Seanad Éireann - Volume 109 - 30 October, 1985
Homes for Incapacitated Persons Regulations, 1985: Motion for Annulment.
Mr. B. Ryan Mr. B. Ryan
Mr. B. Ryan: I move:
“That the Homes for Incapacitated Persons Regulations, 1985 [S.I. No. 317 of 1985] made by the Minister for Health in the exercise of the powers conferred on him by section 2 of the Health (Homes for Incapacitated Persons) Act, 1964, be and are hereby annulled.”
The problem about dealing with statutory regulations and statutory instruments is that we have only got a blunt instrument at our disposal. The blunt instrument is simply to refuse to approve the regulations or to annul the regulations, as it would be in this case, rather than refuse to approve them. Therefore, one has the difficult position of effectively being liable to be accused of throwing out babies and bath water together. Nevertheless there are — and I will go through them in some detail — important reasons why it would be better if these regulations were to be approved in an amended form. I cannot propose amendments. It is not my legal right to do so. This House cannot propose amendments, but the Minister could redraft the regulations and introduce  new regulations without any great difficulty, in my opinion. It would do a lot to improve the quality of the service that is being given in private nursing homes.
It is important to realise that we are not talking about tiny minorities of people here. There are well over 5,000 people resident in private nursing homes, private hospitals and voluntary nursing homes. Of those well over 5,000 people over 80 per cent are over 65 years of age and close on 60 per cent are over 80 years of age.
That is quite a substantial number. That number of people represents almost one-third of all the people over 65 years of age in this age group who are in long term care. It represents 1 per cent of the total population over 65 years of age. It represents one-third of all the people who are over 65 years and in long term care. So we are talking about an important area of long term care for our elderly people, people who are, by and large, not particularly vocal, not particularly able to express themselves or to lobby on their own behalf. Therefore, we have a particular obligation to be sensitive to their needs and to be careful and conscientious in what we do for or on their behalf.
Of people who are in private nursing homes, the figures available to me would suggest that about 30 per cent of them are either bedridden or can do no more than sit in a chair. Close to 30 per cent of them are also defined medically as being in such a state of confusion as to need virtual constant attention and support to do anything.
I would not want to overstate at all the present level of State supervision. We have this provision for approved private nursing homes, but this approval is not really so much a stamp of approval that standards are of a particularly high standard as it is of a willingness to give statutorily to individuals a level of support by the State. Indeed, such approval of such private nursing homes has virtually ceased in recent years because of the state  of public finances. But let it be said that in the Eastern Health Board area the majority of private nursing homes do not come under the heading to being approved. That does not mean that they have not been inspected; it does not mean anything about their level of standards. But a large number of them are not even subject to the level of inspection to meet approval. In my own area, in the Southern Health Board, there are only four approved private nursing homes for incapacitated people and there are 16 which are not approved.
It seems that apart from the regulations introduced in 1966 the most important obligation imposed on persons opening private nursing homes for private profit must be that they must notify the relevant health board. Conditions in these homes have been a matter of concern for a long time. The level of concern was indicated and came to a climax in the sixties and resulted in the passing of the 1964 Act, the Health (Homes for Incapacitated Persons) Act, 1964. This Act contained a number of provisions but, I want to quote from one because it describes the official philosophy for dealing with and regulating such homes. I am quoting from section 2 (1) of the Act of 1964, which says:
The Minister may, for the purpose of ensuring adequate and suitable accommodation, food and care for incapacitated persons while being maintained in homes and the proper conduct of homes, make such regulations as he thinks appropriate in relation to homes.
Without prejudice to the generality of subsection (1) of this section regulations under this section may —
There is a long list, not all of which I want to quote in detail but it states that the regulations may prescribe requirements as to the care of incapacitated persons, prescribe requirements as to the qualifications of the staff of homes, prescribe requirements as to the design, maintenance, etc. of homes, prescribe requirements as to accommodation,  food, cleanliness, the description of the homes, and indeed there is a particular provision that people can be interviewed in private if complaints are being investigated.
The detail of the standards in those areas were to be prescribed by regulation. These regulations were finally published in 1966. If it was not such a serious matter the regulations would be almost laughable because they simply insert words such as “adequate” and “sufficient” and say no more than that. For instance in terms of the prescribed requirements as to the number and qualifications of the staff of the homes the regulations themselves simply say:
Sufficient and competent staff at all times having regard to the number of incapacitated persons.
“Sufficient and competent” being the detail that was elaborated on in the order. This arises in a number of cases. For instance, the prescribed requirements as to accommodation detailed in 4 (d) of the regulations is as vague as one could ask it to be. It says:
Sufficient supply of piped hot and cold water and suitable and sufficient sanitary and toilet facilities.
These words “sufficient” and “sufficient and adequate” surface again and again in the 1966 regulations. Consequently, what we were dealing with until recently were, by and large, words like “suitable” and “sufficient” and “adequate and sufficient”, which were undefinable, and because they were undefinable they were, effectively, unenforceable except in conditions of extreme squalor. There were no real written down minimum standards.
In recent times it appears public controversy has been fuelled again. There have been a number of comments in the media. In 1983 the Bray and District Council of Trade Unions produced a report on conditions in their own area. The general concern was quite global. It had to do with suitability of buildings, the adequacy of nursing staff, in particular  the number of nursing staff, the qualifications of nursing staff and the training given to nursing staff, the need for special equipment and facilities in such nursing homes and, by and large, the widespread allegations that such special equipment and facilities were usually lacking. We are talking about sanitary facilities, toilet facilities, washing facilities and such things. Many people alleged that these were singularly lacking in many of these private nursing homes. The absence of any programme of activity for people resident in these homes was widely adverted to, in other words, anything that would enable people to maintain their normal level of function, separate entirely from any programme of rehabilitation. There was almost a complete absence of such facilities.
The Eastern Health Board, in a report produced in July 1982 said the following:
Complaints which were made concerning unsatisfactory conditions in private nursing homes generally, generally refer to understaffing, overcrowding, inadequate heating, insufficient or poor food and unhygienic conditions or practices.
Consequently there was an increasing, widely recognised need for an improvement in the regulations of those private nursing homes which do not meet the proper standards. Nobody is suggesting that all private nursing homes for elderly incapacitated persons are inadequate but there seems to be a widely perceived view that there are some which do not meet the proper standards. There may be a considerable number which do not meet these standards but the powers which currently exist for regulation of such nursing homes are inadequate.
I welcome the Minister's indication that he proposes to introduce a scheme of licensing but that will require amending legislation. In his speech to the annual meeting of the Irish Private Hospitals and Nursing Homes Association on Friday, 9 March 1984 the Minister said:
I do not believe that the standards  for accommodation and facilities for nursing homes, as set out in the 1966 Homes for Incapacitated Persons Regulations, are strong or detailed enough to ensure that the needs of people in the homes are properly catered for. I do not think that the monitoring arrangements which apply are adequate.
That would represent a fairly strongly worded statement from the Minister of what many people feel about such homes, that the powers are insufficient and the regulations are insufficiently detailed. The Minister produced regulations which were widely looked forward to. I believe there was a considerable level of consultation before they were produced although I would be interested to know if the National Council for the Aged, who have been given a commitment that they will always be consulted on matters of this nature, were, in fact, consulted before these regulations were promulgated.
There are many good things in the new regulations. There is a quite detailed provision for the keeping of proper and adequate records. There is an obligation on health boards to inspect all such nursing homes every six months, which is more than welcome. There is provision that facilities must be made for occupation and recreation. There is specific provision, for the first time, for lighting, that there must be overbed lamps and there must be provision for night lighting. These are simple things but very important if proper standards are to be maintained. There are specific minimum temperatures specified, 65 degrees fahrenheit in bedroom areas, 70 degrees fahrenheit in day areas, and that is also very welcome.
It is because in many other areas similar detail has not been listed that we find these regulations inadequate but where they are specified they are very welcome. A simple provision, for instance, that there must be a washhand basin in each room, which seems like minimal standards for people who are in institutional care, is also very welcome. Unfortunately, and in the light of the inadequate  enforcement and the widely reported inability of health board officials to enforce the previous regulations, words like “suitable and sufficient” are still widely used in the new regulations. This is a matter of great regret.
Article 9 of the new regulations says:
In every home there shall be provided for patients maintained in the home suitable and sufficient care, suitable and sufficient accommodation, suitable, sufficient and nutritious food, properly prepared, cooked and served.
We have again these undefinable, unquantifiable and therefore immeasurable terms, “suitable and sufficient”. Under Article 10 (1) (a) we have a provision that says:
suitable and sufficient equipment and facilities, having regard to the nature and extent of the incapacity.
Under subsection (b) we have the requirement that the home should be provided with suitable and sufficient lighting, heating and ventilation, with bed and bedding appropriate to the incapacity of each patient, with a separate kitchen, which is a useful provision. Article 10 (2) (a) specifies:
In every house there shall be provided adequate accommodation and space.
Here is the word “adequate” again. Words such as “adequate”, “sufficient”, “suitable” are undefinable, immeasurable, unquantifiable and therefore, unenforceable. Article (10) (4) states:
The responsibilities on a person carrying on a home shall be to provide a sufficient supply of piped hot and cold water. A sufficient number of toilets must be provided which are designed to provide access to wheelchairs. There should be a sufficient number of commodes, baths and showers.
Nobody is telling anybody what is a sufficient number or how you decide whether there is or is not a sufficient number. Words like “sufficient” and “adequate” and so on are all very well to use. They  represent pious aspirations but they are not enforceable. It is by way of regrettable contrast I have to quote from proposals for draft regulations produced by the Eastern Health Board in 1982 where they suggested on accommodation standards as follows:
A single room should have a minimum area of 9.3 sq. metres and a shared room should have a minimum area of 7.4 sq. metres per bed.
They are the sort of minimum standards that are measurable and are, therefore, clearly enforceable and because of this they can be insisted upon. They specify that there should be one toilet per eight patients and not less than one bath for every 15 patients.
I am not in a position to judge whether one bath for 15 patients is adequate. I am in a position to state that, if you do not specify standards that are measurable, if standards are not specified that are quantifiable, there are no standards. As a result you have only opinions and the matter will end up in detailed controversy in courts. How can a health board official or an officer of the Minister's Department insist that standards are inadequate if there are not specified, quantifiable and measurable standards to be met? That, in my view, is the nub of the disappointment and dissatisfaction that many people have expressed to me about these regulations: that where they should be specific they are sadly, regrettably and painfully inadequate.
I find it ironic that where we are talking about facilities for elderly people, who are paying quite dearly for services, we use words like “adequate” and “sufficient” in terms of regulating the standards of their comfort, whereas the courts in a big city — New York — in a country that is not known for its commitment to the welfare state when they were defining what shelter should be provided for homeless people, basic minimum shelter, they insisted that the shelter should have at least the following: a minimum bed size — unspecified in our regulations —  a minimum number of toilets — unspecified in our regulations — and a minimum area per person sleeping in a night shelter in New York. There is no such specific minimum for people in a nursing home being run for profit in this country.
I do not understand why it is necessary to leave words like “adequate” and “sufficient” in when competent authorities like the Eastern Health Board are able to work out precise minimum standards that they would regard as enforceable. It is not unusual or strange to specify quantifiable standards. We do it in respect of industrial safety, building regulations and planning permission. Members of the House have personal experience of the planning authorities setting regulations in great detail which people must observe. Why therefore do we have to leave these very vague and consequently unenforceable standards? It is a pity that what is obviously a well-intentioned improvement in standards — and quite dramatic in some areas in the levels of standards of care — will be spoiled by an apparent unwillingness to be specific in areas of basic care. It is because, having read the regulations and having listened to what people have said to me, that I believe the inadequacies of the regulations are so considerable that I therefore have to move that the regulations be annulled.
Mrs. McGuinness Mrs. McGuinness
Mrs. McGuinness: In seconding this motion, I wish to say that a great deal of the area has been covered in some detail by the proposer of the motion, Senator Brendan Ryan. However, to add to what he has said, I agree with him that it is somewhat difficult in this House to try to deal with a matter where one appreciates that efforts are being made by the Minister to bring about improvement and yet we feel they have not gone far enough. The only motion open to us to put down was one annulling the regulations, and it is certainly quite clear that neither Senator Ryan nor myself wish to go back to the 1966 regulations. We feel that the regulations as proposed by the Minister do not go far enough.
 I would like to compliment the Minister on his activity in pressing ahead with putting in amending regulations. It is a very good sign of the Minister's goodwill in the situation that he is trying to improve the situation, so we just ask him to improve it rather more. As far as the Minister is concerned, it may seem to him that we are criticising the various things he has done; but perhaps he can comfort himself that the reason this is happening is because he is someone who is actually doing things. In a sense when you start trying to improve things you will always get people who will say “you are doing this but you should go further.” We are taking the trouble to recognise that he is trying to do something about the situation and we are just asking him to do something a little more effective.
Of course, it is true that the new regulations which the Minister has put forward are very much an improvement on the regulations of 1966. They have introduced matters like the heating of homes, providing of an activity programme, the lighting of the homes and so on which were quite unspecified in the old regulations and which make for a very much improved situation. The 1966 regulations could briefly be described as short, vague and unenforced. Certainly the present regulations are an improvement.
I have taken a particular interest in this area over many years and I am sure the Minister will remember that in the early sixties Senator Mary Davidson conducted a one woman campaign about the necessity to register nursing homes and improve standards in nursing homes. Certainly events which have transpired since that date can have done nothing but prove how right that Senator was in her day in putting this forward. In fact, the 1964 Act was the culmination of her efforts and the fact that she simply refused to sit down and shut up on the subject of nursing homes. She kept bringing in Private Members Bills to the Seanad and so on. It does, therefore, seem to me that it is the tradition of this House that we should be trying to improve and make sure that regulations  covering nursing homes are efficient, effective and enforced.
As chairman of the National Social Service Council — later the National Social Service Board, I was very conscious of the level of complaint and the level of difficulty that was being encountered by all workers in voluntary bodies about the standard of accommodation in nursing homes. In fact when one set up a seminar, a meeting or anything to do with the needs of the elderly, at which one had voluntary bodies, representative volunteer workers, every single time the biggest and most frequent complaint and the most frequent question was, “what about the standards of these nursing homes and is there anything that can be done about it? This is the thing we really want done.”
Obviously, neither I nor any of the voluntary workers were criticising all nursing homes. There are excellent nursing homes for the elderly and for incapacitated persons and we have personal experience of them. The difficulty is to try to ensure that all homes come up to the standards that are set by the better ones. It was extremely noticeable that among all the social workers, both statutory social workers and social workers employed by voluntary organisations, worries about nursing homes were extremely widespread.
This matter, as Senator Ryan said, has been raised in the media from time to time. There was a particular programme on RTE television about the standards of nursing homes and more recently on radio programmes letters have been read out from people and complaints made about the difficulties that individuals have had with nursing homes, elderly people left without heat, without adequate feeding and, in particular, the system of giving someone a fairly inadequate meal at about 5 p.m. and then nothing until the next morning. That seems to be one of the complaints that is fairly widespread.
I understand the National Council for the Aged have been studying this. While their report on it has not yet been published I hope the Minister will go back to them and perhaps consider improving the  regulations in view of the kind of things they have said. It is also the personal experience of so many people, who may have elderly relatives, that it is extremely difficult to find a nursing home of a reasonably high standard and those that have a high standard have long waiting lists. Many of us have had personal experience of elderly relatives who have gone into a nursing home expecting it to provide reasonable standards and then find on visiting the elderly relative that perhaps the relative has not had a bath for the last month, that clothes are not sufficiently often changed and so on.
It cannot be that this need does not exist when one hears on so many fronts the kind of complaints that I have been talking about. They have been dealt with also by the Bray Trades Council and by other bodies. In particular a difficulty arises because a lot of the buildings which are nursing homes are old three or four storey buildings some of which were used as boarding houses or guest houses for a type of tourist demand that no longer exists. This would perhaps have been particularly so in the Bray area which was referred to by the Bray Trades Council. Therefore, these particular buildings may create difficulties for elderly or incapacitated persons.
With regard to the number of nursing staff the Eastern Health Board in the document referred to by Senator Ryan sought a power that the health board should be allowed to nominate the numbers of nursing staff that should be available in each home whether in the day time or at night. One of the difficulties is that there tends to be a very low level of qualified nursing staff at night in these homes and yet it is a fairly well known medical fact that very often the metabolism of elderly people is at its lowest ebb in the early hours of the morning between 2 a.m. and 6 a.m. and it is very often then that they are taken severely ill and that they suffer strokes and other kinds of disabilities. In a sense it is at night that a qualified nurse may be needed there. The health board were not asking for something foolish when they asked for the power to be able to state the number of  nursing staff they felt were needed in each nursing home.
In general the complaints have referred, as Senator Ryan said, to understaffing, overcrowding, inadequate heating, insufficient food and unhygienic conditions. While I accept that the Minister's present regulations go some way towards solving this problem the difficulty is that we are left in so many areas with these words like “sufficient space” and “suitable accommodation” where we should have nominated a particular area of space to be available to each patient, a particular number of toilets to be available per patient, a particular standard. Even say we provide for an over bed light it should not be so difficult to provide that lighting should be at a certain level, that there should be a certain wattage of bulbs and so on because one can get very dim lights being put on which make reading very difficult for elderly people whose eyesight may not be very good, whose sole amusement is reading and who would like to be able to read at least a daily newspaper and in winter darkness in the daytime need not just a light but a light of sufficient strength to allow them to read.
I join with Senator Ryan in saying that what we would look for is in the areas of the Minister's regulations, where he is using these words like “sufficient” and “suitable”, that we should have specific provisions as to how much, how many, what level and so on and also, of course, I feel that the essence of these regulations is the ability to enforce them properly. This was largely where the 1966 regulations fell down, even in so far as they did provide standards they were not really enforced. I would very much welcome the provision that the homes were to be inspected every six months. I hope that sufficient resources will be made available in the health boards and through the Department to enable this inspection to be carried out properly. This is an area in which we are protecting the most vulnerable in our population. No matter how  good our regulations are unless we provide the resources to enforce them properly the regulations will not be of any great use.
Mr. Ferris Mr. Ferris
Mr. Ferris: I want to say a few words on this motion which actually calls on the House to ask the Minister to annul the order he has made. I share the concern of Senators on the other side of the House. The vehicle available to them is a blunt one. We all admit that the regulations are a step in the right direction. The Senators are suggesting that they have not gone far enough. I have the greatest reservations whether asking the Minister to annul the regulations will serve the purpose and I would have to ask the House to reject this motion as it is worded.
It gives us an opportunity to discuss this whole area of private nursing homes for incapacitated persons in the presence of the Minister who has made these regulations and after 21 sitting days they will come into operation. If, after listening to our debate, the Minister will be in a position further down the road to bring in some of the other requirements that have been suggested that will have been a very useful exercise. As a previous member of a health board and a member of The Care of the Elderly Committee I have some reservations in this area. If the Minister were to go as far as all of us would like it is inevitable that some nursing homes would close. That would not concern me unduly if the State were in a position to accommodate the people who would then be without a home.
That is an extraordinary thing to have to say but that is the reality of the situation as I have experienced it and as I know about it to this day. There are some nursing homes, and many of them are in my constituency in south Tipperary, which have achieved a very high standard of nursing care of old and incapacitated people. They have done so with very little assistance from the State. I am suggesting that if we use a very big stick now without some assistance towards them to implement the regulations that we set down we will be doing a disservice to the  old people who are in these homes by choice.
We have the situation where some nursing home beds are subvented by health boards and some are not. Some of the homes that are subvented are of a lower standard than those that are not subvented. In the process of registration of nursing homes in the past, the board, once they had approved of the nursing home and registered it, had no further recourse to the nursing home except when there was a complaint lodged by some medical person or other indicating that the level of care given in the home was not sufficient. What I have advocated as a member of the community care team in charge of the elderly is that where health boards subvent beds those boards should have the right to insist on having a say, through the process of assessment, about the type of people who would occupy the beds which are State subvented. They should certainly have the right, by the process of assessment, to decide if and when a person could be discharged back into the community or out of that particular subvented bed, on the basis that if you subvent beds and do not follow up with control on them, those subvented beds will remain filled by people who might not even need beds but who, because of family situations and social reasons, still occupy such beds in a nursing home when, in fact, they could possibly afford to be in a hotel. That is the stark reality of the situation, as I have come across it. Health boards, this Minister and his predecessor have made major contributions in the whole area of the care of the elderly. In south Tipperary they have set up, as a first pilot scheme, the whole process of assessment of people going into geriatric institutions and/or into psychiatric institutions. In the past people were just committed to these homes, whether geriatric or otherwise, by their relatives, without a proper assessment of whether they should be in a home or not. Today we find that almost 50 per cent of patients in psychiatric hospitals should not be there at all. They are  there for social reasons. They are not psychiatric patients.
Before we set up the assessment unit at St. Patrick's in Cashel many people were committed to the geriatric home there and never saw the light of day again simply because they had not been assessed properly. Now, thankfully, we have made some effort in this area to ensure that patients who are submitted have to go through this process of assessment. The assessment team decide whether the person should be at home, preferably in the community, or whether he would benefit from day-care centre treatment and all the facilities that go with that, or whether he should be admitted as a person suitable to live in a welfare home. I object to the name “welfare home” because it has a whole lot of connotations that I do not agree with, but the whole concept of welfare homes is a tremendous breakthrough. People are allowed a lot of freedom to come and go as they please and to participate in the full life of the community and still have shelter to come back to. The health boards have taken a major step forward in this whole area of the care of the elderly.
The Minister's regulations are a major step forward. Public opinion has demanded that there would be a step forward in this area. It is appropriate that if homes do not come up to the minimum standards required then they should fail in their registration. Certainly, homes that do not come up to the standard of nursing care should not be subvented by the State. There are minimum requirements that we would expect of this particular type of nursing home. They give a tremendous service in the community. It is one that cannot be replaced by the State. That is an unfortunate thing but it is a reality.
I am not sure of the total population of private nursing homes but if, tomorrow morning, the Minister brought in regulations which could not be complied with, then certainly the State would have to satisfy me that they could take up the slack that would be created if all these people were suddenly discharged from  homes that were closed down. That is not to say that there should not be acceptable standards and that the Minister and health boards should have a say in what those standards should be. I welcome the fact that these regulations confer certain rights on health boards that, apparently under the previous regulations they did not have. For that reason I welcome them. If the resolution was carried it would be a backward step.
I am looking forward to the Minister's reply in this area to see what other action he intends to take. I would ask him and the health boards throughout the country to decide that where people are giving a very high standard, comparable and sometimes better than that of the State they should be given assistance. They should serve particularly people who are in possession of medical cards because there are times when people like that cannot get into our institutions because of the long waiting lists. The population of elderly people is increasing with the advances made in medicine. With the care to the elderly given by health boards the numbers of older people dependent on a proper and adequate service is increasing. It is a problem that we will have to address at national level, as well as through health boards, through capital programmes and also through regulations in nursing homes. We have a responsibility for such homes through the registration process. The regulations are a step forward. I welcome them. I certainly would not like to have them annulled. I would be surprised if the Minister did not have the fullest consultation with the people involved in this area.
Mr. Fallon Mr. Fallon
Mr. Fallon: I wish to make a brief observation on these regulations. Like the previous speakers, I welcome any regulations that will provide a high standard of care for the various nursing homes we have throughout the country. Senators B. Ryan and McGuinness were suggesting that these regulations do not go far enough. My view is that we have many nursing homes which are giving a fantastic service now and have done so in  the past. They have a very high standard of nursing care, of hygiene and of food; but I believe that if every regulation in this book were to be implemented some of them would close. Many of them are just one-nurse homes and maybe in some cases a family, a nurse and a husband, running it or maybe a nurse with casual staff doing first-class work for the old people and people who are infirm. I repeat again that if all these regulations were to be fully implemented such homes would have to close. For example, many of the homes that I know could not afford to provide a visitors' reception area and adequate facilities for patients to receive visitors in private. That would be the case in many of the homes. Neither would it be possible to provide an office for staff and for general use. All of this would involve very high expenditure. This kind of expenditure might not be possible in the homes I am thinking of. I stress that they are doing a fantastic job of work without the kind of things that are referred to in the regulations.
There are many regulations that are important in regard to fire precautions and hygiene. Some of the regulations could provide problems for some of the nursing homes that I am aware of in my area. The question also of the health board and of many of the geriatric homes under their control makes us realise that to bring them to the standard required in these regulations would cost quite a considerable amount of money. With the restrictions we have on finances I am not sure that the health boards can afford such expense. If they had to effect such improvements the money should come from central funds.
I accept that these regulations represent a huge improvement on the regulations of the past. I would not like to go much further at this point in time. If many of those regulations were to be fully implemented then many nursing homes would close for the reasons I have given. Nevertheless, it is important and right that the Minister and the Department of Health should from time to time examine these homes and that the health board as the agent for the area concerned should  examine them periodically. The regulations recommend that they should do so every six months.
By seeking very high standards generally we cannot ignore what is already there. We cannot ignore that to improve further the actual fabric of the building would cost many thousands of pounds. Such funds might not be available. At the same time, people are happy in the nursing homes with the kind of care they receive. Overall, I would not like to annul the regulations, as the previous speaker has said. We should aim for a high standard, which is what the Minister has done. A higher standard might create serious difficulties for many of the nursing homes.
Mr. Cregan Mr. Cregan
Mr. Cregan: I welcome the report. While I acknowledge Senator B. Ryan's deep dedication to the interests of the less-well off in society, I would be annoyed that he should ask the Minister to eliminate this instrument and to say that we should be considering something new. There is always a need to consider something new.
When one looks at this report and the updating of it, and looks at the regulations, if they are all right naturally one would welcome them. At the same time there are many questions that have to be asked. In my area the question of the private nursing home is always under consideration. This relates to the private nursing homes which are minding the less well-off and the people who cannot care for themselves.
In the Southern Health Board area there are certain problems which are beyond the scope of the private nursing home. In the eastern side of the Southern Health Board, which is the Youghal area, we have homes for the elderly. They are not really like a big old hospital or an area where one would see a lot of elderly people together. They are community homes where there might be ten or 15 people staying together. They consist of a communal area and their own rooms for the residents. All this costs very little. In comparison with the cost of subsidising the private homes and even with the costs  of our old hospitals where we have a lot of elderly people staying, these places must be better. I have some information to the effect that they cost much less. I do not understand why we are not broadening our minds and creating in all community areas a facility where our elders can be seen to be staying in one place.
I readily admit that, unfortunately, in modern day living we have a situation, unlike our forefathers before us, where we are not prepared to look after our elderly even though very little may be wrong with them. They might only be old. We have a situation where people are prepared to put their elders away. That is a fact of life. We must accept it. We must consider that because a person is old and maybe a little bit feeble does not necessarily mean that he is sick. One cannot say that a person should be in a nursing home when in fact he is only very old or perhaps not able to get around easily. A perfect example is the welfare home I have already referred to. The word “welfare” is one I do not like and it should be abolished. We have a home down there in Youghal which is like a home from home. There is a situation where people can ring a bell if they should need somebody, can go out or be brought out and can have visitors at any time. It does not look like a nursing home, a hospital or a sick area. We should not call these places sick areas when only elderly people are in them.
In each parish, or perhaps in every second parish, within our society we should have community homes. There is no reason to give an impression that because a person reaches the age of 66 or 74 and loses his memory he should be put away into a place which is unsuitable for him and which he does not like.
The realistic factor is the cost. The cost of doing this must be thought out properly by the people involved. A situation could evolve where better facilities could be obtained for less money. One Senator mentioned day centres. These community homes can become a day centre for people from 9 a.m. until 6 p.m. and then such people can be brought home at night. These people can enjoy  themselves in the day in these homes while other people can live in them. There are four of these centres on the south side of Cork city. They are catering for a total of 80 elderly people — not sick people.
There is a need for constant updating of facilities. As Senator Ferris said, people are put away who are not sick at all. There are such people in Our Lady's Hospital in Cork. They should not be there. We must face up to this fact. We have a moral responsibility to rectify this and to bring the problem back to the local parish area and let them take responsibility. The person can say that his or her grandmother is only 200 yards away but is well catered for within the community home. It must be less expensive in comparison with a bed in any hospital, whether it be voluntary, private or a semi-private nursing home or health board hospital. The cost of a bed in a health board hospital is enormous, irrespective of who the patient is. It is obvious that if this were done in a community area it would cost less. Is the Minister aware of this when he is putting emphasis on the updating of the regulations? For example, in regard to heating, the Minister says that the bed area at night should be at least 65 degrees and the living area by day should be 70 degrees. I know of areas in my own home town where there is no way that facility can be obtained in nursing homes. I know such facilities are not going to be provided, even though the Minister will emphasise the point. They are lucky to have a bed. Is there any direction in regard to how many patients should be in the home, what distance should be between each bed? How many windows should there be in a room with so many patients? How is that defined? It is admitted that if a patient is in bed the room should have a natural lighted window. I appreciate that, but that means there can be four patients in the same lighted area. That is unfair. We should be considering what is best for our elderly. It is our responsibility to do that, so let us do it right.
Let us readily admit that there are  massive areas in our society throughout the country that are not good enough for our elderly people. I do not like the emphasis on constant nursing. It is a fact of life that many of these patients are in these nursing homes because they are not wanted elsewhere. The fact that they are old, does not necessarily mean they are sick. To give the impression otherwise and say we are going to stash them away — and that is exactly what we are doing and I have seen such people put away — is a total disgrace. Senator Brendan Ryan has seen it in the Cork area. We are readily admitting that people are being put where they should not be. That is our responsibility. It is the taxpayers' money which is paying for that.
I admit that I have a responsibility as a member of a voluntary hospitals board and as an ex-member of the Southern Health Board. If we give proper priority to considering the amount of money that we spend in the health boards and what it is worth per head for geriatrics, I would gamble on it that we could create a better and happier society for these people in their own local communities by the provision of local people minding them by day and night. The staff should be nurses, and probably semi-retired nurses. I see no reason why that cannot be done. This is not my idea because I have seen it in other cities. This has been done in east Cork. Youghal can be proud of what they do for their elderly but unfortunately, it is only for a certain few. One does not see the community care house. It is only one-storey and there is a garden in the middle. There are one or two such homes in north Cork.
I have seen this situation in north England, in Bradford. They build community homes where the elderly have their own bedrooms and their own television room. There is a person in constant charge but they do not see that person from one end of the week to the other. They have their own washing machine area, their own bingo and television area and they can use the facilities as they want. They keep their own rooms at little cost. At first they cost money, but at the end of the day one is not paying out hundreds of  pounds per week per bed. Maybe we should broaden our minds. I know the Minister has the interest and the dedication. It would be wrong of me to say otherwise, I have heard him speak about it often. Is there a possibility of the Minister setting up a body of people who would be totally dedicated and would look at this in a sincere way and say, “yes, this is the thing to do for our elderly within their own community”.
Mr. Lanigan Mr. Lanigan
Mr. Lanigan: I, like other speakers on this matter, would suggest that it is not the regulations that should be annulled at this stage. I have a feeling that even the movers of the motion do not feel that the regulations should be annulled. Basically, what they want to do is to see a strengthening of the regulations to make certain aspects more specific. Whether that is what is in their minds or not I feel that it is good that we were allowed to go through these regulations because they are extremely important for a number of reasons.
There have been homes which in the past have not been up to the standards which were necessary for the proper care of our elderly and incapacitated people. The standards in certain homes were atrocious. It has been noticeable that in the registered homes over the past years standards have improved immensely. Many of the sections that have been added to the regulations of '64 have already been implemented in the better regulated homes. There are homes which are not well regulated. I suggest that in a lot of cases the blame could be put on the health boards or on the people from the Department of Social Welfare who are supposed to inspect places where food is kept and where hygiene standards are supposed to be upheld. If these people had been doing their job over a number of years, standards would have improved faster than they have.
My main reason for speaking is to express the hope that these regulations would not alone apply to homes which are open for profit. I suggest that these regulations be equally enforced on public homes and on homes which are being run by health boards in particular. I am sure  there is not one Senator here who does not know in his own area of a home for elderly people for which money is being sought from the Department of Health and Social Welfare. Such money cannot be got and these homes are in an atrocious condition at present.
There are elderly people living on second floors of hospitals around the country, in conditions which are not suitable for ambulant patients not alone non-ambulant patients. It would frighten people here if I passed on the comment that was made to me by a person when asked: “What would you do in case of a fire? ” Even though it was a frightening answer I think that it should be given. He said: “You would have a choice, you could fry them or you could drown them”. That is not the kind of home I would like to see continuing throughout the country. The health boards are doing their best, but because of financial constraints they are not getting the amount of money they need in order to change these homes into homes which are modern, clean and up to the standards which are laid down for private nursing homes.
There are homes around the country in which patients are being kept in upstairs rooms from which there is no adequate egress. There are not adequate safety precautions. There are not adequate fire attendants who work in these homes cannot do their job properly even though they are working to their maximum capacity. They are working in homes which are in some cases up to 300 years old. The homes have very steep stairways with no adequate fire escapes even though there are notices which state that there are fire escapes. It would take a very fit, healthy man to get out of some of these homes. In bringing in these regulations and enforcing them, I hope the Minister will ensure that every home which is under the care of the Department of Health and Social Welfare will be brought up to at least the standards that are laid down in these regulations. There are a number of homes which are at this stage coming up to the standards  required and I have no doubt that the Minister got in touch with the people who run these homes when he was making up the regulations. Mention was made of the part that community homes can play in the care of the aged and incapacitated. Senator Cregan mentioned that an extension of these homes would be very advantageous and that because the people would be living in their own areas they would feel more at home and they would get a better local visitation scheme. They could keep in touch with the people they went to school with and grew up with — keep in touch with the social scene — and in that way they would have a better life even though an incapacitated one.
There should be more concern given to the co-ordination of the means of assessment for entry into these community homes and the homes for the aged which are run by the health boards because in certain cases elderly people are admitted to them and once they get in they are there for the rest of their lives. They are not properly assessed before they get in. The assessment that takes place is probably not the same type of assessment that would take place in the case of an elderly person going into a long-stay hospital for elderly people under the health board. Most community homes are run by community voluntary social service groups perhaps aided by the health board.
Once a person is comfortable in a community home it is very very hard to take him out again. It is very very hard to get him back into his home. It is equally very hard sometimes to persuade the sons or daughters or their relatives that these people are fit to go back into their own homes. Too often people are kept in homes even though they are quite fit to go back to their own community. Again, in a lot of cases where people are in homes for the incapacitated and aged under the health boards there is no adequate means of rehabilitation. In some of these homes which are sponsored by the Government the rehabilitation system, because of constraints of finance  and space consists merely of patients supporting themselves on a pair of bars. In most homes there is not even an infrared lamp to give heat treatment. This is not the fault of the very excellent people who spend so much of their time caring for elderly people, but in their caring they get more and more frustrated because it appears that people are being dumped into these establishments and are not getting adequate care in terms of the ambience of the home or the treatment necessary to rehabilitate them or to reconcile their sons and daughters into accepting them back into their homes when they are well able to do so.
Finally, a lot of these regulations are overdue. They are necessary and I sincerely hope that the Minister will ensure that there is not a home in the public sector which will not be brought up to these standards. If that does not happen there is no point in having regulations for private nursing homes.
Mr. Robb Mr. Robb
Mr. Robb: It was very interesting to hear the contributions of the Senators regarding this problem. As a consultant surgeon in a small rural hospital it is inevitable that one is faced with the difficulty of coping with psycho-geriatrics with no home to go to. Physically they are no longer sufficiently strong to forage for themselves. One also comes across the difficulty of placing such people.
Some years ago — this is a story which will highlight one aspect of the problem — I was confronted by an irate Methodist minister who told me that the hut in one of the hospitals to which I was attached was not fit for animals, let alone human beings. It was not the hospital where I mainly work, and I hasten to add that I had only recently arrived in the locality concerned. I went to inspect the hospital to find that at night there was one nurse to attend some 17 to 20 very old people and certainly very grossly incapacitated people, many of them with catheters and some of them semi-comatose. She could get another nurse from the main hospital by pushing a bell. What was needed was a much greater human commitment, but then we come up against the cutbacks,  and the Minister knows all about the cutbacks. So what do we do?
I suggested to the Minister that he might go back to all the Churches — as you know in Northern Ireland there are many of them — and ask for one volunteer for every night, and then go to the relatives of the people concerned and ask for one volunteer from all of the relatives for every night and then say to the tenants' associations and community groups that there is a big problem and seek one volunteer from them. So it would be a rota of one night in 50 or 60 nights. But the problem only starts there because when those well-intentioned people arrive at the gates of the hospital there will be members of my profession and the nursing profession standing across the gate saying: “No, you have not the right certificate and we are not insured for you. You cannot come in here.”
This brings us back to the problem that Senator Cregan identified so well, and that is how do we involve the local community and how do we break down the resistance of institutional imperialism and institutional barricades? How do we jump over them or mow them down so that we can get at the problem and do something about it?
The question of awareness arises. National social service is, for very good reasons, anathema to the trade union movement; but national social service properly thought through, with all properly built-in protections, could be a very good way of educating the young emerging citizen, particularly at this time of terrible unemployment, about what actually goes on in our country. One of the things he might be engaged in is attendance in such institutions, helping out in psycho-geriatric or long-stay institutions or even in hospitals where such patients are, to use the in-term of today, “stashed away”.
Another factor one has to consider is the goodwill that is available in every community throughout Ireland if it could only be tapped. At present there is very little access, except in situations such as the one described in Cork, to a network  of all the agencies that can provide support. Here again it needs to have a focus. I have heard a day centre mentioned. In Northern Ireland the day centres are associated with the social workers. Some very excellent day centres have been built in the last 15 years. A day centre could become the focus where representatives of the medical profession, social workers, schoolchildren, the unemployed, the clergy, relatives, the occupation therapists, if there are any, physiotherapists and so on could meet. Even if they met once a year in a local community health guild and that the topic of discussion was: “What are we doing in this community for our phychogeriatric, geriatric and long stay patients”, the aim would be to raise the level of awareness so that they would become interested in the problem. At the moment far too few people know anything about it except that old Aunt Lizzie is on the top floor of one of the various hospitals that have been mentioned here and they cannot take her home because there is fear. One of the ways we cope with it in our neck of the woods is that we tell the relatives the position. We bring them together and say: “You are not going to be left with this problem. Take Aunt Lizzie home for 48 hours and see how you get on. We promise we will take her back. Or take her home for the weekend and we will take her back”. Once the threat has been removed of the total responsibility for an almost impossible problem which cannot be coped with adequately by a hospital institution on the one hand, by social workers on the other, by GP's, by nurses or by family — once you begin to get involved in the lot and there is trust you begin to build up a feeling of community. Then an awful lot can begin to happen.
That comes back to community. We can talk until the cows come home about what we should be doing — and it is easy to talk about it here as most people are well-intentioned towards a renaissance of community spirit — but we cannot achieve that as long as the community that we talk about is too big and the power held in that community too little. We must start to decentralise really one  of the most over-centralised countries in western Europe. We must give back to the people power to do what they feel is right in the community where they exist and the opportunity to become more aware about the problems. So, if we are talking about these institutions, I would make one practical suggestion: that they do not need an inspectorate of experts from Dublin with a set of regulations in their hands the length of your arm. What they do need is concerned people locally who are articulate and the balance of one or two from outside of the community so that it does not become an exercise in self-protection for the person who has the most clout to run the worst home. We then begin to try to answer that what is happening in these homes becomes known to the community which they are serving and we do everything we can to raise levels of awareness about the problem among the people who are affected and allow them to have the power — it is a long-term thing but we must move in this direction — to take the decisions.
We shall effect the changes which Senator Brendan Ryan and Senator McGuinness would like. But at the bottom of it all, until we move in that direction we must have regulations which ensure a basic standard. That is why it is important to take cognizance of what the proposer and seconder of this motion have said. But there are many imaginative things that could take place. We recently tried a dog-handling service — you may laugh — in an old people's setup in Ballymoney, where youngsters go down with their dogs once a week and the old people love it. They have actually something to touch, to communicate with. Perhaps young children have the same effect, but as long as we keep classifying society into strata and sects, we will continue to fragment our communities and we will lose what Senator Cregan has been trying to tell us about, and which it is possible to recapture.
Before I resume my seat I would suggest that it is very well worth exploring the day centre and how you can develop the day centre concept. It is certainly  worth exploring the need for networks for particular problems and how to bring them together in a focus in the community. It is necessary to get back to the concept of smaller communities and to give them the power to be effective in community and, above all else, we do need an exercise in the raising of awareness about all that happens inside our communities and in this particular instance it is about what is happening with regard to the treatment, care and reintegration of old people where they live.
Mr. Fitzsimons Mr. Fitzsimons
Mr. Fitzsimons: My contribution will be very brief. I realise that this motion was motivated by people who have a great concern for human beings who have to be taken into care in this way. I am sure there are many places throughout the country where standards are not high enough. I believe that in many instances a little love, a little concern, and a little attention will make up for many defects. I think we need that at all times.
I agree that standards must be very high, but rather than annul the regulations we should have them removed to incorporate the immeasurable standards that the Senators who proposed and seconded this motion spoke about. I agree that too many of our old people are committed to homes, institutionalised, put into a virtual prison for a great part of their lives. In general the State does encourage society to keep its elderly people. I do not think it is realised generally that people who build new houses can also get a grant for a granny flat under the same roof of the house. The maximum limit for a new house for grant purposes is 1,346 square feet for which there is a grant of £2,000 and a mortgage subsidy of £3,000. For those who build a granny flat for their in-laws or relatives there is a further grant of £2,000 if those people have not claimed a grant before in their lifetime. But the regulations empower people to build a granny flat as well as build the house. This is an encouragement. Too few people know about this and for that reason too few people avail of this.
 I also feel that the essential repairs grant is very important and helps to keep elderly people in society. By and large it is intended for a house that has passed its useful span but on which a moderate outlay will keep the house fit for the time of the people who live in it, the elderly people. I welcome the increase in that grant.
The disabled person's grant of up to £4,000 is most important. It has helped many people to remain in our society. I appeal to the Minister, as I have done before, to ensure that people who qualify for these grants would have simple plans prepared by the local authorities in their area. For example, in the area of Dublin Corporation people who qualify for disabled person's grants have the plans prepared by Dublin Corporation. This is a great help and I see no reason why it could not be extended throughout the country.
In the latest revision of the reconstruction grants some tangible encouragement should have been given to build extensions to homes for the purpose of housing elderly relatives. This could be looked at. I know at present there is a great scarcity of space in geriatric hospitals. I know that in St. Joseph's Hospital, Trim, which must be one of the best geriatric hospitals in the country, there is a long waiting list. Many people on the waiting list will die before they can be admitted. This is unfortunate.
I agree generally with what the Senators have said. I agree that the highest standards are essential but I feel we should incorporate what we have and build on it to achieve these higher standards.
Mr. FitzGerald Mr. FitzGerald
Mr. FitzGerald: I think it is important that we get the opportunity, which Senators McGuinness and Ryan have given us today, to discuss the Homes for Incapacitated Persons Regulations, 1985. As Members of this House are all too well aware, regulations do not very often reach this Chamber or the other House, or are discussed in sufficient detail. There are certain regulations which have a major impact in one area of Government  policy or another. This is a particularly important motion regarding an area of concern to a number of Senators who have contributed today and no less so to myself. I have been calling for a considerable time to have the 1966 regulations, which were brought in to govern the standards of accommodation of the elderly, updated and made more pertinent to conditions as they now are.
My concern about the regulations the Minister has laid before the Houses and which are under discussion today is not that they are not welcome but that they are not going anything like far enough and, to some little extent, I feel there is a certain face-saving element in them. It has to be said that in the course of the last 12 years — and speaking particularly of the Eastern Health Board area with which I am much more familiar with than I am with the country at large — the commercial nursing homes, the places to be governed by these regulations, have increased in numbers to a very large degree. In 1970 there were only 23 beds in the Eastern Health Board area which received per capita payment from the Eastern Health Board as assistance towards the patients in the homes, whereas in 1982 there was 1,371 patients receiving that per capita assistance. I do not need to contrast for the Minister the difference between what is provided in this country by way of per capita assistance to the elderly in homes when they are in care in private nursing homes such as those we are discussing and what is available in the United Kingdom. There is a vast difference in the scale of assistance and in the scale of provision for this category and for our senior citizens. I am concerned, along the same lines as Senator McGuinness and Senator Brendan Ryan, with the vagueness of the regulations. On page 5(10) (2) we talk about:
adequate accommodation and space in single and shared sleeping areas . . . adequate day space for each patient in an area separate from the circulation and sleeping area, and adequate dining and sitting room space for mobile patients . . . doorways and corridors  which allow for easy use of wheelchairs and walking aids and access ramps where appropriate, a visitors' reception area and adequate facilities for patients to receive visitors in private.
For the purposes of making my point I will quote a relevant section from a report of the Eastern Health Board dealing with private nursing homes. It was produced in July 1982. It states:
The Nursing Staff vary in terms of numbers, qualifications and training. ...almost all of the buildings were not designed for their present use. Adaptions which had been carried out could only be regarded as partially successful. Multiple occupation of rooms with more than 3 beds per room was quite common. Ventilation space available for each individual could only be regarded as barely adequate. Few homes have separate day or dining rooms. A lift is rare and fire hazards must be a cause of concern to many proprietors. The quality and standards of toilet and bath facilities are much less than ideal for the needs of the elderly or infirm residents. Provision of special equipment and facilities such as assisted baths, specially equipped showers and toilets, wheelchair toilets and other aids, for example, ramps, grab rails and hand rails, is lacking in a number of homes. Only one of these homes has a room available for mortuary purposes.
I could develop what I have been saying to make my point even more substantial because the reality is that within the Eastern Health Board area the private nursing homes have been taking up the lack of provision for the elderly by the Department of Health directly through its agency, the Eastern Health Board. There is a disparity between the services provided for the elderly in one health board area and another. I know that most of the buildings that are provided were built in the 18th century or 19th century. Little provision has been made by way of institutional care by the Department of Health or by its agency, the Eastern  Health Board, or its predecessor, the Dublin Health Authority, since the foundation of this State. On the one hand we are not providing the regulations; on the other hand we are not providing a sufficient per capita assistance to those running the homes. Thirdly, there is not a sufficient scheme of encouragement by way of loans and grants to make these regulations have teeth, upgrade the facilities and help not just the patients but also the proprietors who are running some very good homes. In instances, however, they are running homes that should be closed. These people should be assisted to bring their homes up to an adequate standard.
We are not really looking at this problem in a global enough way. I hope the Minister will be able to do so when responding and that we will be able to make some attempt to provide the assistance — we must face up to assistance by way of loans and grants — to the proprietors of these homes in order to upgrade, improve and to bring facilities up to date, to conform to the aims that are in the regulations before us.
I welcome the regulations, although I do not think they are adequate. We must get something done to improve the standards by way of assisting those who are operating these homes when otherwise the responsibility would be on the Department of Health. We should inaugurate a scheme of considerable loans and grants to be made available to achieve objectives which could be achieved so that we can expect standards of a higher kind than are contained here, providing for more detail in regard to the amount of space per patient and the amount of day room and other facilities which should be available, down to the number of nurses and so on.
This is an area we really need to take on in a spirit of — I refer to my colleague, Senator Cregan's contribution earlier — trying to achieve better standards in these homes by the suggestions I have put forward. But equally we should look at the prescribed relative's allowance, which at present provides £24.60 per week, as one attempt to rectify the need for support in  the community care area for the home in the first place. I do not see why we are not opening up that allowance and making it more generally available to families. At the moment if you have children over 18, provided they are not handicapped, you are not eligible for that assistance. That is the sort of area that could, in the first instance, begin to improve conditions in the community by way of encouraging families in difficult economic conditions to keep their elderly at home, to maintain them and to give them an adequate standard of care, nutrition and heating, with all the extra expenses involved.
These are very real considerations for people who have to consider what to do in relation to an elderly person. We should not just increase the availability of grants and loans to the proprietors of homes but to those who might start a neighbourhood type of development, activities for the elderly such as Senator Cregan mentioned. For example, in the eastern region the vast majority of these facilities are to be found in the Dún Laoghaire and Bray areas. There is not enough encouragement to each community in each neighbourhood to go ahead and provide facilities themselves.
I would hope that the Minister is only regarding these regulations as an interim measure and that we will hear more from him about how he is going to seek to encourage those running the nursing homes. This should be done in a spirit of partnership with them, given that the Department itself over a much longer period than the Minister has had responsibility for has not been seriously providing the level of institutional care that is needed alongside the development of community care. We should seek to work a scheme of encouragement to ensure that the standards are seen to work and that we are not simply introducing those regulations after a long period of neglect in relation to regulations when their effect will be minor enough. We have got to ensure that whatever regulations are passed now are improved in the foreseeable future and will be the kind that will raise standards in some  of the homes that are a real cause for concern. I need not make this point any more to the present Minister who is well aware of the complaints that arise about a small but a worrying number of homes. The standards need to be improved and I do not think these regulations, as they are now before us, can have sufficient effect.
Minister for Health (Mr. B. Desmond) Barry Desmond
Minister for Health (Mr. B. Desmond): May I thank the many Senators, particularly Senators B. Ryan and McGuinness, for their expression of concern about this fundamental issue. However, I strongly differ in that I believe the expression of concern does not warrant the annulment of the regulations. I can assure Senators that the introduction of these regulations is not — and I want particularly to assure Senator FitzGerald on this — a face saving exercise at all. The reality is that I am the first Minister for Health in almost 20 years to bring in new regulations relating to nursing homes. It has been a difficult exercise. I have consulted with the health boards throughout the country, and I had the observations of the Eastern Health Board on these regulations, and the observations were not that they were inadequate. I had observations from the National Health Council and from the Council for the Care of the Aged. Admittedly, that latter council had some reservations. I assured them that I would, as a continuing exercise, take into account the reservations they had regarding the precision of some of the standards and that I had taken into account the reports of the two studies which the National Council for the Aged had done in the general areas. I want to state that these regulations will certainly enhance the role of the good nursing homes and result in the closure of those that should be closed and which are particularly inadequate.
The regulations are reasonably specific in relation to a number of areas. Admittedly, I have not been able to lay down precise criteria as to the square footage in relation to bedroom accommodation and living room accommodation for those homes because they vary so much. The  particular conditions of those who occupy them also vary. The criteria would be so subjective that it would not be possible to lay down specific standards. With due respect to Senator B. Ryan, who mentioned the New York criteria in terms of the homeless, I can assure him that the criteria laid down here and the inspection powers of the health boards are far superior to anything which might be alluded to in that regard. For example, the regulations do specify that the health board will be empowered to lay down the number of persons in each particular group. The accommodation will vary considerably throughout the country but I have no doubt that the health board staffs in carrying out the inspection of the accommodation will ensure that there is not gross overcrowding to the extent that proper care cannot be provided.
These are the only two areas where there is a degree of imprecision and it is a necessary degree of imprecision because we have to bring in new regulations — the old regulations are entirely out of date and we have to introduce them. In some respects they are intermediate in their impact and when they are in we will certainly review them again.
When it comes to the definitions relating to accommodation, and relating to sufficient, suitable and nutritious food properly prepared, cooked and served, I cannot be precise in those areas for the simple reason that it is not possible at this stage of drafting the regulations. In many other areas, notably those relating to records, which are of critical importance in the running of any nursing home and in terms of employment, for example, we have been precise. No Senator alluded to the fact that I have included the definition of a “nurse” a nurse meaning a person registered in the general division of the register of nurses established under the Nurses Act, 1950. In other words, a psychiatric nurse cannot be in charge of a nursing home, which is a critical change. This has not been alluded to. There has to be precise records of the employment of persons within those homes.
 I would stress that the general atmosphere and level of care in a home cannot be defined in a statutory way. One could have a home acting with great precision within those regulations and yet it could be a diabolical place. The level of assessment has to have the broad criteria of sufficiency and adequacy. These words in the legislative framework and in the framework of going to court to enforce the regulations do have a statutory meaning. They are not redundant, contrary to the inference of Senator B. Ryan and Senator McGuinness. I have been assured by the parliamentary draftsman that such a subjective assessment can be made on foot of a complaint by a health board inspector and a court of law can arrive at an assessment in those areas where there is not precision.
I want to stress that in the area of fire procedures, including the question of fire drills, escape procedures and facilities, the regulations are quite precise. They are also precise in relation to the entitlement to enter and inspect the homes and inspect the records kept in the homes and to provide facilities, which are of critical importance here, for designated officers of the Minister for Health or the health board to conduct interviews in the homes with persons residing in them or with staff. That arises where the Minister has reasonable cause to believe that a patient in a home is not or has not been receiving proper care and attention. That usually arises in terms of a complaint, so the procedures for dealing with complaints are precise in that regard.
The provisions relating to heating and lighting, the provisions of cold water, hot water, the general sanitary arrangements in the homes are quite precise, be they the operation of sluice rooms, the provision of hot and cold washhand basins, the provision of commodes and toilets. I have not laid down the precise minimum number of toilets per person, per room because the nursing homes vary so much it is not possible to say that there shall be X number of toilets because some homes are on a single floor, some are three storey and some are even four storey with fire escapes and the level of toilet and  sanitary arrangements within each home can very greatly. I would be particularly concerned about doorways and corridors which should allow the easy use of wheelchairs and walking aids. These are just some of the areas where there is substantial precision. We produced, as I indicated, ten pages of duplicated regulations in that area.
By contrast, when one goes back the 1966 regulations did not provide for the maintenance of any records in homes. The 1966 regulations, for example, made no provision for the care of the dying and there is specific provision written in here. The provision was not made for the notification of deaths. The basic provisions of the 1966 regulations were quite inadequate in terms of sanitary requirements and they were equally inadequate in terms of safety precautions regarding fire prevention, the safe keeping of drugs and patients' personal belongings and, above all, the general storage of food and general maintenance because an outbreak of illness within a home can frequently be traced to the food supply situation.
The regulations, while they have had to be broad in some respects, are, I think, a very substantial improvement on the 1966 situation. There are currently some 200 private nursing homes in the country with about 7,000 beds and there are about 6,000 people catered for in those homes. With the increase in the number of nursing homes and the growing elderly population in the country I think all Senators here will agree with me that there is an urgent need to update the Homes for Incapacitated Persons regulations. I must stress that in several of the health board areas there is a parallel development.
I listened with interest to the points made by Senator Lanigan. A great deal has been done in the past three or four years in his health board area. There have been major changes in Clonmel, major improvements in Carlow and Dungarvan, just to take three areas of the South Eastern Health Board. In relation to the Eastern Health Board area we have made very considerable changes. One of the things I find disappointing about many  public representatives — not Senators — and many people who are interested in this area is that they do not visit those areas. I recommend that people should visit St. Mary's in the Park where a great deal of money has been spent and facilities have been enormously improved for the general geriatric and psycho-geriatric population and the care of the elderly. Brú Chaoimhín has been substantially improved. Anybody who wants to may come up to Vergemount in Clonskeagh, to Leopardstown Park Hospital or to the Royal Hospital in Donnybrook where we are pouring in a great deal of money now. All of that money has been spent in the last three or four years and I have deliberately taken the money out of the acute hospital area — and I have acquired an appalling reputation because of the abysmal perception as to what constitutes health in this country — and put it into those areas. As a result there have been substantial improvements in the Dublin area.
For the special new geriatric units we have made every year a growing capital provision. Right around the country in the past five years and notably in the past three or four years there has been a very substantial improvement in the general level of facilities for the geriatric population who require institutional care. I use the word advisedly because unquestionably the best care anybody can get is in their own home for as long as possible with the backup of day care services, home help services and community care services in small units. That is the best level of nursing home care; your own home for as long as possible. Unfortunately we seem to have opted to put people into hospitals and a great many of the residents in our acute hospitals are over the age of 65. At any one time approximately four out of every ten people in the beds in acute hospitals are over the age of 65. One frequently gets the impression that more and more people are admitted into such hospitals and of course that imposes an enormous strain on the Exchequer and the provision of health services.
Therefore, I come to the central point  made by Senator Ryan and Senator McGuinness, namely that they feel that more precise standards should have been included in the new regulations. I would point out that great consideration was given to the contents of these regulations including consultations with the health boards, the National Health Council, the Irish Private Hospitals and Nursing Homes Association. They were consulted and I met them formally and a copy of the regulations was forwarded to the Council for the Care of the Aged. It is my view that the provisions contained in the regulations give the health boards reasonable powers to ensure that private nursing homes operate to acceptable standards. Regulations containing a multitude of very precise standards would be extremely difficult to enforce and they might defeat the whole purpose of the exercise.
That brings me to the question of implementing the new regulations. There is no point in the House enacting them unless they can be effectively implemented. The responsibility for maintaining standards in private nursing homes in the first instance is a matter for the individual health boards. As I have already indicated the new regulations provide for the inspection of nursing homes by health boards at least twice a year. That is the minimum laid down.
It is vitally important, therefore, that these regulations be properly enforced. My Department will shortly be holding detailed discussions on this aspect with representatives of each of the health boards. When these regulations have been in operation, say for 18 months or two years, I will certainly have another look at them and where there is a need for more precise definition or for amendment of the regulations, I will have no reluctance to come before the House with such amendments. I intend to monitor this situation. These regulations represent a significant step forward in the establishment of proper safeguards for the care of patients in private nursing homes.
 My interest in this whole area was originally aroused by Senator Mary Frances Davidson who was mentioned by Senator Catherine McGuinness, and who was a distinguished Member of this House and who campaigned right through the early sixties in the Seanad where she had many motions down relating to the 1966 regulations. Indeed, Miss Davidson, now very elderly, lives in a nursing home herself. The reform and development of these regulations in many respects can be attributed to the single-handed campaign which she conducted at that time.
I should like to assure the House and Senators Ryan and McGuinness that I would be very reluctant to annual the regulations. However, I will keep the regulations under close review. I would welcome the observations of individual Members on the implementation of the regulations in their own health board areas. They should write to me or to the Secretary of the Department, Mr. Liam Flanagan, in relation to any aspect, incident or complaint. The Department of Health are entirely sensitive and non-bureaucratic and expeditious in taking up complaints. Senators should feel free to send in complaints in writing. We are not interested in rumour or stories; we are interested in facts as they are known to Deputies and Senators who are prepared to stand over their allegations. I can assure every Member of the House that they will be rigorously and impartially investigated by the health boards and by the Department of Health officers where necessary.
A good day's work has been done in implementing these regulations which are overdue.
Mr. B. Ryan Mr. B. Ryan
Mr. B. Ryan: I will be brief. This was an extraordinary debate in the sense that it began, as we had intended it, as a discussion on a statutory instrument and it then extended into a debate on the way we care for our old people generally. All the better for this. What was at the back of everybody's contribution — the Minister and all Members of the House — was the quality of care that we give to our old  people at a time when they are vulnerable. I relished the comments of my colleague from the North, Senator Robb. It is always stimulating to hear a member of that most protected of professions talk about that profession with a healthy scepticism that it badly needs — that it is only made up of human beings with the same needs and the same inadequacies and the same willingness to protect its own interests as every other profession. Senator Robb and I have often agreed on this as we have agreed that the engineering profession — which is my own — is indeed similarly capable of looking after its own interests. I will carry with me for a long time his phrase on the imperialism of institutions: it is a classic of what happens to people when they try to be helpful or flexible.
It was interesting to hear something that has come up again and again; he mentioned our unwillingness to care for our elderly relatives and the demand for institutions. There is some truth in that but it is ironic to hear men talk about the unwillingness to care for the elderly members of our society and for elderly relatives because while I cannot talk yet, there is not much evidence that men ever cared for elderly relatives either at home or indirectly. It has been a responsibility and a burden that women have carried all through history. It is perhaps the understandable and justifiable reluctance of women to carry yet another burden unpaid for, unthanked and unnoticed into late middle age that has precipitated some of this problem.
To wring our hands and to see it as simply a decline in community values is too simple; it has far more to do with the fact that women are refusing to have yet another one of men's burdens landed exclusively on their shoulders. It also has something to do with the fact that the ruthless and viciously competitive society that so many people approve of destroys values like sacrifice, commitment, and the whole concept of love without a price is ridiculed. Indeed it is often ridiculed by the same people who stand officially for traditional values, as they see them  themselves, but then support an economic and social order which fundamentally is in conflict with values like love and commitment and sacrifice.
It is true that neither I nor Senator McGuinness unequivocally wishes to throw out these regulations: there is too much in them that is a considerable improvement; there is too much in them that is light years ahead of what was there in 1966. The reason for our raising this matter in the way it was done is that it is the only device available to us to raise the matter which would not have imposed constraints and postponed discussion on it until after the regulations had come into force. It is more appropriate to have these regulations discussed before the statutory period elapses. It increases the usefulness of the discussion and it is also one of the few unqualified powers the House has. If this House chooses not to approve statutory instruments or chooses to annual regulations, we cannot be overruled by the other House; it is an unqualified power which this House has. It is the only power the Seanad has which is not a delaying power. Regulations like this can be annulled by either House of the Oireachtas and, therefore, it is a worthwhile procedure to use. It is a very blunt instrument but I wanted to seek answers and to get clarification.
One of the issues that was raised in the light of my seeking clarification as to the lack of specificity in certain areas, particularly in areas relating to sanitation and bed spaces and so on, was the worry that people have that if you make the regulations too strict it will result in institutions being closed down. This should be thought out because if we believe that there are minimum standards below which it should not be tolerable for any institution which is caring for old people to go, then that particular argument cannot hold. If there are minimum standards, then we should be in a position to specify them. If we do not know what they are, they do not exist. This is separate from the argument of whether they have to be written down in numbers.
You cannot say that if we make the regulations too strict institutions will  close down. This means we are saying that, because there is so much poor provision around, it is all right to leave people in poor provision. What we want are honest minimum standards which reflect honest attempts to define what we regard as the acceptable standards for our old people. Therefore, as the Minister quite honestly and bluntly stated, I hope that these regulations will result in some institutions being closed down because if they are half as bad as some of the appalling stories that surface in the media from time to time they deserve to be closed down. Whatever is wrong with hospitals in the public domain — and many of them are inadequate — they are at least accountable in a clear-cut and definite way. Consequently, after a long and useful discussion, it comes back to the issue that I raised and that Senators McGuinness and FitzGerald raised, which is why in certain areas the regulations are not more specific.
The Minister in the course of his characteristically able defence of the regulations pointed to all the good things and there are a lot of good things. The reason he gave was that these homes varied so much in terms of the number of floors and the number of patients etc. but the fascinating thing is that the health board within whose area of responsibility close to 50 per cent of all the nursing homes in the country are situated — that is the Eastern Health Board — and therefore must be a representative sample of nursing homes generally, did see fit to propose very specific regulations about floor space, numbers of toilets and things like that. It is very difficult to accept that what the Minister says is the reason, is the only reason, why. If the biggest health board in the country, with the biggest reason for concern in this area, could identify what they regarded as acceptable minimum standards, given their expertise, given their knowledge and given the number of institutions they had experience of, I cannot understand why the Minister could then ignore that particular health board and decide, presumably either on the advice of his own officials  or the advice of other health boards, such specific regulations were neither feasible nor presumably desirable. That is what is at issue between us.
I mentioned the standards in New York and I was not trying to be flippant; I was simply pointing out that in very, very difficult and very demanding circumstances other bodies had found it possible to be specific because they recognised that without specific regulations it becomes extremely difficult to enforce them. It means that each individual case will have to go to a court to have words like “adequate” teased out in detail whereas if you have specific, numbered, quantifiable regulations, quantifiable standards, then these things do not have to proceed to the court because officials can say: “This is not adequate because it fails to meet a specific standard.”
I accept what the Minister has said in the spirit in which he has said it, which is that this is not a once-off exercise to be filed away in the Oireachtas Library never to be looked at again, that this is something that is capable of future revision, future amendment and future upgrading. I hope I am proved wrong and I hope that the complaints will peter out. I hope that we will not hear complaints about overcrowding, about people being frozen with the cold — though that should not happen under the current regulations — about poor sanitation and so on because everybody in this House shares exactly the same concern which is that our old people should be looked after properly.
Consequently I have no intention of pushing this motion to a vote. I am very glad that we had the discussion. I would like to thank the Minister for agreeing to discuss it after particularly short notice. I am grateful for the detail of his reply, grateful that we had the opportunity to discuss it and with your permission, A Leas-Chathaoirleach, I would like to withdraw the motion.
Motion, by leave, withdrawn.
Sitting suspended at 5.35 p.m. and resumed at 6.30 p.m.
Seanad Éireann 109 Homes for Incapacitated Persons Regulations, 1985: Motion for Annulment.