Riitta-Leena Paunio's conclusions based on reports from the State Provincial Offices and observations
In March 2009 Ombudsman Riitta-Leena Paunio asked the social welfare and health departments of the State Provincial Offices to report on, inter alia, their inspection activities as well as their observations regarding staffing levels in care facilities and any shortcomings associated with the care given elderly people and the way they are treated. The State Provincial Offices gave their replies in late August 2009.
Now standing in for one of the Deputy-Ombudsmen, Mrs. Paunio emphasises in her comment on the reports that it is not possible on their basis alone to make a comprehensive evaluation of the quality of care that persons needing it round-the-clock are given. If the State Provincial Offices have not observed some or other shortcoming, it does not mean that shortcomings of this kind do not exist in treatment facilities. Their oversight is not comprehensive, because it has been and remains possible to conduct inspections in only some facilities. Something that likewise cannot be concluded, at least in all respects, from the reports is whether the shortcomings observed have been isolated cases or part of a more general malaise in the care facilities.
Staffing levels specified in quality recommendations not implemented in all municipalities
The Ministry of Social Affairs and Health and the Association of Finnish Local and Regional Authorities drafted a set of quality recommendations concerning services for the elderly in 2008. It emerged from the reports submitted by the State Provincial Offices that these had proved a useful instrument when evaluating the quality of care. In private care facilities they seemed, generally speaking, to have been adequate to safeguard the staffing level demanded as part of the licensing procedure. The quality recommendations seemed to have been accepted also in municipal care facilities. However, the staffing level indicated in the recommendation had not been implemented in all municipalities.
Mrs. Paunio informed the Ministry of Social Affairs and Health of her opinion that it should assess whether the quality recommendations are sufficient to ensure implementation of the fundamental rights of elderly people in round-the-clock care, especially with respect to the recommended staffing level, or whether legislation is needed in the matter. The Ministry must also take a stance on whether, in the light of the shortcomings cited in the State Provincial Offices' reports, there are grounds for changes to staffing levels. In her view, this assessment could be carried out in conjunction with legislative projects ongoing in the Ministry.
There is no legislation on the use of restraint and restriction in care for the elderly
It emerged from the State Provincial Offices' reports that a variety of restraint and restrictive measures (raised bed rails, restraints, locking outer doors) were in general use in care facilities for the elderly.
At the moment, the legislation that the Constitution requires and which would authorise intervention in elderly person's right of self-determination does not exist. In practical care situations, however, staff have to resort to measures for which they have no authorisation enshrined in legislation.
Mrs. Paunio took the view that guaranteeing an elderly person's care and safety can require his or her right of self-determination being restricted, such as by strapping with a belt or other restraint to a chair or bed or locking the door of a ward or even a patient's own room. Of essential relevance in assessing the acceptability of a procedure is for what purpose restraint and restriction have been resorted to and have they been employed only as a last resort. If the purpose is to compensate for insufficient personnel or the measure does, on the whole, more harm than good, the measure can not be accepted.
According to the reports received, restraint and restriction had been resorted to mainly to ensure the safety of elderly persons, although some State Provincial Offices suspected that they had also been used unnecessarily. Decisions to employ restraint measures and restrictions of movement had largely been based on a doctor's assessment. Restrictions of movement had most often been entered in the patient records. However, the entries were often deficient in, for example, the way the reasons for the restrictions were stated.
Mrs. Paunio informed the Ministry of Social Affairs and Health of her view that drafting of the legislation on confirmation and restriction of rights of self-determination now in the pipeline at the Ministry is important and urgent in order to safeguard the fundamental and human rights of the elderly.
Need and resources for supervision
All of the State Provincial Offices took the view in their reports that with the resources available to them it was not possible to conduct sufficient supervision for the purposes of prevention and guidance; instead, a considerable share of resources was used in the licensing procedure for private care operations. They were also concerned about the resources that would be available for supervision after the restructuring of regional administration came into effect on 1.1.2010.
An expansion at the beginning of 2010 of the tasks of Valvira, the National Supervisory Authority for Welfare and Health, to include national guidance and oversight of round-the-clock care of the elderly will probably help the new Regional State Administrative Agencies in their oversight task. At the beginning of 2010, eleven posts connected with oversight of social welfare were transferred from the State Provincial Offices to Valvira, whereby the number of staff conducting practical oversight in the new Regional State Administrative Agencies was reduced commensurately. The State Provincial Offices doubted whether the contribution made by Valvira in national guidance and oversight would compensate for the input that the personnel transferred from supervisory tasks to Valvira had made.
For their information and to be taken into consideration, Mrs Paunio informed the Ministry of Social Affairs and Health and Valvira of her opinion regarding assessment of need, implementation and oversight resources.
In her decision she drew the attention of the Regional State Administrative Agencies to the following matters in oversight of care facilities:
- Staffing levels in care facilities so that the minimum level recommended by the Ministry of Social Affairs and Health is observed everywhere
- Monitoring of the nourishment given elderly patients and their nutritional level
- Adequate hygiene
- Outdoor exercise opportunities
- Preventing medication errors and regular visits by doctors to homes for the elderly and serviced dwellings
- The appropriateness of use of restrictions on movement and their being carefully recorded in patient records.