May 21, 2022

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Nursing Homes For Elderly In Spain Is An Opaque System Since 2014

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With the pandemic, when some 30,000 elderly people living in nursing homes died, these centers became a priority and a cause for concern. When approaching them, a model emerges without any transparency that hides the lack of control that governs them.

A system with insufficient inspections, which imposes often derisory sanctions and, finally, frequently leaves users defenseless, who see their complaints ignored. Many citizens despair at the state of their relatives, they see that reporting is useless and they feel abandoned by the institutions: dozens of organizations have emerged that question the system and ask for clarity on residences.

An investigation by EL PAÍS sheds light on all this. One of the keys, the starting point, is the dubious supervision of the model: before the outbreak of the coronavirus, from 2014 to 2019, most of the autonomous communities, 10 in all, did not inspect residences once a year on average. In total, 11 territories if Bizkaia is added, since in the Basque Country the competition is divided between the three councils. They account for 51% of all residences in Spain. In 2020, even with a reinforcement of inspections due to the pandemic, there were still seven that did not send a control to any of them.

Several elderly people in one of the rooms of the Carballo Residence for the Elderly, on June 19, 2021, in A Coruña, Galicia (Spain). The Xunta de Galicia has decided to lift the restrictions activated in the last year and a half in residences and day centers, after not counting any case of coronavirus since March.

More similar to homes and less to hospitals: how to improve nursing homes in Spain
One inspection per year is the minimum that the experts consider necessary and the norm in neighboring European countries. There are communities that impose it —Madrid establishes two annually—; others do not. But often the goal is unfeasible: there are not enough inspectors.

In Asturias, with 232 residences for six inspectors, each one has to control 39; in Catalonia, 33. The calculation is only indicative because these officials also supervise many other social centers, such as those for minors or those for the disabled. They cannot cope.

But also the result of their work is not public, unlike in other western countries: the citizen must choose blindly. Whoever enters a residence in Spain cannot know if they have been sanctioned and why. The fines, in any case, are very low: the average for serious infractions is 5. 000 euros. A quarter of themthey are due to lack of personnel , with penalties for an amount much less than what it costs to hire someone, for example.

“The real inspectors are the relatives, in our residence, if the relatives had not been, half of the inspections would not have been carried out,” says Ester Pascual, 44, who had her mother in a residence in Elche where she presented 10 complaints, no response, and that managed to change her center just a few months ago.

“In many rooms there are no curtains, they cannot sleep well. The air conditioners are broken. Last year there were two bed bug infestations. Now they have finally bought a scale, but do you know what it cost us? Months.

They also lose their clothes. My mother had mouth sores, the dentist told me that her teeth were not being cleaned, and the director told me that she could not guarantee that they would be washed once a day. I joined a complaint association when I saw these things ”,

The inspections and fines that are imposed are now public for the first time at the national level thanks to the data obtained by EL PAÍS, which reveals that 21% have been sanctioned since 2014. They can be seen in the created search engine that allows you to consult all the fines imposed. Except in Catalonia and the Balearic Islands, which have not provided the names of the centers.

Spain is a rarity among other Western countries, because this work in Germany, the United Kingdom or the United States is done by the authorities. They have star systems like hotels, or rating notes on the door or on the web. In Spain, a large part of the sector, also companies and social entities, are in favor of changing to total transparency.

They know that mistrust towards residences stems from the secrecy in force until now. A fact: nobody even knows how many residences and users there are in Spain, there is no general census. EL PAÍS has counted a total of 5,463 centers, compiling data from each community. The CSIC and the Imserso have 133 and 113 more, respectively.

See the 1,100 residences for the elderly sanctioned in Spain, community by community
Before the pandemic, an event made people talk about residences from time to time. For example, in 2017 an 80-year-old man died in the garden of a residence in Alcorcón , with 220 residents, but they did not find him until the next day. Family members reported lack of personnel and control. Mariví Nieto had her mother there: “We think: what kind of control is there?

If he doesn’t go to dinner, if he doesn’t go to bed… Then everyone would tell you a story, we all had the same problems in all the residences, you protested and nobody did anything ”. A change of model has been discussed in the sector for years, but as a result of the covid, the debate is deeper. “There has been a lot of institutional abandonment, we were forgotten.

That’s how we got organized ”, explains Nieto, who is now part ofMarea de Residencias , born in 2019. Another group, laPlataforma, brings together 15 associations at the state level that have been working for years in almost all autonomous regions . These organizations channel a discontent that has erupted with the pandemic.

How is the system organized? Seven out of 10 residences are private, according to the CSIC, although many places are arranged. Social services are regional competence and there is no state framework that establishes how these centers should be controlled: there are as many models as there are communities, and it is even further subdivided in the Basque Country, in its three county councils, and in the Balearic Islands, in the three island councils.

Total, 21 systems. For this investigation it has taken seven months to collect all the data, using the Transparency Law and with requests to the ministries, and even so they are incomplete. The Ministry of Social Rights and the autonomies agreed, within the framework of a shock plan for the agency, to reinforce the inspections. And the ministry will finance with European funds a study to propose a state evaluation system.

Beatriz Cano, who lives in a residence in Usera, Madrid, has a record: more than 900 complaints in 10 years. For the food, the staff, the facilities … “And they have never agreed with me, not one. They say everything is fine. I say that at least sometime what he said would be true ”.

It shows a letter that the Community of Madrid wrote to him, blaming him for how much he protested. “But I don’t do it for fun, as if I had nothing else to do. I keep reporting because what is wrong remains the same, and I am a fighter ”. When there are deficiencies and penalties, the inspection verifies that they are corrected, with documents or with a new visit, although there are usually no fixed deadlines.

Sanctioned residences are normally prioritized in inspection plans. The companies assure that there is usually one a year and, in some communities, extra controls in case of having arranged places. There are also annual visits from Health and occasional Labor.

Joseba Zalakain, director of the SiiS Documentation and Studies Center and an expert in social services, believes that in Spain “few inspections are carried out and they are done poorly”. “In countries like Germany and the United States there is a mandatory annual evaluation”, he points out, “which is not based so much on regulations and procedures but on the quality of life of the elderly, and is published center by center; you have the right to know ”.

In the United States there is a star system, like hotels, based on inspections. In Germany there is a plaque on the door of each residence with the note of each inspection, each center can put next to another one of a private audit, and also the evaluation of the users.

Miguel Vázquez, president of Pladigmare, an association in Madrid that is part of the Platform, says that they do nothing more than denounce, but the complaints of residents and relatives are of almost nothing: “The inspections are a real paripe. Report a family or a worker, they send an inspection, but only ask the management of the center, not the one who has denounced. And then they just believe what they are told and it’s over. ” He explains that in Madrid the 2002 law establishes strong sanctions, allows the intervention of a residence or prohibits the public financing of a center, but “it has never been done.”

“In a residence in Madrid, public and privately managed, at least since 2010 the air conditioning system has not worked. We have been asking for a temporary intervention for years, to solve it and then ask for damages. But nothing is done ”. Paulino Campos, president of the Galician federation Rede, another member of the Platform, agrees: “With the body of inspectors there is, it is impossible to monitor effectively and with quality,” he says.

“It is frustrating to report and many families regret the lost time. If a surveillance body existed as it should, it would mean that some of the serious injuries and human rights violations in residences would be avoided ”, he points out.

When Josep de Martí —jurist, gerontologist and professor of legal matters related to residences— was an inspector, an elderly woman asked him in despair: “Will I never eat fish that is not frozen again?” “Well, maybe not,” he replied. “He is paying what he is paying and complies with the law, in quantities, proteins …

In many complaints they may be right, but it is not illegal.” He was an inspector for 18 years, until 1998, and then head of inspection in Catalonia. He believes that “the problem with complaints is that many times they have nothing to do with the law. Two typical complaints are that there are no staff, because they don’t see anyone, and that the food is bad.

But the inspection goes and everything is legal ”. De Martí believes that secrecy dominates in Spain. “The question is: who is it inspected for? If it is paid with taxes, it is for everyone and it should be public ” to shed light on a very dark world: this platform offers the centers to post their inspection records, personnel number, the contract that is signed, prices. Only a third of the residences have agreed to collaborate, and only 2% give all the data.

“When everything is public, we will hallucinate. It will be hard at the beginning, because it will show that not everyone inspects the same, that public residences are not inspected the same, ”says De Martí. The EL PAÍS investigation also clears this doubt raised by the private sector, convinced that there is a double standard: 15% of sanctioned residences are public, a figure that is approximate because in a hundred cases the information does not clarify ownership from the center.

According to EL PAÍS research, 25% of the sanctions imposed in recent years are for lack of personnel, a clear symptom of one of the main problems of residences, with ratios set years ago and that do not adapt to the level of dependency with which users now arrive at the centers.

A doctor who prefers to remain anonymous and has just left the Madrid residence where he worked indicates: “I have been more than a year and a half, I ate the entire pandemic, and I couldn’t take it anymore, I don’t want to go through that again, I will not go back to a residence in my life. You are without sufficient nursing staff, and you do it, who sometimes you don’t even know, or an assistant, who has no training or title for it, and you are the last person responsible if something happens ”.

In March 2019 in Avilés, Asturias, A police patrol found an elderly man disoriented on the street in the center at dawn. He had left a residence and the agents verified that there were no employees at night, the users were alone. Was closed.

75% of the penalties are for serious or very serious offenses, but although the average of the penalties for them exceeds 20,000 euros in most communities, the most common real fine is 5,000 euros. The fines move in the lower range of the legal range. In Bizkaia, the average is the lowest, 400 euros, because the penalty can be reduced to a minimum if the failure is corrected.

In 2019, in a video recorded by a relative with a hidden camera at the Los Nogales Hortaleza residence in Madrid , three aides were seen laughing and insulting two residents, and treating them with violence. “As you bite me, I will tear your head off,” a worker was heard saying. One of those residents was Francisco Polonio’s mother, who had placed the camera because she feared ill-treatment.

“Shortly after he entered the center with an arranged place, in 2015, he already had suspicions. He appeared with a swollen knee or broken glasses temple, for example. I would present writings to the director and tell me that everything was fine, “says this lawyer. “I even reported to the court in 2016, but it was shelved.”

He says that after the video, he started looking for another residence but within a few months his mother died. The Community announced that the center was facing a fine of up to 600,000 euros, but in reality official data indicates that it has remained at 78,622.86 euros, for “deficiency or inattention in the provision of the service that implies a situation of danger, serious discomfort or noticeable abandonment in the care and protection”. Los Nogales sources assure that it was an isolated event, regardless of the company and the management, and that the three employees were fired.

In 2019, Polonio submitted three videos to the Prosecutor’s Office. The case is still in the investigation phase, the company sources explain, with the three workers and the director (who continues to work in the company, but is no longer in charge of the residence) investigated, not the company.

These sources explain that they appealed the Community sanction and that it is “on hold”, pending the judicial decision. 8% of the sanctions recorded by EL PAÍS, a total of 131, have been for physical or mental abuse or degrading treatment.

The companies in the sector, also fragmented into four large employers, explain that they are the first interested in ending bad practices. They ensure that most residences work properly. In reality, there is general consensus on the need for rigorous inspections and transparency.

Cinta Pascual, president of the Círculo Empresarial de Attention to People (CEAPs), the one that groups the most centers, points out: “I have been in this for 26 years and we have spent our lives asking for common indicators and a common checklist for all of Spain, and that there is a return, that they tell us the result of the inspections, the sanctions .

They serve as an audit. We are in favor of objectivity, with quality indicators, and total transparency, it is the only way for people to see that a residence is working well ”.

The Association of Dependency Services Companies (Aeste), another employer association that brings together large groups, proposed to the Government, together with CC OO and UGT, among others, to review “public control of the quality of services.” Ignacio Fernández, from the Federation of Dependency Companies (FED), points out that he would agree that the model be changed, but “so that the inspections reflect the good and the bad.”

“There is no need for more control because we receive inspections very regularly, what is needed is to improve and modernize the system.” Juan Vela, president of the Lares Federation, of non-profit residences, believes that the model is not well planned: “Historically they are very focused on compliance with the norm. It might seem like it’s alright if you need to put one more towel or one less towel or the width of the corridors, but this does not greatly improve care for the elderly ”.

“I know of inspections in which residents have not been asked anything, they have only looked to see if you have the menu, if a bed is well made … we do not have the elderly to talk about how they would like to live,” he explains.

How is an inspection done? The models are disparate and the degree of detail they enter varies in each autonomy. In Aragon, for example, sources from the Department of Citizenship and Social Rights detail that inspection visits should last from four to eight hours and they should interact with all residents, to check their physical condition, hygienic-sanitary conditions and possible injuries.

They have to go all over the center and check the equipment, dimensions of the rooms, state of the beds and safety bars, callers, switches, storage of medication … in addition to reviewing documentation. “The inspections are not complacent, they are quite exhaustive and it is very difficult for a record with observations not to come out,” says Andrés Rueda, member of the Association of Directors and Managers of Social Services.

He believes, yes, that the regulations are “so general that there is not enough classification”, something that in his opinion generates legal insecurity. Explain that residences must have records of daily hygiene, falls, food, medication, ulcers, and that the inspectors always review them. “But then there are things, such as the perception of the resident’s state of well-being, which are very subjective.”

He points out that the failure is not in the officials, “but in the procedures, with outdated tools, and that the Administration has insufficient inspection staff.” something that in their opinion generates legal insecurity. Explain that residences must have records of daily hygiene, falls, food, medication, ulcers, and that the inspectors always review them.

“But then there are things, such as the perception of the resident’s state of well-being, which are very subjective.” He points out that the failure is not in the officials, “but in the procedures, with outdated tools, and that the Administration has insufficient inspection staff.” something that in their opinion generates legal insecurity.

Explain that residences must have records of daily hygiene, falls, food, medication, ulcers, and that the inspectors always review them. “But then there are things, such as the perception of the resident’s state of well-being, which are very subjective.” He points out that the failure is not in the officials, “but in the procedures, with outdated tools, and that the Administration has insufficient inspection staff.”

Alejandro González, a consultant, managed a nursing home for the elderly in Gipuzkoa for 12 years. He considers that the system “does not work.” “They are not guarantees,” he explains. “How is care perceived? Hardly. In the end they are procedural evidences. Do you have such a protocol?

And you have it, but how do you check that it is applied? ”, He says. “Also, it depends a lot on the person who is going to inspect you, the burden of subjectivity is enormous.” It is one of the main complaints of center directors and entrepreneurs.

There is another controversial point: among users and their families, the conviction prevails that inspectors often give notice before they are going to go. “In the residence where my mother was staying a week before, they painted the cafeteria, fixed a bathroom, put flowers at the reception,” says Mariví Nieto.

For the employers it is a legend, something that never happens, although it is true that Gipuzkoa does have planned visits that are preannounced, although never in the event of a complaint or complaint.

The Ombudsman’s reports have warned about inspections for years. In 2020 it pointed out again that “the autonomous communities must reinforce the inspection services so that they are sufficiently equipped and can carry out their function effectively”. The autonomies begin to move tab. In Navarra they are promoting a new residential model and the centers have four years to adapt.

In Castilla y León, a draft law provides that the evaluation reports and sanctions are public, and “a global score that synthesizes the level of quality of services.” In Gipuzkoa they are also studying a change in inspection, more focused on the quality of care. Several autonomies have given a boost to the inspection in recent years and many communities have reinforced their workforce.

On the sanctions list there are many repeat offenders, without having too many consequences. The record for the accumulation of fines is from the residence of Villanueva de la Cañada in Madrid, almost all of them during the Sanyres administration, until 2016, when it was bought by Orpea: it has added 12 penalties since 2014, most of them due to lack of personnel, for a total of 191,192 euros.

It is the ninth most sanctioned in Spain by accumulated amount. Although the legislation provides for high penalties, it is by no means the norm. The highest fine in the last seven years has been to Las Peñuelas, in Madrid, a privately managed public residence, which in 2016 was fined 499,799 euros. The autonomous community collected it from the guarantee that Eulen, the company that managed it, had deposited at the end of the contract.

But even when the Administration does its job, it is difficult to come up with drastic measures. The Government of the Valencian Community fined the Sant Llorenç residence in Vila-real (Castellón) three times since 2014, a total of 43,915 euros, due to lack of personnel, treatment of users and not having administrative authorization.

Until in 2019 he imposed 140,000 euros and ordered its temporary closure in August 2020. But he collided with the families and the City Council, who appealed the measure and the Superior Court of Justice paralyzed him. The Valencian Community has taken a turn these years. According to data from the Generalitat, in 2015 the PP had left a system with seven inspectors and now there are 32. In 2019 it approved a law that toughens penalties.

In the record of sanctions that EL PAÍS has compiled, there are 22 closures of residences for being illegal or as a precautionary measure. But not all of those that have occurred are included in the list, since not all of them are conceived as sanctions.

In 2015, a fire caused by a user in the Santa Fe nursing home, in Zaragoza, caused nine deaths and prompted the newly elected Socialist Government to implement an inspection plan. Since then, it has closed 43 residences, which do not appear in the list obtained by EL PAÍS through Transparency. Just when the pandemic broke out, in April 2020, the Xunta de Galicia closed a residence in A Fonsagrada, Lugo, due to symptoms of abuse and its “deplorable” conditions. 29 elderly people lived in it and 23 could fit.

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