. Kennealey:
Obviously the longer people live the frailer they are going to get. We are all living longer. The support that we get from public health especially and other social services is fabulous. If we have a bed available and they have a patient that they feel we could meet their needs, we have a very good working relationship with them.
Deputy R.G. Le Hérissier: I think, unless Julien has --
Mr. J. Forder:
Just your opinion on the number of beds that are now available on the Island overall, in particular some of the new arrivals, Silver Springs and the big companies, whether you have any views on whether that is a good development or a bad development, or whether the Island was over or under served in respect of beds?
Ms. M. Jewell:
I think it is very well served, possibly over served in residential beds. The nursing beds I think are the problem. The staffing levels and all of the attendant things that go with that. Then, of course, there is Zero/Ten but let us not discuss that.
Deputy R.G. Le Hérissier:
That is an interesting answer, thank you. I would like to thank you both very much for coming.
Ms. M. Jewell:
Thank you for inviting us.
Deputy R.G. Le Hérissier:
It has given us a real insight and we -- to a lot of the public this is sort of a hidden area but it has been quite revealing and very touching to hear the incredible work being done. So we do thank you.
Ms. M. Jewell:
Thank you.
Ms. C. Kennealey: Thank you very much.