Strengthening t h e LINKS THE CO-ORDINATION OF

STATUTORY & VOLUNTARY SERVICES

FOR THE ELDERLY AT LOCAL LEVEL

A REPORT BY THE DUN LAOGHAIRE PROJECT TEAMS

L

M B M B f f B S OF THE DUN LADOWATWTC PROJECT TEAMS

(1967-1991)

Steering Committee

Mr. J o h n Byrne Sr. Patricia Byrne Ms. Kay Cahill Dr. Denis Keating Dr. Sheila Lynch Dr. Sheila MacEvllly Ms. Aileen McNicholas Ms. Frances Mullins Mr. Cormac O'Broin Dr. Darlna O'Flanagan Ms. Norah Owens Dr. Pat Quinn Mr. George Ramming Mr. Seamus Shields Mr. Liam Gaffhey Ms. Ailish Walsh

Local Committees

Blackrock

Sr . Patricia Byrne Ms. Ann Clyne Dr. Darina O'Flanagan Ms. J e t Dunlevy Ms. Patricia Fallon Ms. Kathleen Holohan Ms. Aileen McNicholas Ms. Cathy Neagh Dr. Maura O'Dwyer Ms. Karen Peile Ms. Brid Tedders Ms. Cathy Lanigan Mr. Tom Haugh

Dun Laoghaire

Sr. Patricia Byrne Ms. Val Cave M s Mary Collins Ms. Liz Cooney Ms. Marie Egan Ms. Patricia Fallon Sr. Una Lennox Ms. Patricia Lynes Dr. Sheila MacEvilly Ms. Aileen McNicholas Mr. Tom Murphy Ms. Pauline Nolan Ms. Norah Owens Mr. George Ramming Rev. Richard Rountree Ms. Cathy Lanigan Dr. Paul Lacey

* Ms. Niav O'Daly

CONTENTS

Preface

Acknowledgements

Introduction 1

Section 1: Project Structures a n d Programme of 4 Work.

Section 2: Issues of Local Service Provision Identified b y Project. 1 5

Section 3: Issues of Service Organisation Identified by Project. 5 4

Section 4: Summary of Recommendations 7 2

Appendix 1: List of Committee Members 8 4

Appendix 2: Project Submission on Private Nursing 8 9 Home Legislation.

Appendix 3: Project Submission on Interim Report 9 9 of the Dublin Hospital Initiative Group.

PREFACE

The needs of t h e elderly in Ireland have been t h e subjec t of m a n y

s tud ies over t h e p a s t n u m b e r of years . Various well researched

repor ts have addressed these needs, a n d have recommended t h a t

cer tain proposals should b e considered, o r t h a t specific m e a s u r e s

should b e implemented.

This repor t i s different. It i s a r e sponse t o t h e needs of elderly

people in a given local area, namely t h e Borough of D u n Laoghaire.

T h e r epor t i s an_ ana lys i s b y t h r e e pro jec t t e ams , (a Steer ing

Committee a n d two Local Committees), of t h e concerns expressed

b y older people a n d of t h e problems encountered in t h e provision

of services for t he elderly in t h e Borough.

As age advances , m a n y f ind they have t o come to t e r m s wi th

difficulties they did n o t expect or prepare for. These include t h e

possibility of qualifying for home help, meals on wheels, or day care

services, uncer ta inty abou t their security of t enure in the i r h o m e s

a n d t h e possible need for f u t u r e sheltered accommodation. There

is also the possibility of entering hospital or a nurs ing home a n d t h e

consequent worries abou t loss of mobility a n d independence.

These concerns have been addressed b y a variety of s ta tu tory a n d

voluntary agencies, i n m a n y ca se s act ing independent ly of e a c h

other . With increasing d e m a n d s on t h e resources of government

d e p a r t m e n t s , hea l t h b o a r d s , hosp i t a l s , local au tho r i t i e s a n d

voluntary organisations, there is a need to kni t together t h e m a n y

services available into a planned framework of suppor t a t local level.

This i s w h a t t h e pilot project h a s b e e n abou t . The th ree project

t e a m s were selected f rom personnel i n t h e Heal th Board, Local

Author i ty a n d volunta iy agencies a n d o u r brief w a s t o identify

p r o b l e m s i n local service o rgan isa t ion a n d t o improve t h e s e

services where necessary.

We see th i s project a s t h e first organised a t t empt in t he country t o

a d d r e s s t h e needs of t h e elderly a t local level. The challenge t o

improve local services app l ies t o a l l a r e a s of t h e coun t ry ,

part icularly cities, larger towns a n d ru r a l a r e a s with a high elderly

population. Many of ou r recommendations, while emanating locally,

h a v e n a t i o n a l implicat ions a n d t h i s r e p o r t could serve a s a

handbook for other groups initiating similar projects in their own

area. This report should b e studied i n t h a t light.

John Byrne, Chairman, Steering Committee.

Acknowledgements

The Dun Laoghaire Project Teams wish to acknowledge the valuable

assistance a n d co-operation of all those involved in the Pilot Project

on the Co-Ordination of Services for t he Elderly a t Local Level. The

commitment a n d co-operation from the Eastern Health Board, D u n

Laoghaire Corporation, St . Vincent De Paul, Active Retirement

Associations, Old Folks Associations a n d t he Irish Private Nursing

Homes Association is also very gratefully acknowledged.

A special word of t h a n k s goes to t he Administrator and Catering

staff of Clonskeagh Hospital who facilitated u s during t he pas t four

years for ou r various meetings. Special t h a n k s also goes to t h e

Supervisor a n d staff of Beaufort Day Centre who facilitated the Local

Committees for t he duration of the project.

The teams wish to gratefully acknowledge t h e contribution of Ms.

Ann O'Mahoney who assisted the teams in the editing of this final

report .

A very special word of t h a n k s goes to t he elderly people of D u n

Laoghaire who, over t he pas t four years assisted the teams on t he

ground, and without whose assistance the project would never have

come to fruition.

Finally, the support and assistance of all who contributed in any way

to the project i s truly a n d gratefully appreciated.

1

INTRODUCTION

This repor t i s compiled b y t h e Steer ing Committee of t h e D u n

Laoghaire Pilot Project o n t h e Co-ordination of Services for t h e

Elderly a t Local Level w i t h t h e a s s i s t a n c e of t h e two Local

Committees in D u n Laoghaire a n d Blackrock. The Report s e t s ou t a

ser ies of i s s u e s i n r e spec t of t h e provision a n d organisat ion of

services for t he elderly i n t h e D u n Laoghaire area. The i ssues arose

o u t of t h e experience of a Pilot Project o n t h e Co-ordination of

Services for t h e Elderly a t local level which operated over a fou r

year period, 1987 - 1991. T h e Pilot Project w a s located i n D u n

Laoghaire Borough adminis t ra t ive a r e a which fo rms p a r t of t h e

Eas te rn Health Board Communi ty Care Area 1. It w a s one of two

s u c h pro jec ts es tab l i shed i n 1987, t h e o the r be ing located i n

Tipperary Sou th Riding.

The pilot projects were es tabl i shed in accordance wi th Terms of

R e f e r e n c e d rawn u p b y t h e National Council for t h e Aged (an

advisory body t o t h e Minis ter for Health). T h e D u n Laoghaire

Project w a s initiated joint ly b y t h e Eas te rn Health Board a n d D u n

Laoghaire Corporation. T h e bas ic a im of t h e Project w a s to develop

t h e concept of service co-ordination for t h e elderly a t local level.

Th i s entai led t h e e s t a b l i s h m e n t of s t r u c t u r e s wh ich b r o u g h t

together t h e Health Authority, t h e Housing Authority a n d t h e non­

statutory sectors involved i n t h e provision of services to t h e elderly.

The Dun Laoghaire a rea w a s selected for a number of reasons:-

(i) The Terms of Reference stipulated t h a t there b e a n u r b a n a n d

r u r a l d imension t o t h e pilot projects a n d D u n Laoghaire

fulfilled t h e criteria for t h e u r b a n project.

(ii) There h a d b e e n a h i s to ry of good re la t ions be tween t h e

Eas t e rn Health Board a n d D u n Laoghaire Corporat ion i n

respect of providing services for t h e elderly in t h e a r e a a n d

t h i s w a s regarded a s a n impor t an t cons idera t ion in t h e

establishment of t h e Pilot Project.

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(iii) Key p e r s o n n e l i n t h e two s t a t u t o r y au tho r i t i e s were interested i n t h e concept of service co-ordination a n d in establishing the Pilot Project in t he Dun Laoghaire area.

(iv) Dun Laoghaire Borough h a d higher t h a n average proportions

of it's population in the older age groups.

The T e r m s of Reference h a d s t ipula ted t h a t t h e local

authority a reas selected for the pilot projects b e coterminous

with health board community care areas and tha t they have a

population of 75,000 - 100,000. The Dun Laoghaire Borough

funct ional a r e a w a s not , however, coterminous with t he

health board community care a rea and h a d less t h a n 50% of

i t s to ta l populat ion, a s i tua t ion which w a s n o t entirely

satisfactory from a n organisational perspective.

Since the Pilot Project w a s the first experience of inter-agency and iriter-professional working for t he elderly a t local level, i t w a s considered important to carry out a n evaluation of i ts development and outcomes. This task was undertaken by the National Council for t he Elderly a n d a n evaluation report h a s been published b y the Council (Browne 1992). The present report documents t h e views a n d experiences of part icipants in t h e Dun Laoghaire Project in respect of key service and co-ordination issues in t h e area . It is envisaged t h a t t h e recording of these experiences a n d views of project participants will:-

(i) inform t h e general process of service co-ordination for the elderly a t local level;

(ii) contribute to the formulation of a policy programme for the elderly i n t h e D u n Laoghaire area , involving t h e Health Authority, t he Housing Authority and the voluntary and private sectors.

3

Outline of Pilot Project Report.

The Report conta ins three main sections:

Section 1 descr ibes t h e core project s t ruc tu re s a n d p resen t s t h e

demographic character is t ics of t h e project a rea . T h e programme

of work under t aken b y t h e D u n Laoghaire Project i s summarised i n

th i s section.

Section 2 of t h e Report d iscusses th ree a r e a s of sendee provision

for t h e elderly u n d e r t h e general headings of:-

(i) housing;

(ii) liaison between t h e general hospital a n d t h e community;

(ii) day centres.

Section 3 deals wi th key organisational aspec ts of local service co­

ordination for t h e elderly a s identified b y the project committees:-

(i) liaison between the voluntary a n d statutory sectors;

(ii) t he s t ruc ture a n d function of t h e Eastern Health Board Care

Team i n Community Care Area 1.

Section 4 of t h e Report contains a s u m m a r y of recommendat ions

m a d e b y t h e Pilot Project Committees in respect of a n u m b e r of

service a n d co-ordination issues.

The Report conta ins three Appendices: -

Append ix 1 l i s t s t h e m e m b e r s h i p of t h e Pro jec t S tee r ing

Committee a n d t h e two Project Local Committees.

Appendix 2 i s t h e submis s ion m a d e b y t h e Project Steer ing

Committee t o t h e Department of Health on Private Nursing Home

Legislation.

Appendix 3 i s t h e submission made t o t h e Department of Health on

t h e Interim Report of t he Dublin Hospital Initiative Group.

4

SECTION 1: PROJECT STRUCTURES AND PROGRAMME OF WORK.

1.1. PROJECT STRUCTURES:

Steering Committee

The project Te rms of Reference st ipulated t h a t t h e project

steering committee w a s to b e t h e pr imary project s t ruc tu re

wi th responsibility for t h e es tabl ishment , development a n d

monitoring of t h e project activities a n d s t ructures . The ma in

func t ion of t h e s teer ing commit tee w a s s e t down i n t h e

Terms of Reference a s a p l a n n i n g one i n respect of services

for t h e elderly i n t h e project a rea . This required t h e project

steering committee t o develop a n overview of existing needs

a n d services i n t h e a r e a a n d t o b r ing together exist ing

service-providers i n order t o provide a n in tegrated a n d

comprehensive range of services t o meet identified needs . A

series of subsidiary funct ions for t h e steering committee were

se t o u t i n t h e Terms of Reference:

(i) t o a s s e s s t h e specia l accommodat ion , h e a l t h a n d

welfare needs of t h e aged i n t h e a r e a having regard t o

local social a n d demographic factors;

(ii) t o p ropose p r o g r a m m e s of ac t ion t o t h e p a r e n t

s ta tu tory authorities for meeting these needs;

(iii) t o m a k e recommenda t ions t o t h e p a r e n t s t a t u t o r y

authorit ies on the priorities which should b e adopted;

(iv) t o c o - o r d i n a t e t h e i m p l e m e n t a t i o n of a g r e e d

programmes a n d regularly evaluate t h e effectiveness,

e f f ic iency a n d d e g r e e of s a t i s f a c t i o n w i t h t h e

accommodat ion a n d s u p p o r t services for t h e aged

provided b y s t a tu to ry au thor i t ies a n d b y voluntary

bodies;

5

(v) t o m a i n t a i n c o n t a c t w i t h regional , na t i ona l a n d

international developments in providing for t h e special

needs of t h e aged, and , i n particular, to identify "good

practice" i n other a r ea s t h a t might b e followed;

(vi) t o provide a mechanism for the integration of services

for elderly persons provided by the voluntary sector and

the private sector.

The composition of t h e project steering committee recommended

in t he Terms of Reference w a s a s follows;

a senior heal th board administrator (with clearly designated

responsibility for mat ters relating to t he elderly);

a senior local authori ty administrator (with clearly designated

responsibility for mat te rs relating t o t h e elderly);

the director of community care for t he designated area;

the superintendent public heal th nu r se for t h e designated

area;

a consultant physician i n geriatric medicine;

a representative of t h e voluntary sector;

other relevant personnel t o b e co-opted by the steering

committee a s deemed necessary.

Local Committees

The Terms of Reference for t h e projects also required t h a t each

s teer ing committee e s t ab l i sh local commit tees t o co-ordinate

services for catchment a reas of 15,000 - 20 ,000 population. The

functions of t he local committees a s se t ou t in t he project Terms of

Reference were to:

6

(i) co-ordinate the delivery of services to the elderly a t th is level

so a s to ensure the most effective u s e of local resources;

(ii) identify t he needs of the elderly in t he a r e a a n d t h e local resources with a view to informing the planning process in

t he designated area;

(iii) maintain a n up-to-date inventory of the elderly persons likely to b e "at risk" in t he area and carry out a regular assessment

of their needs;

(iv) evaluate regularly t he contribution of existing sys tems of

service provision both voluntary a n d statutory;

(v) provide a n advocacy role for individual elderly persons with relevant service agencies, (e.g. in relation to a n application for a local authority dwelling or a n application for a home help

service);

(vi) ma in ta in close contac t wi th inst i tut ional facilities bo th

private/voluntary and statutory in the area;

(vii) make recommendations to the steering committee a s to how services should be developed in t he particular local area.

The recommended membership of the local committees w a s :-

a public health nurse; a home-help organiser; a social worker; a physiotherapist; a general practitioner; a n occupational therapist;

_ representatives of local active voluntary organisations; a n officer designated by the housing authority; a n officer designated by the health board; family carers; elderly people.

The actual membership of the Dun Laoghaire Project Committees is

included a s Appendix 1 to the report.

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1.2 DEMOGRAPHIC CHARECTERISTICS OF THE DUN

LAOGHAIRE PROJECT AREA

T h e demographic charac te r i s t i cs of t h e D u n Laoghaire

project a r e a a r e summar i sed i n Table 1. In 1986 D u n

Laoghaire h a d a populat ion of 54,715, 14% of whom were

aged 6 5 years a n d over a n d 6% of whom were aged 7 5 years

a n d over. These percentages were higher t h a n the Sta te

ave rages w h i c h were a l m o s t 11% a n d j u s t over 4%

respectively. The elderly living alone a r e regarded a s being

more vulnerable a n d more a t r isk t h a n those living in multi-

person households. In D u n Laoghaire t h e proportion living

alone, a t 25.4%, i s also higher t h a n t h a t of t h e State a s a

whole wh ich w a s 21.1%. T h e age dependency r a t e i s

calculated a s t he ratio of dependent persons aged 0 - 1 4 years

a n d 6 5 years a n d over t o t h e r e s t of t h e population. D u n

Laoghaire Borough h a s a ra te lower t h a n t h e Sta te ra te of

66.1. The vital age rate, t he proportion of the population aged

be tween 2 5 a n d 4 4 yea r s , wh ich i s a m e a s u r e of a

community 's capacity t o suppor t i t s dependent population,

points t o a relatively heal thy demographic s t ruc ture in Dun

Laoghaire Borough where t h e ra te is marginally in excess of

t h e Sta te average. D u n Laoghaire Borough h a s also a high

number of persons per square kilometre, indicating a highly

urbanised area.

Table 1

Dun Project Area - Basic Demographic Characterises 1986

Area Population Percentage Population Aged 6 5 Tears a n d over

Percentage Population Aged 7 5 Years a n d over

Persons P e r Square Kilometre

Percentage Disbrlbutlon Population Aged 6 5 Years a n d over l iv ing Alone

Vital Age Rate Percentage

Age Dependency Pe r 1 0 0 Active Age Persons

Dun Laojjghalre Borough 54,715 14.0 6.0 3,181 25.4 25.4 59.3

State 3,540,643 10.9 4.1 51 21.1 25.1 66.1

Source: Census of Population, 1986

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1.3 DUN LAOGHAIRE PROJECT PROGRAMME OF WORK

The project steering committee w a s established in May 1987.

Two local committees (one, t h e Blackrock local committee to

cover t h e Blackrock/Booterstown/Sallynoggin catchment a rea

with a population of 25,900 a n d the other, t he Dun Laoghaire

local committee t o cover the Dun Laoghaire/ Dalkey/Glasthule

ca tchment a rea wi th a population of 28,800) were established

i n November 1987.

Committee chairpersons and secretaries were appointed a n d

e a c h committee m e t o n a monthly bas i s for t h e durat ion of

t h e Pilot Projec t . A p ro jec t development worker w a s

employed o n a contract bas i s by the Eas tern Health Board in

November, 1988.

T h e m a i n fea tures of t h e programme of work under taken by

t h e D u n Laoghaire Project were a s follows:-

(i) T h e establishment of a n additional Day Centre for t h e

Elderly. This scheme w a s undertaken b y the Blackrock

local committee a n d is described i n 2 . 4 commencing

o n page 47..

(ii) Suppor t for family carers.

A s t ruc ture w a s p u t in place for t he compilation of a

comprehensive series of information leaflets on various

aspects of caring for t he elderly, including:-

Mobility a n d the older person;

Communication impairment a n d t h e older person;

Community - based support;

Residential care a n d older people;

A checklist of medical symptoms for carers and

older people;

Equipment for promoting the independence of

older people;

Sheltered Housing;

Change and loss;

1 0

The process adopted in t he preparation of these leaflets consisted of bringing together in working groups a range of professions including nurses , occupational therapists, psychologists, physicians, social workers and day care centre staff. This process was facilitated by the project development worker a n d all relevant agencies a n d personnel were contacted. The designing and printing of the information leaflets was funded by the Eastern Heal th Board . Some prepara tory work w a s a lso undertaken b y t h e project in respect of a voluntary relief sitting service for family carers and a protocol for t he establishment of such a system was drawn up .

Service a n d Co-ordination Issues The Project committees addressed a number of aspects of care provision and service co-ordination:

I s sues i n respect of inter a n d intra-s ta tutory

liaison a n d co-ordination in the project area were

identified a n d a submission was made to t h e

National Council for the Elderly in this regard.

The establishment in 1990 by the Eastern Health Board of a Care Team to co-ordinate services for the elderly a t Community Care Area level (see 3.3. below) a s p roposed in The Years Ahead

(Department of Health, 1988) and endorsed in t h e E.H.B. Policy Document, Services for the

Elderly (1989), w a s considered. Of particular concern here w a s t he relationship between t h e Care Team a n d t h e Pilot Co-ordination Project a n d how t h e experience of t he Pilot Project to date could inform the process of establishing the Care Team in the area.

The housing needs of elderly persons in the Dun Laoghaire Borough were documented arid t h e issues arising are discussed in full in 2.2. below.

11

The Nursing Homes Bill (1989) a n d the related

Code of Practice were considered by the project

committees. This w a s regarded a s important

because of t h e high n u m b e r of nursing homes

within the catchment area, a n d submissions were

made to the Department of Health on the Code of

Practice (See Appendix 2).

The Interim Report of t h e Dubl in Hospital

Initiative Group (Kennedy, 1990), which w a s

p r epa red for t h e Minis ter fo r Heal th w a s

discussed, with particular reference to the needs

of the elderly in the D u n Laoghaire area and the

organisa t ional a r r a n g e m e n t s m o s t likely t o

address these needs. A submission was made by

the project on this report (See Appendix 3).

The need for a comprehensive review of transport arrangements for elderly persons was identified. A small-scale voluntary car pool to provide limited transport for selected elderly persons was p u t in place on a trial basis . Recommendations were also made to the appropriate agencies in respect of t h e design a n d access aspec t s of public

transport.

Emergency information leaflets (which were to be filled in by the elderly persons or their carers and provide basic information likely t o b e of u se in a n emergency) for display in the homes of elderly persons were circulated to a number of homes in the area.

The project identified a need for addit ional support services for t he elderly mentally infirm -day centre care night care, relief care a n d long stay care b u t did no t succeed in developing any of these services.

12

Recommendat ions were m a d e t o An Post i n respect of modifications to buildings t h a t would a s s i s t elderly p e r s o n s in conduc t ing the i r business.

(iv) Voluntary/Statutory Forum

The establishment of a forum to co-ordinate the vo lun ta ry a n d s t a t u t o r y sec to r s of service provision for t he elderly was under taken b y the D u n Laoghaire local committee. The forum was envisaged a s a mechanism where t h e various suppor t services for individual elderly persons could work toge ther i n o rder t o maximise resources. The realisation of the forum concept took t h e form of discussions with a range of voluntary bodies i n the catchment a r e a over a number of months so a s (i) to explain the na ture a n d purpose of t he proposed forum a n d (ii) to elicit t h e co-operation of t he relevant voluntary groups. As par t of th is process a general meeting w a s h e l d i n F e b r u a r y 1 9 9 0 b e t w e e n r e p r e s e n t a t i v e s of t h e s t a t u t o r y s e c t o r , representat ives of a large range of voluntary bodies working in t he area and representatives of t he pilot project. However, i t w a s n o t possible, due to lack of resources, to progress t he forum idea further during t he course of the Pilot Project a n d t he mat ter w a s referred to t he Care Team, (See 3.3. below), for consideration.

(v) Voluntary/Statutory Liaison Various aspects of liaison between t he voluntary and statutory sectors were considered during the course of the Pilot Project. The outcome of these deliberations i s presented in 3.2 below.

1 3

(v) Loneliness a n d isolation were identified b y project committees a s affecting m a n y elderly people. The telephone w a s identified a s being very important for elderly persons living on their own b u t the current cost of installation is too high for some of the elderly. An approach was made to Te lecom E i r e a n n t o c o n s i d e r i n s t a l l i n g telephones free of charge for the elderly living on thei r own dur ing 1993 t h e Year of t h e Older People a n d Solidarity between Generat ions . However, t h e response f rom Telecom was not favourable to the idea.

Inter Project Meetings:

During t he course of the project a number of joint meetings were held wi th t h e members of t h e Tipperary South Riding Project Committees. Some general i ssues affecting service co-ordination were identified a t these joint meetings:-

t h e problem of insurance cover for volunteers/voluntary

groups providing services on a voluntary basis;

t h e need for a review a n d a broadening of t he criteria for

eligibility for t h e Depar tment of Social Welfare Carers '

Allowance;

t h e need for t h e provision of a more comprehensive a n d targetted system of t ransport provision for elderly persons, particularly transport t o day care centres and to outpatient

clinics;

the need to address specific environmental issues, e.g. access a n d seating facilities which would enhance the quality of life of frail elderly persons.

14

General Comment:

While t h e project committees undertook a wide range of t a s k s a n d

while m a n y impor tan t i s sues were d iscussed, t h e programme of

work w a s hampered somewhat b y t h e heavy work load of s ta tu tory

staff a n d b y t h e f ac t t h a t project w o r k frequently could n o t b e

afforded t h e t ime o r a t tent ion required for a comprehensive a n d

planned co-ordinated approach. However, there w a s a high level of

participation b y health, housing a n d voluntary sector personnel over

a four-year period. The mere fac t t h a t t h e Pilot Project survived

over a four -year period despi te m a j o r obstacles of t ime a n d

r e s o u r c e s w a s a s ignif icant ach ievement i n itself. T h e in t e r ­

discipl inary composi t ion of t h e commit tees m e a n t t h a t m a n y

b a r r i e r s we re b r o k e n down, t h a t t h e r e w a s a h i g h level of

information exchange between t h e var ious sectors a n d disciplines

a n d t h a t a s e n s e of m u t u a l t r u s t evolved. All of t he se fac to rs

contr ibuted t o establ ishing a platform for t he fu ture co-ordination

of services i n t he D u n Laoghaire area.

1 5

SECTION 2 ISSUES OP SERVICE PROVISION

2.1 INTRODUCTION

This sect ion of t h e repor t dea l s with t h ree key a r e a s of

service provision i n respect of t h e elderly a s identified b y t h e

project committees. Firstly, t h e role of housing in t h e care of

t he elderly i n t h e community i s described. The n a t u r e a n d

extent of cu r ren t hous ing provision in t he a rea i s outlined.

Various aspec t s of hous ing policy relevant to t he elderly a re

discussed a n d t h e recommendations of t h e Project Steering

Committee a re presented.

Secondly, t h e i s sue of l iaison between hospi ta ls a n d t h e

community i s discussed. Current practices are described and

various problems a r e identified. A number of proposals for

improving liaison between t h e community a n d hospi ta ls in

respect of t h e admission a n d discharge of elderly persons are

set out.

Thirdly, t h e role of day centres in the provision of care for

t he elderly in t h e community is discussed. The extent of day

care provision in t h e D u n Laoghaire a rea i s described. An

outline account of t he establishment and development of one

day centre i n t he a rea i s described. Some recommendations in respect of day care provision are included.

*

2.2. HOUSING PROVISION FOR THE ELDERLY AND RELATED ISSUES

2.2.1 The Pilot Project a t a n early stage of i ts deliberations agreed

t ha t t h e provision of adequate accommodation for t h e elderly

i s a bas ic need, a n d a n a r e a i n which m a n y agencies, both

statutory a n d voluntary, have a n involvement. It w a s decided

t h a t t h e project would s t u d y t h e varying hous ing needs of

elderly persons in t he D u n Laoghaire Borough area, how these

needs were being met , a n d how bes t to co-ordinate t he

various services in t h e provision of housing ih t he fu ture .

1 6

The following areas were identified dur ing the course of t h e

project a s being of particular importance:

(i) t h e need for the increased provision of housing un i t s

for elderly persons;

(ii) grant assistance to disabled elderly persons;

(iii) t h e provision of emergency accommodation for

homeless elderly;

(iv) refurbishment, repairs a n d maintenance to homes of

t he elderly, both publicly a n d privately owned;

(v) t he provision of accommodation for the elderly by

voluntary housing associations;

(vi) t he design of housing accommodation for elderly

persons.

Each of these areas are now considered:

2.2.2 The Need for Increased Provision of Public Housing Units for

the Elderly

There i s ongoing co-ordinat ion between D u n Laoghaire

Corpora t ion a n d t h e E a s t e r n H e a l t h B o a r d i n t h e

identification a n d a s se s smen t of t h e housing needs of t h e

elderly. This h a s b e e n improved b y increasing contac t

between officers from bo th bodies a t local level a n d a s a resul t

of t h e pilot project commit tees . In addi t ion to t he i r

involvement i n t h e deve lopment of vo lun ta ry h o u s i n g

schemes, voluntary agencies in t h e Borough a re also actively

involved in identifying hous ing needs a n d bringing them to

t he attention of t he Corporation where necessary. In the pa s t

t h e S t . Vincent De Paul, t h e Y.M.C.A. a n d Friends of t h e

Elderly have played impor tan t roles in identifying i s sues

17

which otherwise might no t have come to the attention of the relevant agencies.

The total housing stock of D u n Laoghaire Corporation a t 3 1 / 1 2 / 9 0 w a s 5254, a lmos t half of which have been purchased under the tenan t purchase schemes. There were

» 220 local authority housing uni t s built specifically for elderly people in addition t o s tandard local authority homes occupied by elderly persons.

Of t he 2 2 0 un i t s of special housing provided for elderly persons, 123 were sheltered housing having a warden and a n alarm/communications system.

The following is a brief description of elderly housing provided by Dun Laoghaire Corporation.

(i) sheltered housing (alarm/warden linked);

(ii) purpose-built small schemes for the elderly; (iii) a number of uni ts within mixed housing-schemes; (iv) allocation of 1 or 2 bedroom ground-level flats to

elderly by priority (this i s a long-term policy of the Borough).

(i) Sheltered Housing

D u n Laoghaire Borough Corporation h a s three such schemes with a total of 123 (57+32+34) lettable units. These are;

Beaufort 5 7 lettable uni ts + 1 caretaker flat (warden service i s funded by the Eastern Health Board).

Rochestown House 2 phases:

Phase 1 3 2 lettable units of sheltered housing (linked to a n alarm and a warden flat), (1 warden flat);

18

Phase 2 18 lettable uni t s of non-sheltered housing (no alarm) (have use of facilities of Phase 1).

Brookfield Lawn 32 lettable uni t s of sheltered housing - 1 uni t a s warden's flat (warden is recruited and funded by Dun Laoghaire Old Folks Association).

(ii) Purpose-Built Schemes for the Elderly

Kilbegnet Close: 3 0 lettable units, (one uni t is used a s a base for a 'meals-on-wheels' service). Each house h a s a n a la rm system linked directly to Eas te rn Health Board Ambulance Control Centre in St. James ' s Hospital.

(iii) Units for Elderly within Mixed Housing Schemes

A number of housing schemes in the Borough have units (approximately 3 0 in total) allocated to elderly persons - Dunedin, Loughlinstown, Rollins Court, Cross Avenue, Frasca t i (Blackrock), Sorrento Close (Dalkey), St . Patricks Close, Brookfield Place (Blackrock).

(iv) Ground Level Flats

It h a s been the traditional policy of the Corporation to give preference to the elderly in the allocation of flats a t ground level. The Corporation h a s approximately 3 0 0 s u c h flats, mostly one-bedroom, b u t some two bedroom flats.

In addition to the above schemes Dun Laoghaire Corporation

h a s plans submitted for the construction of 2 1 one-bedroom

dwellings for elderly persons in various locations and sanction

t o t h e s e a r e awai ted f rom t h e D e p a r t m e n t of t h e

Environment.

1 9

T h e n u m b e r of elderly o n t h e D u n Laoghaire Corporation's

Housing List for t h e period since t h e inception of t h e Pilot

Project i s set out below:-

These figures show a gradually increasing n u m b e r o n t h e

hous ing list over t h e p a s t four years. The Project Steering

Committee, therefore, considers t h a t there i s a need for a n

ext ra housing capital provision from t h e Depar tment of t h e

Environment in order t o deal with the built u p demand.

2.2.3. Grant Assistance t o Disabled Elderly Persons

The Disabled Persons G r a n t s Scheme in t roduced by t h e

Minister for Local Government i n 1972 provided a s follows:-

The grants m a y b e m a d e b y County Councils (for t h e

e n t i r e c o u n t y - a t - l a r g e ) a n d C o u n t y B o r o u g h

Corporations a n d may in the ease of a non-vested local

authori ty dwelling represent t he approved cost of t h e

work and in all other cases may amoun t t o a maximum

of two-thirds of th i s cost. The local authori ty m a y a t its

discretion, carry o u t t h e reconstruct ion improvement

work themselves.

D u n Laoghaire Corporat ion w a s no t included a s a local

au thor i ty for t h e pu rposes of t he Disabled Persons Gran t

Scheme a n d accordingly Dublin County Council administers

the scheme for the whole of County Dublin.

Dublin County Council a n d Dublin Corporat ion carry o u t

approved works on their n o n vested dwellings a t n o cost to

t h e tenants . However i n t h e case of tenants of D u n Laoghaire

December 31s t

1987

1988

1989

1990

8 9

9 4

9 7

110

2 0

Corporation some confusion arose over which authority was

responsible for the cost of work above t h e approved grant

amount.

In 1975 t he Department gave approval to Dun Laoghaire Corporation, to operate "a scheme for t h e provision of structural alterations to facilitate disabled persons occupying non-vested Corporation houses".

As a result of this approval Dun Laoghaire Corporation h a s operated a number of different schemes over t h e years a s follows:

(i) The Corporation engaged contractors to carry out the approved works a n d recouped t h e Disabled Persons Grant from Dublin County Council. Any expenditure in excess of the grant was borne by the Corporation. This scheme remained in operation until 1982, when due to financial constraints the Corporation was obliged to discontinue it.

(ii) From 1984 the Corporation allowed tenants carry out the approved works themselves a n d the tenant claimed the grant from Dublin County Council. The Corporation would then make a contribution to the cost of the work subject to a maximum of £1,000.

(iii) The presen t scheme, operated b y D u n Laoghaire Corporation since June , 1986, allows for t he payment of a contribution which does not exceed a maximum of 50% of the grant approved by Dublin County Council. This grant is only paid when the full grant amount h a s been paid by the County Council.

2 1

As can be seen from the foregoing, Dun Laoghaire Corporation

h a s operated a number of different schemes over the years in

relation to their disabled tenants . While the current scheme

is a n improvement on the position between 1982 and 1984 it

i s a major disimprovement o n t he position from 1975 to 1982 w h e n t h e cost of t h e works w a s bo rne b y t h e Corporation.

At p resen t D u n Laoghaire Corporation is t h e only local

authority in the Dublin area which does not cover the full cost

of works carried ou t on non-vested dwellings. The Committee

considers t ha t t he Corporation a s Housing Authority and a s

landlords h a s a duty to provide adequate accommodation for

their tenants who are disabled.

While accepting t h a t t h e Corporation h a s difficulties with providing the necessary finance in their annual estimates for th is type of work the Committee would request t h a t serious consideration b e given to providing sufficient funding in the Annual Est imates of Expenses to meet the balance of the approved costs not covered by the Disabled Persons Grant. In particular, the Committee requests t ha t the D u n Laoghaire Borough Council give serious consideration to implementing the necessary policy changes to allow their tenants the same benefits a s are enjoyed by the tenants of Dublin Corporation and Dublin County Council.

The Steering Committee, therefore, makes t h e following recommendations in respect of the Disabled Persons' Grant Scheme.

(i) The amoun t of grant should cover t he ful l cost of approved works including architects fees.

The current grant i s £5,000 and h a s not been increased since 1985. In tha t time the Wholesale Prices Index for the Dublin area h a s increased a s follows: -

2 2

Base 1985

1986 1987

1988 1989

100 102.30 105.10 108.70 116.40

On these statistics alone the grant should be increased to £6,400. However a s the 1985 grant level of £5,500 w a s no t sufficient a t t h a t t ime to meet the costs involved, it i s considered t h a t the scheme should b e revised to provide for the full costs of all approved works including Architect's fees.

(ii) The Disabled Persons' Grant should b e subject to a

means test: -

In t he course of its examination of the existing system the committee h a s established tha t in a number of cases grants are being paid to householders whose income is sufficient to meet the full costs of the necessary works without any undue hardship. The payment of grants in these cases i s reducing the amount of money available for grant applicants whose financial situation does not allow them to meet these sort of costs. The Committee considers t h a t i n t h e cur ren t climate of financial res t ra int t he limited resources available should b e directed towards those in most need of assistance.

(iii) All local authorities should be required to cover the

costs of any works deemed necessary o n non-vested

local authority dwellings:-

At present in the Dublin area, Dublin County Council and Dublin Corporation carry out any work deemed necessary for their disabled tenants. In the case of Dun Laoghaire Corporation the tenant is obliged to carry out the work with a grant being paid by Dublin County Council. The Committee considers t h a t all Local Authority disabled tenants should be provided with

2 3

adequate facilities to meet their needs irrespective of

which Local Authority a rea they live in.

(iv) Local Authorities should draw u p a panel of approved

local Contractors: -

The Committee considers t h a t this type of panel would

b e a great benefit t o disabled persons, particularly the

elderly who may have n o experience of dealing with

con t rac to r s . E a c h local au tho r i t y s h o u l d invite

appl icat ions f rom qualified con t rac to rs /bu i lde rs for

inclusion on a panel from which grant applicants would

b e advised t o m a k e the i r own choice. The Local

Authority could then monitor the s tandard of the work

a n d the prices being charged.

T h e Steer ing Commit tee r ecommends t h a t t h e c u r r e n t

s c h e m e s b e e x a m i n e d i n l i gh t of t h e foregoing

recommendations, and whatever action necessary to have the

scheme amended should be implemented a s soon a s possible.

2 .2 .4 The Provision of Emergency Accommodation for Homeless Elderly.

T h e Housing Act, 1988 (Section 2) which h a s been in

operation since 1st J a n u a r y 1989 defines a homeless person

for t he purposes of the Act a s follows:

"A person shall b e regarded b y a housing authori ty a s being

homeless for the purposes of th i s Act if -

(a) t he re i s n o accommodat ion available which, in t he

opinion of t h e authori ty, he, together wi th any other

person who normally resides with h im or who might

r e a sonab ly b e expected to reside w i t h h im, c a n

reasonably occupy or remain in occupation of, or

(b) h e i s living in a hospital, county home, night shelter or

other s u c h institution, a n d is so living because he h a s

2 4

n o accommodation of the kind referred to in paragraph (a) and he is, in the opinion of the authority, unable to provide accommodation from his own resources.

During t he project period, the needs of the homeless elderly were investigated and the responses of the health board, local authori ty a n d voluntary bodies in meeting t h e need were examined wi th a view to put t ing in place pe rmanen t arrangements. The legal duty of housing the homeless falls on the Health Authority by virtue of Section 54 of the Health Act 1953. In practice, however, the need h a s been traditionally met by t he local authorities by accepting applications from homeless persons , a n d by offering dwellings f rom local authority housing stock. In this way, many elderly people who for some reason found themselves without accommodation in D u n Laoghaire secured a permanent home through t h e

Corporation.

While th is continues to be the Corporation's policy, in recent

years t h e increasing number of persons falling into th i s

category h a s p u t severe pressure on the very limited amount

of accommodation available.

Homelessness h a s many causes and each particular case mus t be assessed on its own merits. The generally accepted image of a homeless person is of a man /woman wandering t he streets by day a n d sleeping rough by night, depending o n charitable a n d voluntary services for sustenance. In the case of the D u n Laoghaire Borough, the potential homeless a re more likely to be persons already in accommodation, b u t facing the loss of th is accommodation through a variety of

causes.

These would include straightforward evictions through legal processes; persons asked to leave because of house sales; and

persons reaching retirement and being asked to leave t he house they retained in their employment. Normally, t h e

2 5

Corporation becomes aware of t he impending homelessness

i n advance, a n d there i s time to a s se s s t h e application,

determine t h e exact hous ing need, taking into account

medical factors, a n d provide a dwelling to meet t h e need

when it arises.

In the years 1987 to 1990, the Corporation housed a total of 5 3 cases of homeless persons of all categories. Ah analysis of th i s figure reveals t h a t 2 3 of these cases, or 43%, were middle aged or elderly applicants. By way of illustration, the cases of t h e elderly a n d middle aged housed u n d e r th is heading of 'Homeless' in 1989 are described below:

a n 8 5 year old woman who had no accommodation available to her on leaving hospital:

a middle aged single m a n who was a victim of family

violence;

a n 8 2 year old woman who was unable to afford nursing

home accommodation;

a middle aged single man, had to leave a nursing home

when it was sold;

two middle aged single brothers housed together - one h a d been staying with friends, one was sleeping rough;

a 6 4 year old woman whose accommodation w a s no longer available to her following her re turn from illness (house sold);

a 59 year old m a n who was living in a city centre hostel;

A 62 year old woman who was evicted following house

sale;

a 5 0 year old single m a n who was made homeless a s a

result Of fire.

2 6

The above cases are typical examples of homeless persons

coming to t he at tention of t he Corporation. This trend is

increasing in the last three years and a number of causes can

b e suggested:

(i) t he rise in property values in Dun Laoghaire in recent

years resulting i n increased property sales:

(ii) the high cost of nursing home accommodation; and

(iii) t he lack of a n emergency hostel facility for the elderly

in Dun Laoghaire.

Section 10 of t h e Housing Act 1988 empowers housing

authorit ies (in addition to their existing powers to house

persons a s described above) to make arrangements with

voluntary bodies for t h e provision of accommodation for

homeless persons. They are also empowered, if necessary, to

ren t accommodation, arrange lodgings or contribute to the

cost of such accommodation or lodgings. Homeless persons

who are assisted under this Section retain their entitlement

to be included on a Housing Assessment and to be rehoused

in the normal way b y the Authority. The Housing Authority

may arrange such accommodation for a person while making

enquiries to determine if tha t person is homeless.

While liaison arrangements have been made with the Eastern Health Board to meet t he demand for accommodation, the reality i s t ha t t he lack of emergency accommodation in the Borough means t h a t elderly and middle aged persons finding themselves in homeless s i tuat ions have to await official eviction or move in temporarily with friends before being housed by the Corporation. This is not a desirable situation a n d one which should b e addressed by increasing t h e provision of shor t or medium term accommodation in Dun

Laoghaire.

The Corporation h a s made efforts to establish permanent effective arrangements with private bed and breakfast owners

2 7

t o meet t h e needs a s specified in Section 10 of t he Act, b u t

only limited success h a s been achieved. The voluntary bodies

were also consul ted i n t h i s regard a n d i n 1988 t h e St .

Vincent De Paul Society in D u n Laoghaire w a s able to offer

bed a n d breakfas t accommodation on a limited scale through

o n e of i t s m e m b e r s . T h e Projec t S tee r ing Commit tee

considers t h a t there i s a substant ia l need for more emergency

hostel-type accommodation in t h e Borough to cater for t he

growing n u m b e r s of elderly a n d middle aged w h o f ind

themselves homeless.

2.2.5 Refurbishment, Repairs and Maintenance t o Homes of t h e Elderly.

The provision of good quality accommodation h a s always been

seen a s fundamenta l to t h e well being of t he elderly. For many

people their accommodation is t h e centre of their activities,

a n d accordingly i t i s necessary to ensu re t h a t t he physical

quality of thei r h o m e s i s main ta ined a n d improved where

necessary.

T h e Project examined t h e v a r i o u s p rob lems of service

provision in th is a rea and the following issues arose.

(i) t h e high incidence of elderly living in accommodation

lacking modern facilities in the Borough area;

(ii) t h e increas ing n e e d for ma in t enance a n d repair of

homes, b o t h in t he public and private sectors.

Local Authority Accommodation Lacking Modern Facilities:

The total rented housing stock of Dun Laoghaire Corporation

a t 3 1 / 1 / 9 1 w a s 2 ,339 . Included in t h i s f igure a r e 6 5 2

h o u s e s / f l a t s wh ich a r e i n t h e sub - s t anda rd category a n d

which are in need of upgrading. These housing un i t s were all

cons t ruc ted wi th in t h e period 1880 - 1944, all wi thout

ba throoms, 133 of which have only a n outdoor toilet. The

majority of these dwellings a re occupied by elderly residents.

2 8

In 1985 the Department of t he Environment introduced a scheme of remedial works for local authority housing in a state of serious deterioration due to age. The intention of the scheme of remedial works was to prolong the economic life of the houses, a n d improve the social fabric of the area. Dun Laoghaire Corporation h a s availed of the scheme of remedial works a n d t o d a t e t h e following s chemes have been successfully refurbished:-

(i) Barret St., Dun Laoghaire - 2 4 uni ts from 3 6

original units;

(ii) St. Patrick's Square, Dalkey - 24 uni ts from 24 original units;

(iii) Brookfield, Blackrock (Phase 1 ) - 6 units from 8

original units;

(iv) Brookfield Place, Blackrock (Phase 2 ) - 1 1 uni ts

from 14 original units;

(v) Cumberland Street, Dun Laoghaire - 15 uni ts from

20 original units;

(vi) St. Patrick's Avenue, Dalkey - 12 uni ts from 12

original units.

The works carried out on these schemes involved complete refurbishment which included the provision of indoor toilets, ba throoms a n d general upgrading of the dwellings. The refurbishment h a s extended the life of the dwellings and it is considered t h a t t h e occupiers have developed a renewed sense of pride in their surroundings.

The Corporation i s continuing to modernise all of these dwellings on a phased bas is and the current remedial works priority list is a s below:

2 9

(i)

(ii)

Phased refurbishment of older dwellings in Central Dun Laoghaire Area.

Brookfield Place, Blackrock. (Phase 3 & Phase 4)

(iii) St. Anne's Square Blackrock.

(iv.) Glasthule Buildings

Phase 1 - Dominic Street Conversion of 2 0 sub­standard flats to 6x1 bed­room, 8x2 bedroom and 1x3 bedroom refurbishment units

Conversion of 2 6 uni ts into 19 refurbished units. Scheme completed late 1992

Refurbishment of 3 6 flats.

Refurbishment of 7 5 one bedroom flats. Work on Phase 1 expected to begin early 1993.

1991 - 2 3 bathrooms completed. 1992 - Work in progress in 2 9 bathrooms

(v) Bathroom Replacement Programme - 242 single dwellings lacking modern bathroom facilities in different areas of the Borough.

The completion of the above programme is dependant o n a n A n n u a l Remedial Works Scheme Allocation f rom t h e Department of the Environment. The allocation for 1992 is £450 ,000 (£360,000 for u r b a n renewal programme a n d £60 ,000 for bathroom replacement programme) which will facilitate t he continuat ion of t he central Dun Laoghaire refurbishment programme a s well a s the commencement of works a t Glasthule Buildings, Glasthule, based o n t h e allocations so far.

The final completion of works would appear to be some

distance in the future . Accordingly, it is recommended tha t

the Department of the Environment substantially increase the

Remedial Works Allocation to enable a s ta r t to be made on

refurbishing the two remaining schemes in St. Anne's Square,

Blackrock and Glasthule Buildings. These are occupied

almost exclusively by elderly and middle aged persons.

3 0 Maintenance and Repair of Elderly Persons' Dwellings

Public Housing

The general main tenance a n d repa i rs needed to Local Authority rented dwellings are the direct responsibility of the relevant authority. In the pas t few years in Dun Laoghaire, however, voluntary redundancies a n d t h e Government 's embargo on public sector employment h a s led to a decrease in staff in the Corporation's maintenance department.

This h a s in t u rn led to delays in the carrying out of normal repa i r work. However, essent ial repai r work i s always under taken without delay with priority given to repairs in elderly persons ' housing. To a large extent, t h e works required a re directly attributable to t he age of t he dwellings, a n d t h e s e a r e being addressed b y t h e r e fu rb i shmen t programme described above. However, in light of the time needed t o complete t h e r e fu rb i shmen t scheme, i t i s recommended t h a t in the interim period, t he Corporation should increase the amount of skilled tradesmen for housing maintenance and repairs and effect a significant increase in the annua l estimates of expenses for house repairs and re­decorating.

Private Housing

In t he Borough of D u n Laoghaire there a re 4 ,621 private households headed b y persons aged 6 5 years and over. This represents 30% of all private dwelling uni ts in the Borough.

The majority of these uni ts would be owned by the occupant while rented a n d formerly rent-controlled dwellings would account for the balance. Many of these are older dwellings requiring a higher level of repairs and maintenance t h a n more modern dwellings, b u t because of financial constraints the residents are not in a position to initiate improvements.

3 1 Private Rented Dwellings

The Housing (Private Rented Dwellings) Act 1982 and the Housing (Private Rented Dwellings) (Amendment) Act 1983 a n d t h e Housing (Private Rented Dwellings) (Standard) Regulations 1984 a n d the consequent establishment of the Rent Tribunal, have enabled the setting u p of s tructures to deal with t he problems associated with dwellings tha t were subjec t to ren t control under the Rent Restrictions Acts, 1960 to 1981. Under the 1982 Act 4 7 0 formerly ren t

control led dwell ings have been regis tered wi th t h e

Corporation. The standard Regulations require landlords to

meet certain minimum standards in regard to the structural

condit ion of t h e dwellings, water supplies , ventilation,

lighting a n d services. The landlord is also required to keep

clean a n d in good repair common areas , boundaries a n d

services used by the tenant in common with other persons.

All de-controlled dwellings are required t o meet these

s tandards with effect from 1st January, 1988, and the penalty

for contravention of the Regulations set out in Section 2 7 of

the 1982 Act is a fine not exceeding £500.00.

Despite these regulations, a number of tenants surveyed in the Dun Laoghaire area, mainly elderly persons, indicated tha t they did not want any action taken against the landlord a s they feared tha t their existing low rent would b e dramatically increased if t he landlord was forced t o carry o u t major repairs. There was also a number of tenants who indicated t h a t they feared eviction if action w a s initiated by t he Corporation.

The Project Steer ing Committee cons iders t h a t D u n Laoghaire Corporation should continue to make every effort to seek improvement in t h e housing conditions of elderly tenants in formerly rent-Controlled dwellings b y a rigourous enforcement of t he Housing (Private Rented Dwelling) (Standard) Regulations 1984.

3 2 Owner Occupied Dwellings

The Task Force on Special Housing Aid for the Elderly, which

includes representatives of voluntary bodies, local authorities,

the Departments of Health and Social Welfare and AnCo, was

set u p under the aegis of the Department of the Environment

in 1982 to undertake a n emergency programme to improve

the housing conditions of elderly persons living alone in unfit

or insanitary accommodation and who were not themselves in

a position to under take t he necessary remedial work. The

programme is operated b y t h e regional health boards and

provides ass i s t ance u p t o t h e ful l cost of necessary

improvements for eligible applicants . The range of j obs

undertaken are carpentry, plumbing, painting and decorating

a n d general cleaning a n d repa i rs t o windows, doors,

floorboards, etc. The scheme caters for elderly persons (i.e.

m a n a n d wife, s i s te r /b ro ther etc.) who have insufficient

means to arrange any of the above services for their homes

and who have no able-bodied relatives residing in the house.

T h e s c h e m e app l i e s t o p e r s o n s who own or a r e

buying/purchasing their own home. Rented local authority

houses do not qualify.

The scheme is operated in t he Eastern Health Board area by

Eastern Community Works Limited and the Eastern Health

Board allocations under the Task Force Scheme for the last 4

years are set out below: 1988 £313 ,000 1989 £338 ,000 1990 £338 ,000 1991 £336 ,000

Information is not available on the proportion allocated to the Dun Laoghaire area. The current waiting list for Task Force repairs in Dublin South Eas t (Community Care Areas 1 and 2) is 5 8 and 268 for the whole of the Eastern Health Board.

The operation of the Scheme a n d i ts effects on the living condit ions of t h e elderly w a s reviewed b y t he Project Steer ing Committee a n d i t w a s generally felt t h a t i t

3 3

represented a major advance in improving housing conditions

for those n o t i n a position t o afford their own repairs.

The waiting list, however, is continually growing, a n d i t i s felt

t h a t a greater financial commitment f rom the Department of

t h e Environment would go a long way towards reducing th i s

l i s t a n d relieving elderly pe r sons of worrying a b o u t the i r

housing conditions. It w a s also noted t h a t t h e eligibility for

inclusion i n t h e scheme, while quite str ingent a t t h e outset,

h a s over t h e years become more flexible in nature , a n d th is i s

t o be welcomed.

T h e Projec t S tee r ing Commit tee r e c o m m e n d s t h a t t h e

D e p a r t m e n t of t h e E n v i r o n m e n t s h o u l d i n c r e a s e t h e

allocation t o Eas tern Community Works Ltd. to expedite t h e

performance of repairs a n d t o reduce the existing waiting list.

2.2.6 The Provision of Accommodation by Voluntary Housing Associations

In 1984, t h e Depar tment of t h e Environment in t roduced a

n e w s c h e m e wh ich enabled Hous ing Author i t ies u n d e r

Section 12 of t he Housing Act, 1966 to provide loan finance

a n d a n a n n u a l subs idy towards loan charges t o approved

vo lun ta ry bodies for t h e provision b y t h e m of h o u s i n g

accommodation for elderly a n d other disadvantaged persons.

The ass is tance i s conditional o n the authority being satisfied

t h a t a t leas t 75% of t h e un i t s being provided will b e rented

to:-(a) elderly persons eligible for local author i ty hous ing or

institutional care a t public expense, o r

(b) handicapped persons , homeless persons , deserted or

ba t tered wives, single pa ren t families a n d families o n

approved waiting lists of local authorities w h o could not

reasonably b e expected t o secure adequa te hous ing

accommodation f rom their own resources.

3 4

In general, persons of 6 0 years or over may be regarded a s

"elderly" for t h e p u r p o s e s of t h e scheme, b u t Local

Authorities may no t apply this age limit rigidly if it considers

such a course is justified.

Assistance u n d e r t he scheme for projects commenced on or af ter 14th February, 1991 i s currently £22,000 per un i t provided in t he case of one or two person accommodation, and £25,000 per un i t for larger family type accommodation. The limit of assistance i s 90% of the approved project cost a n d 95% i n t h e case of accommodation provided for t he homeless.

Since the introduction of t he new scheme, there h a s been a good response from voluntary organisations anxious to relieve t he housing needs of elderly in t he Dun Laoghaire Borough. The Corporation h a s liaised with a range of voluntary bodies and a number of housing schemes have been provided for local elderly people. Details of these are given below: -

1988 - Abbevfield Housing Society Ltd.:

This voluntary housing society received loan assistance of £200,000 for the acquisition of a substantial Victorian House a t Orton, 2 9 Seapoint Avenue, Monkstown. Ten self-contained un i t s were provided including a housekeeper's flat, kitchen, large communal dining and sitting room.

Dublin Central Mission: Altadore, Upper Glenageary Road.

The Dublin Central Mission received loan assis tance of £960,000 towards t he cost of building a housing complex consisting of 4 0 residential uni ts linked by covered corridors to a central block containing a staff room and communal accommodation. The total cost of the project was £2.7m. The housing complex was opened in October, 1990.

3 5

Y.W.C.A.: Trench House, Crosthwaite Park East .

The Y.W.C.A. owned a premises a t Trench House, Crosthwaite

Park Eas t which w a s in danger of being sold because of lack of

f u n d s a n d because t h e condition of t h e h o u s e did n o t lend

itself t o t h e con t inu ing provision of accommodat ion for

elderly persons with a housing need.

I n 1989 t h e Assoc ia t ion app l ied for a l o a n t o w a r d s

refurbishment works t o enable t h e homes to be fully utilised

for t h e hous ing of elderly a n d middle aged persons . The

works involved t h e installation of central heating, upgrading

t h e premises t o m e e t t h e requ i rements of t h e Chief Fire

Officer, window rep lacemen t a n d to ta l re -pa in t ing a n d

redecoration. The loan ass is tance received w a s £114,000 a n d

there a r e now 16 u n i t s of accommodation, 2 wi th e n sui te

bathrooms, a communal dining hall a n d living room with one

main meal served daily.

Sue Rvder Foundation

The S u e Ryder Foundat ion have been approved for a loan

ass i s tance of £594 ,000 for t h e construct ion of 2 4 sheltered

dwellings a n d a pavilion building on Leslie Avenue, Coliemore

Road, Dalkey. Planning permission h a s been received for t h e

development a n d i t w a s d u e to commence in Au tumn 1992.

2.2.7. The Plan for Social Housing

The Plan for Social Housing announced b y t h e Minister for t h e Environment o n 14th February, 1991 w a s welcomed b y the Project Steering Committee, particularly in relation to it 's provisions for Voluntary Housing Associations.

The p lan increases t h e ass is tance available u n d e r i t s current

Scheme of Ass is tance t o Voluntary Bodies t o 90% of t h e

approved project cost (previously 80%). The u n i t grant limit

i s increased f rom £20 ,000 t o £22 ,000 for one or two person

3 6

accommodation with a new provision of £25,000 for larger

family type accommodation. These limits apply to projects

commenced on or a f te r 14th February, 1991. The Capital

Provision was increased t o £ l l m in 1991 from £9.575m in 1990 a n d £6.6m i n 1988. A new provision of £ 0 . 5 m from Lottery F u n d s was made available in 1991 towards the provision of communed facilities in both new and existing voluntary housing schemes.

This did n o t affect existing schemes in Dun Laoghaire, a s Abbeyfield, Altadore a n d Y.W.C.A. already had good quality communal facilities. A new rental subsidy scheme w a s introduced for res idents i n new voluntary schemes. The income limit is £8 ,000 per annum. The occupier will pay a ren t of the same order a s a typical local authority differential rent . The subsidy i s t he shortfall between this "rent" and the cost t o t h e voluntary body of providing the dwelling. A provision of £100,000 w a s made for the subsidy in 1991. The Local Authority pays t h e subsidy to the Voluntary Housing Body a n d is recouped i n full by t he Department of t he Environment.

The Project Steering Committee i s concerned about t h e question of ongoing maintenance costs for voluntary housing schemes and recommends t h a t Department of Environment grants for th is purpose should be increased significantly. A special allocation should a lso be made to each voluntary hous ing associa t ion approved i n order t o help defray management costs.

Liaison between Local Authorities and Voluntary Housing Associations

The Steering Committee also considers tha t there is a need

to designate a n officer in each local authority to liaise with

voluntary bodies applying for grant assistance. Such a n officer

would have responsibility for co-ordinating the responses of

t he planning a n d building bye laws department, chief fire

officer, a rchi tec ts ' a n d engineers ' depar tmen t , f inance

3 7

depar tmen t a n d hous ing administrat ion. By appointing one

officer t o liaise with all sect ions it i s likely t h a t a speedier

r e s p o n s e would b e fo r thcoming a n d prob lems could b e

identified a n d tackled a t a n early stage. The Project Steering

Commit tee r ecommends t h a t t h e local au thor i ty h o u s i n g

officer b e assigned th i s overall co-ordination role in respect

of voluntary housing associations applying for grant aid.

2.2 .8 The Design of Housing Accommodation for Elderly Persons.

T h e Committee 's a t tent ion w a s d rawn to some problems i n

respec t of t h e design of local author i ty house s occupied b y

elderly persons . This i s sue w a s brought to t h e at tent ion of

t h e relevant personnel in t h e local authority.

T h e Steer ing Committee r ecommends t h a t a formal l ink

should b e established between local authori ty architects a n d

heal th board occupational therapists so a s to ensure optimum

design in respect of elderly persons ' dwellings.

The Committee also recommends t h a t a National Resource

Centre o n Housing Design should b e established to give all

in teres ted g roups a n i n p u t into hous ing design for specific

u s e r s . These would inc lude local author i t ies , voluntary

h o u s i n g assoc ia t ions , -occupat ional t he rap i s t s , d isabled persons a n d elderly tenants .

2.2 .9 . An Agreed Definition of Sheltered Housing

The Commit tee recommends t h a t a n agreed definit ion of

shel tered h o u s i n g be worked ou t between local authorit ies,

h e a l t h b o a r d s , r e l evan t gove rnmen t d e p a r t m e n t s a n d

voluntary groups. S u c h a n agreed definition would facilitate

service p lanning and , particularly, would clarify t he n a t u r e

a n d financing of auxiliary support services for s u c h housing.

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2.3. LIAISON BETWEEN HOSPITALS AND COMMUNITY.

2 .3 .1 Hospital Services and Community Care Services.

Historically, general hosp i ta l s , b o t h vo lun ta ry /pr iva te a n d

s t a t u t o r y (heal th board) h a v e developed s epa ra t e ly a n d

independent from t h e communi ty care services. Communi ty

services have also b e e n developed separately b o t h f rom one

another a n d from the hospi ta l sector. In t h e l a s t twenty years

t h i s separateness h a s been somewhat institutionalised b y t h e

organisation of s ta tu tory services into separa te hea l th board

programmes. It i s a lso t h e ca se t h a t a n emphas i s o n 'high

tech' hospital-based medicine h a s resulted in resources being

allocated t o t he acu te hospi ta ls i n preference t o low image

b u t a l so essential communi ty ca re services. All services,

w h e t h e r hospi ta l -based o r communi ty-based , n e e d t o b e

integrated a n d organised a n d f u n d e d i n s u c h a way a s t o

provide appropriate ca re fo r elderly pe r sons w h o frequently

need a range of s u c h services. The D u n Laoghaire Project

Steering Committee explored some of t h e i s sues sur rounding

t h e interface between hospi ta l services a n d communi ty care

services i n respect of t h e elderly a n d these considerat ions a re se t o u t below:-

2.3 .2 Hospital Admissions of Elderly Persons

Admissions to general hospitals are usually categorised as:

(i) planned - non acu te for investigation a n d treatment; (ii) unplanned - emergency admissions.

T h e elderly accoun t for a large proport ion of emergency

admiss ions and there i s good evidence t o suggest t h a t m a n y

a r e inappropriately admi t ted to hospi ta l where the i r needs

could b e more adequate ly m e t a t h o m e if t h e r e w a s a n

adequate community ca re service. It i s also t h e ease t h a t a

large proportion of those elderly admit ted to hospi ta l on a n

emergency b a s i s a r e red i rec ted eventual ly t o long-s tay

ins t i tu t ions a n d n u r s i n g h o m e s which a r e n o t equipped to

3 9

deal with acute medical conditions. Also, such insti tutions f requent ly do n o t have appropr ia te phys io therapy a n d occupational therapy support services.

Over 25% of admissions a n d over 40% of bed days i n acute

hospitals a re t aken u p by t he elderly - although the over 6 5

years group const i tu te 11% of t he population - 50% of

casualty admissions are aged over 6 5 years. The average s tay

in hospital for elderly pat ients i s from 13.4 to 17.6 days in

comparison to t he 2 5 - 4 4 year age group where t he average

s tay is 5 .6 days. Hospitals with a Department of Geriatric

Medicine t end to have a shor ter durat ion of s tay for t h e elderly t han other acute hospitals.

Acute hospitals a r e geared to t reat shor t episodes of acute illness in patients who are otherwise healthy. Elderly patients are frequently accused of "blocking beds" by the staff of t he acute medical and surgical departments. Delayed discharge may be due to:

(a) inadequate resources in the community. (b) unplanned hospital discharges.

Improved services i n the community may address th is a n d should b e expanded e.g.. t he model of t he District Team which involves General Practitioners, Public Health Nurses, Occupational Therapists, Physiotherapist, Home Help, Care Attendants, State Registered Nurses h a s helped considerably to solve this problem and may also offset carers' reluctance to accept responsibility without adequate back u p services.

The description a n d designation of patients into planned a n d unplanned admissions i s largely too simplistic. Often t h e elderly patient falls into a n important intermediate categoiy. The elderly pat ient should no t be allowed to deteriorate to the point of a "crisis admission" in order to gain admission t o

4 0

hospital th rough i ts casual ty depar tment . Early consultat ion

a n d r e su l t an t diagnosis a n d appropria te prescribing would

r e d u c e t h i s type of c r i s i s a d m i s s i o n s . A faci l i ty f o r

in termedia te category admiss ions would r e su l t i n a more

sys temat ic approach t o il lness a n d allow all options to b e

explored. It would also help t o deal with w h a t h a s b e e n

referred to a s a problem for t he acute general hospitals - t h a t

of bed blocking' by elderly pat ients a s a resul t of emergency admissions.

More intermediate categoiy admiss ions would also allow for

bet ter streamlining in te rms of assessment a n d rehabilitation

i n hospital geriatric departments .

In order t o avoid inappropriate admiss ions t o hospi tals t h e

Project S tee r ing Commit tee r e c o m m e n d s t h a t p a t i e n t s

should b e encouraged in every way t o see their G.P. before

a t t e n d i n g a hospi ta l ca sua l ty depa r tmen t . I n o rder t o

encourage th is , i t is recommended t h a t t h e existing £ 1 0

hospital charge should b e waivered where a person h a s been

referred by a General Practitioner.

2.3.3. Service Co-ordination in the Community.

Since December 1990 new s t ruc tures have been in place for t h e co-ordination of services for t he elderly. These are:

(i) a care team a t community care a r e a level which br ings

toge the r r epresen ta t ives of va r ious care-provid ing

agencies a n d professions in order to p l a n services for t h e elderly;

(ii) a d i s t r i c t t e a m to provide in ter -d isc ip l inary c a r e

services for selected incapacitated elderly persons i n

their own homes for a period of six to eight weeks.

The Care Team:

4 1

The Care Team h a s been found to be a useful forum for the

p l a n n e r s of t h e services. I t h a s b r o u g h t together

representat ives of t h e hospi ta ls , t h e hea l th board, t h e

voluntary organisations a n d the general practitioners, all of

whom provide care for patients. The interchange h a s helped

to iron ou t preliminary fears a n d mis t rus t between t h e

represented bodies . I t h a s also helped to s t r u c t u r e

procedure and policy and h a s laid down guidelines for a co­

ordinated approach. This h a s avoided possible confusion regarding policy and roles.

The District Unit:

A procedure h a s b e e n es tabl ished for admiss ion a n d discharge into t h e District Team and criteria h a s been laid down for a patient 's acceptance into the team. Close liaison with St. Columcille's and St . Michael's Hospitals h a s been established with weekly meetings between t he liaison nu r se and hospital personnel. The District Team Nurse's attendance a t case conferences, he r discussion with Ward Sisters, the early notification of hospital discharges and t he arrangement for ger ia t r ic a s s e s s m e n t s a n d l ia ison wi th Genera l Practitioner have all combined to help in the smooth running of the service. Close liaison with the General Practitioner prior to h i s / h e r pat ients admission to hospital and prior to the patients discharge have been shown to be a key factor in establishing a community based service. During it's first year of operation the district team catered for some 130 elderly patients.

While the original policy of admission into t h e service, i.e. with geriatric assessment with a view to improved quality of life of the patient a s the goal, h a s worked well i n getting the service u p a n d running, it is desirable t h a t referrals from G.P.'s be also accepted pending early geriatric assessment.

4 2

T h e des igna t ion of a c o m m u n i t y p h y s i o t h e r a p i s t a n d

occupat ional t he r ap i s t wi th specific commi tmen t t o t h e

elderly h a s proved to b e a vital component of t h e service.

The hospital physiotherapist and occupational therapis t now

liaise closely wi th t h e communi ty services t o es tabl ish a

cont inuum of t reatment . Also improved quality of life c a n be

e s t ab l i shed i n t h e c o m m u n i t y i n c a s e s t h a t a r e n o t

hosp i t a l i sed a n d wai t ing l i s t s f o r p h y s i o t h e r a p y a n d

occupational therapy in the hospitals can b e reduced.

2.3.4. Need for Improved Liaison

The conventional mode of liaison - reporting findings f rom

one agency or professional to another - needs t o b e extended

subs tan t i a l ly . In o rde r t o achieve t h i s , t h e Genera l

Practitioner a n d Public Health Nurse on t h e one h a n d and the

hospital Consul tant a n d h i s / h e r medical staff o n the other,

m u s t work together, meeting regularly a n d involving all care and support staff a s appropriate.

Inappropr ia te admiss ion t o hospi ta l s of elderly p e r s o n s

through casualty departments m u s t b e regarded a s a failure of

t he geriatric services in particular a n d of t he heal th services

in general, a s m u s t be t he discharge of pat ients to institutions

a n d n u r s i n g h o m e s lacking i n appropr ia te s u p p o r t a n d rehabilitation facilities.

2.3.5. Recommendations for improved liaison

The development of comprehensive integrated communi ty

services c a n n o t occur in isolation f rom hospi ta l service provision.

The Committee i s in agreement with T h e Kennedy R e p o r t

(Kennedy 1989) a n d with The Years Ah earl (Department of

Health 1988) both of which recommended t h e improvement

of geriatr ic services i n t h e Dublin a r e a . T h e Steer ing

Committee makes the following recommendations in respect

4 3

of developing a n integrated range of hospital and community-based services for the elderly.

Geriatric Departments

A geriatric department should be established in St. Michael's

Hospital, D u n Laoghaire a n d a Consul tan t Physician i n

Geriatric Medicine should b e appointed to the hospital. A Day

Hospital should also be established in St. Michael's.

Psycho-Geriatrics

The appointment of a Psycho-Geriatrician would help t o

develop the services so urgently needed in this area. We have

identified a need for acute assessment , t reatment and long

stay beds for psychogeriatric patients. Presently this is partly

addressed by the Nursing Homes b u t this is only available to patients who can afford the accommodation.

Waiting Lists

The Committee considers t h a t the waiting list for what a re t e r m e d elect ive p r o c e d u r e s (e.g. h i p r e p l a c e m e n t , ophthalmic surgery) should b e reduced a s a matter of priority. It i s anomalous to have waiting l ists for elderly people urgently in need of such procedures.

Hospital Discharges

Discharges of elderly persons from hospital require to b e care fu l ly p l a n n e d a n d organised a n d t h e following recommendations are made in this regard:

A liaison nurse should attend a case conference prior to discharge.

A care p lan should be drawn u p prior to discharge involving the medical co-ordinator of services for t he elderly, t h e G.P., t h e publ ic h e a l t h n u r s e , t h e

4 4

physiotherapist , t h e occupational therapis t and t h e social worker a s appropriate.

The community-based physiotherapist , occupational therapis t a n d social worker should liaise with the i r hospital-based counterparts.

Attendance a t casualty departments by elderly persons should be notified to the G.P. a n d to t he community care services.

An interim care uni t should be established to cater for people who are no t ready for immediate home care on discharge from hospital. (It is noted t h a t the proposed mult i -purpose u n i t for Dalkey encompasses s u c h a scheme).

Where a pe r son i s being discharged to long-term institutional care (statutory or private) from a n acute hospital, a medical report and a comprehensive nursing report should b e sen t simultaneously t o the relevant nurse manager i n the long-stay institution. This also pertains to a pat ient being discharged from long s t ay care back into the community.

Rehabilitation

The possibility of us ing t he National Rehabilitation Centre, Rochestown Avenue a s a rehabili tation u n i t for elderly persons should be explored. There are 39 rehabilitation beds required in Communi ty Care Area 1 in order to meet recommended norms.

Extended Care

In order to meet the recommended norms for long-stay care beds, a total of 130 beds i s required in Community Care Area

1. The building of the proposed purpose built un i t in Dalkey should be expedited in order to meet this need. Presently we

4 5

have 19 Nursing Homes in t he a r ea providing long s t ay accommodation. A greater input by the Health Board in staff training and other advisory services would b e of benefit to the residents.

Transport

Transport h a s been identified by the Project Committee a s being a key issue in maintaining patients a t home.

Very often it i s a factor identified among the reasons for

inappropriate hospital admission. Attendance a t day hospitals

or day centres may be causative in maintaining the elderly a t

home for years . Hospitals and community care services should liaise in providing transport for:-

day hospitals day centres

out-patient departments day admissions.

A t r a n s p o r t commit tee , s i t u a t e d locally a n d w i t h representat ives f rom both hospitals a n d t he community, should be set u p to co-ordinate a transport system.

Community-Based Social Work Service for the Elderly

The appointment of community-based social workers for t he elderly is long overdue. Presently the work of a social worker is done by t he co-ordinator of services for elderly, the public heal th nurse , t he physiotherapist, occupational therapist or, in fact, whoever arrives first to see the patient. The specialist knowledge and expertise of the social worker is needed to deal with t he wide range of financial and social benefits available to the pat ient . Liaison between the hospital a n d community social worker would allow for the smooth transfer of services from hospital to community and vice versa.

4 6

Other Community-Bases Services

T h e C o m m i t t e e we lcomes t h e r e c e n t dep loymen t of

a d d i t i o n a l c o m m u n i t y - b a s e d p h y s i o t h e r a p i s t s a n d

occupational therapists . It i s recommended that , in addition,

a community-based speech therapy service for t he elderly b e established.

2.4. DAY CARE SERVICES

2.4.1. Day Care Provision

Day care services have become a n integral pa r t of community

care services for t h e elderly. The Working Par ty on Services

for t h e Elderly (Department of Heal th 1988) recommended

t h a t there should b e 1 day centre pe r 1,800 persons aged 6 5

years a n d over. There a r e currently over 13,000 persons aged

6 5 y e a r s a n d over in Community Care Area 1. There a r e

currently 7 day centres in t he a rea a n d 1 day hospital; 1 day

centre for Alzhiemer patients; 1 day centre for Alzhiemer a n d

dement ia patients; 1 high suppor t day centre - Leopardstown

Park Hospital; 1 day hospital - Loughlinstown Hospital; 4 day

centres offering a lower level of suppor t a n d care. Details of t h e day centres are provided in Figure 1.

A d a y centre for D u n Laoghaire i s presently a t t h e planning

stage a n d will be operational in 1993. It is s i tuated in Corrig

Avenue in Dun Laoghaire Old Folks premises. It will be r u n by

D u n Laoghaire Old Folks Association a n d Eastern Health Board.

It wiU accommodate 1 2 - 1 5 people initially.- Funding is from

D u n Laoghaire Old Eplks and Eastern Health Board.

The Project Committee considers t h a t there i s a n urgent need

f o r f u r t h e r d a y c e n t r e s f o r t h e c o n f u s e d e lde r ly

(psychogeriatric pat ients) t o meet t h e n o r m of 3 0 day care

places for confused elderly per 25,000 - 30 ,000 population a s

recommended i n T h e Years Ahead Report (Department of

Heal th 1988). The committee also considers t h a t there i s a

4 7

need for 3 more high suppor t day centres in t h e area. As c a n

b e seen f rom Figure 1 there i s only one (Leopardstown Park

Hospital) s u c h d a y centre i n t he a r e a a t p resen t providing t h e

h igh level of s u p p o r t a n d services requi red b y d e p e n d e n t elderly in t he community.

Factors Necessary for the Effective Management of Day Centres

T h e Project Committee h a s identified a n u m b e r of f ac to r s

which a re important for t he effective runn ing of day centres, a s follows:

(i) There shou ld b e adequa te guaran t ied f u n d i n g for t h e runn ing of t he day centre.

(ii) T r a n s p o r t t o t h e c e n t r e s h o u l d b e a d e q u a t e a n d appropriate to the levels of disability of clients.

(iii) Premises should b e adequately a n d sui tably fu rn i shed attractively decorated a n d well-heated.

(iv) The day centre supervisor is a key person a n d should b e adequately remunerated and supported by a management committee. Careful selection of a sui table candidate i s crucial.

(v.) The day centre staff should be adequa te t o provide t h e serv ices offered b y t h e d a y c e n t r e a n d a r e a s of responsibility should be clearly defined.

(vi) Volunteer he lpers should have appropr ia te induc t ion sessions.

(vii) The management committee should be broadly-based a n d should include voluntary a s well a s s tatutory personnel.

(viii) The day centre should develop s t rong links with t he local communi ty s o a s to e n s u r e s u p p o r t for t h e cent re in terms of bo th funding a n d local involvement.

(ix) Day c e n t r e p r o g r a m m e s s h o u l d h a v e a n a d e q u a t e s t imula t ive con ten t depend ing o n t h e n e e d s of t h e clients.

FIGURE 1: 4 8

DAY CENTRES IN THE F-ASTFWN TTRAT.TH BOARD COMMTTWrrv f-tpR app-A i

Hap Centre

Area 8enred/ Referrals

Transport Arrange­ments

No. days Centre Operates

No. attending/ Clientele

Activities/ Services Offered

Staffing Funding Source

Accomm­odation/

CrtnKen House Centre for Alzheimers pa t i en t s / pa t i en t s wi th behavioural problems

Bray, Shankil] and other ports of Area 1

Transpor t is provldec for those In Shariki]] Area. Those in other areas m u s t provide

5 days per week. 10 a m 4 pm

16 - 18 dally

Physio, O.T., General Motivation General Hygiene e.g. bathing of patient w h e n

2 Full-time 1 par t -t i m e

Funded by St. J o h n ol God Order Patients pay £ 2 per day.

1 Kecept. 1 t reat­m e n t R / Office Prayer Room Kitchen Day Room/ Dining Room Physio Room with parallel bars. Bath Room with special bath/laund eret te with washing machine.

own t ranspor t

necessary

1 Kecept. 1 t reat­m e n t R / Office Prayer Room Kitchen Day Room/ Dining Room Physio Room with parallel bars. Bath Room with special bath/laund eret te with washing machine.

Dav Centre Patients accepted from all areas

Mini-bus 5 days 16 - 20 dally

Social Activities Games, Walks, etc., Sing Alongs. Dancing. Bathing Facilities

1 Nurse 1 Cook 24 Volunt­ary he lpers who work on a Roster basis

Alzhelmers Sit t ing Tenrnle Hill Blackrock

Patients accepted from all areas

16 - 20 dally

Social Activities Games, Walks, etc., Sing Alongs. Dancing. Bathing Facilities

1 Nurse 1 Cook 24 Volunt­ary he lpers who work on a Roster basis

Association Room. Dining Room.

Social Activities Games, Walks, etc., Sing Alongs. Dancing. Bathing Facilities

1 Nurse 1 Cook 24 Volunt­ary he lpers who work on a Roster basis

Activity Room. Bathroom Showers & Toilets.

Monks-town House

All pa r t s of Area 1

Mini-bus Driver paid milage.

5 days per week 10a.m. 4p.m.

12 - 18 Gentle exercise to music

1 Super­visor 2 Helpers 1 Driver.

Grant from E.H.B. Fund raising Pts. pay £ 3 including t ransport cost.

Reception area. Common Room. Kitchen/ Dining Room.

orooKlield Blackrock

Blackrock Botters-town Deans -grange

Mini-bus Driver Paid

2 days Mon and Thurs.

16 approx. Chiropody Gentle Exercises wi th supervision Reminis­cence

1 Super­visor 2 Helpers 1 Driver

Grant from E.H.B. Fund raising.

Reception Area-Common Room. Dining Room. Kitchen. Toilets.

Beaufort Glasthule

Dalkey, Glasthule, Dun Laoghaire Sallynoggin

Mini-bus 5 days per week

10 - 18 daily

Bingo. Physio. Hair-dressing. Musical Evening. Bathing Facilities

2 Super -visors(alte-mat ing) 1 Cook 2 Helpers. 1 Driver

Grant from EHB. Fund raising Pts pay £2.50 per day including t ransport cos t

Reception Area Common Room. Kitchen/ Dining Room. Toilets

Old Folks Cen t re

Shankill, Ballybrack, Cabinteely

Mini-bus 3 days. Mon., Wed., & Frl.

14 - 2 0 each day

Bingo. Group Physio. Crafts. Painting. Social Activities, e.g. Card Games. Sing Alongs

1 Super­visor

2 Helpers. 1 Driver

Grant from E.H.B. Fund raising

Common Room. Dining Room. Kitchen. Toilets

town Park Dav Centre High Suppor t

Area 1 and Area 2

Mini-bus ivith lift for wheel­chairs

E> days 18 - 2 0 ?ach day

i t

Jhysio. Dcc. Therapy Crafts. Social Activities. - g. indoor Howling, Ditch & nut. bathing '"a o i l ties. lair-Iressinfi

1 Physio. 1 O.T. 1 Nurse 2 Nurses

Aides

Grant from E.H.B.

'

Reception Area-f in ing ioom. )hysio ioom. D.T. Room. 3athroom St Toilets.

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(x) Day centre supervisors a n d day centre management commit tees shou ld ho ld regu la r meetings wi th t h e i r coun te rpa r t s i n o ther d a y cent res in order to exchange ideas a n d experiences.

2.4.3. Brookfield Lawn. Day Centre

One of t h e schemes unde r t aken b y t h e D u n Laoghaire Pilot

Project w a s t h e establ ishment of a n additional day centre for

t h e elderly. The establ ishment of t he day centre necessitated

the co-operation of t he Eas te rn Health Board, Dun Laoghaire

Corpo ra t i on , a v o l u n t a r y o r g a n i s a t i o n a n d t h e local

communi ty . T h e experience of establishing the day cent re

therefore provides use fu l insights into t h e local co-ordination

process . The location proposed for t h e day cent re w a s a

communi ty cent re i n t h e Brookfield Lawn housing complex

which is owned b y D u n Laoghaire Corporation. The hous ing

s cheme h a s 3 2 dwelling u n i t s mostly occupied by elderly

persons . The premises i s a lso u s e d a s a meals on- wheels

centre which i s r u n b y a local voluntary body, Dun Laoghaire

Old Folk's Association. This lat ter body also covers the cost of

a resident caretaker for t he hous ing complex and pays for t he

electricity a n d hea t ing of t h e communi ty centre. Another

vo luntary body, Blackrock Old Folk's Association u s e s t h e

c o m m u n i t y c e n t r e twice weekly a n d m a k e s a n a n n u a l

payment to t h e D u n Laoghaire Old Folk's Association for t h e

u s e of t h e premises. It w a s therefore necessary for t h e pilot

project local committee (Blackrock Local Committee) to link

u p with t h e D u n Laoghaire Old Folk's Association a n d t h e

Blackrock Old Folk's Association to d iscuss with t h e m t h e

p l a n s for t h e se t t ing u p of a d a y centre. Officers of D u n

Laoghaire Corporation were also involved in these discussions.

There were fears on t h e p a r t of t he D u n Laoghaire Old Folk's

Association a n d Blaekrock Old Folk's Association because of

p a s t history. It appeared t h a t in t h e recent pa s t a voluntary

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committee made u p of members of both Dun Laoghaire Old Folk's Association a n d Blackrock Old Folk's Association a n d o ther voluntary people were asked b y t he Eas tern Health Board to open a n d operate a day centre in t he proposed premises a n d were given a g ran t for th is purpose . This committee me t several t imes b u t on the eve of the opening they decided against being involved a n d returned the grant to the Eastern Health Board.

The Blackrock Local Committee, having obtained the good­

will of Dun Laoghaire Old Folk's Association a n d Blackrock

Old Folks Association, decided to call a meeting of all t he

voluntary groups working with t h e elderly i n the a r e a of

Blackrock to p u t the p lans for a day centre before them a n d

to t ry a n d gain their support for th is new venture. The idea

w a s received with en thus iasm a n d some of those presen t

volunteered to help get t he project off the ground. However,

in practice very few volunteers actually came forward.

The Projec t Commit tee t h e n formed a M a n a g e m e n t Committee made u p of representatives of Dun Laoghaire Old Folk's Association, Blackrock Old Folk's Association, members of St. Vincent de Paul Society a n d including the Director of Community Care, the Community Care Administrator and 3 members of the Pilot Project Local Committee.

At th is first meeting the over-all plan for the day centre w a s

discussed including running costs. There were difficulties in

this a rea a s Dun Laoghaire Old Folk's Association h a d been

paying for t he heat ing of t h e premises with a n a n n u a l

dona t ion f rom Blackrock Old Folk 's Associat ion a n d

expressed concern tha t the day centre committee would pay

their share of the costs. The Eastern Health Board agreed to

finance in pa r t the running of t he Centre, b u t n o s u m of money was actually mentioned.

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The rooms which were to be used for the day centre were in

need of redecorating a n d some furni ture necessary for t he day centre h a d to be acquired.

The Eastern Health Board undertook to cover some of these cos t s a n d D u n Laoghaire Corporation under took t h e re-decora t ion of t h e rooms . The Management Committee entered into negotiations with the Eastern Health Board in respect of t he funding of t ransport t o the centre. Following protracted negotiations t h e Board undertook to contribute towards t he cost of t he t ransport and a minibus operator was engaged for one day a week. A supervisor for the day centre w a s recruited, clients were identified a n d volunteer helpers were also recruited. A da te w a s se t for the opening of the centre which would operate initially for two days pe r week

® clients. The cleaning of the premises prior to opening presen ted some problems a s t he Health Board w a s not p repared to employ con t rac t c leaners . This t a s k w a s under taken by volunteers with the Health Board covering the cost of t he carpet cleaning.

Difficulties Encountered

The supervisor terminated h e r employment after two weeks.

However, it w a s possible to identify another supervisor quite

quickly a n d th i s appointment was very satisfactory. There were also problems with t he t ranspor t arrangements. The initial arrangement was t h a t t ransport would be provided by voluntary drivers on one of the two opening days b u t this was unsat isfactory. The drivers were n o t consistent in their a t t endance a n d some did n o t w a n t t he responsibility of t ransport ing elderly people. Also, the elderly tended to feel insecure no t knowing who would be bringing them since the drivers changed f rom week to week. The problem w a s resolved when t h e Health Board undertook to f inance the t r anspor t to the centre for t h e two days of opening. The regular availability of voluntary helpers presented some

5 2

problems a t the outset with people opting o u t for var ious reasons.

The pool of volunteers was, however, extended and a training

session was organised to help t h e m in working with elderly

people in a day centre setting. There is currently a pool of 10

voluntary helpers. The ongoing cleaning of t h e centre w a s

also problematic and h a d to b e done b y t h e supervisor

initially. Eventually a cleaner w a s employed and t he problem was rectified.

Current Situation

(i) The centre h a s extended it 's opening to three days a week.

(ii) A shower un i t and the provision of easier toilet access

for t he immobile elderly a n d wheelchair u s e r s have been installed.

(iii) It is planned to provide a chiropody and a hairdressing service.

(iv) F u r t h e r decoration a n d improved h e a t i n g of t h e

premises are being considered a s i s the acquisition of a Video system.

It i s the view of the Pilot Project Steering Committee tha t t he day centre, while quite fragile a t it 's inception, i s r unn ing well a t present . Specifically, t h e Committee feels t ha t t h e Management Committee needs t o b e expanded to include more locally-based volunteers.

This t ask of establishing t he day centre necessitated a high level of information exchange, co-operation between a n d among both voluntaiy and statutory groups. The experience of t he Blackrock Local Committee h a d b o t h positive a n d negative aspects. Delays in decision making and difficulties in

5 3

accessing f u n d s were identified a s barr iers t o progress, b u t

these were overcome b y t h e commitment a n d goodwill of all

t he participating bodies.

Summary

This section of t he report h a s discussed three key a reas of

service provision in respect of t h e elderly - Housing, liaison

between hospital and the community a n d day care. It h a s se t

o u t some of the issues surrounding the provision, organisation

a n d deve lopmen t of s u c h serv ices . A n u m b e r of

recommendations by t h e Pilot Project Steering Committee in

respect of these services h a s been outlined. The next section

of t h e report will discuss some key service organisation issues

a s identified by the Project Steering Committee.

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SECTION 3 ISSUES OF LOCAL SERVICE ORGANISATION

3.1. INTRODUCTION

This section of t h e report d iscusses two key aspects of local

service organisation. Firstly, the i ssue of voluntary-statutory

liaison is discussed. The experience of t h e pilot project i n

th i s regard is described a n d t h e i s sues arising o u t of t h a t

experience are identified. A number of recommendations for

t h e improvement of voluntary-statutory liaison a t local level

a r e presented.

Secondly, t he concept of t h e care t eam for t h e elderly i s

discussed and i ts s t ruc ture and funct ions are outlined. The

experience of establishing the care team in t h e D u n Laoghaire

a rea i s described and the problems arising a re identified. A

n u m b e r of recommendat ions a re m a d e in respect of t h e

s t ruc tu re and programme of work of t h e care t eam in t h e

Health Board Community Care Area 1.

3.2. VOLUNTARY - STATUTORY LIAISON

3.2.1. The Voluntary Sector and the Statutory Sector

The i ssue of voluntary-statutory liaison w a s considered in

detai l b y t h e Pilot Project Commit tees . T h e different

perspect ives of t h e two sec tors were identified a n d t h e

problems associated with voluntary-statutory collaboration

were explored. In order to appreciate fully t he complexity of

t h e t a s k of voluntary-s ta tutory liaison it i s necessary to

understand the na ture and values underpining each sector.

Volun ta ry g r o u p s very of ten emerge f rom a s e n s e of

f rus t ra t ion a t things no t being done; they are often inspired

by a particular ideology or faith and a sense of obligation to

help those in need. They a r e often initiated b y one highly

5 5

committed and charismatic leader who draws others to the same work.

The characteristic strengths of the voluntary sector can be listed a s follows:

they are effective a t identifying urgent needs, very often from personal experiences;

they c a n quickly ha rnes s community resources -people, f unds and skills;

they can pioneer new approaches and stimulate self-help projects;

they can b e available on a flexible basis and can exercise a high level of discretion in t ha t they are answerable only to their own organisations;

volunteers c a n bring a personal dimension to their work which frequently professionals cannot do.

Statutory agencies and services are more subject to public

accountability a n d scrutiny than their voluntary counterparts

and their roles and functions are enshrined in statute. While

statutory personnel have authority to implement policies i t

may be tha t their statutory obligations and functions preclude

innovation a n d flexibility. It is also t he case tha t large

organisations, whether statutory or voluntary, tend to have

complex administrative structures which limits the scope for

individual decision-making. This also means t h a t frequently

policy decisions are taken a t a level quite removed from t h e

point of delivery. It is also difficult in practice to achieve a

balance in the statutory sector between discretion in service

provision and uniformity according to agreed policies.

In contrast to t he statutory sector volunteers frequently do not work within a clear policy framework. Flexibility of approach, which i s one of the hallmarks of t he voluntary

5 6

sector, while allowing for individual expression, may also lead

to inconsistency a n d to interventions t h a t are inappropriate.

The Project Committee takes the view tha t there i s a need for

a careful balancing between the two approaches and clear

recognit ion b y e a c h sec to r of i t s own s t r eng th s a n d weaknesses.

It h a s emerged t h a t one of t he mos t constructive outcomes of

t h e project w a s t h e establ ishment of closer contact between

statutory and voluntary groups. This networking h a s shown to

have been of great benefit a n d is ongoing e.g.. with t he Care

Team a n d in one to one relationships in t he community. The

identification of problems concerning the elderly by the Care

Team c a n be p u t forward when policy decisions are being made by Statutory Bodies.

3.2.2. Statutory sector obligations in respect of voluntary agencies:

Few s t a t e or semi-s ta te bodies have a n y direct s ta tu tory

obligations in respect of voluntary groups. Section 65 of t he

1953 Heal th Act m a k e s provision for t h e m to sanc t ion

financial g ran t aid t o voluntary bodies which carry ou t a

service for or on behalf of or ancillary to tha t provided b y a

hea l th board. In addit ion t o this, Section 4 0 of the 1970

Health Act provides for t h e acquisition of land by the heal th

board for voluntary bodies providing a service which t h e

health board may provide.

Since 1984 housing authorit ies have been empowered t o give

ful ly subs id i sed l o a n s t o approved vo lun ta ry h o u s i n g

associations (see 2.2.6 above ). The 1988 Housing Act and i t s

Sta tutory Ins t ruments of 1989 require local authori t ies t o

notify a n d liaise wi th voluntary groups in respect of thei r

assessment of housing needs . This clause is significant i n

t ha t this was the first t ime local authorities were obliged t o

contac t local voluntary g roups a n d formalise a n y liaison

s t ructures a s may have been in existence. The fact tha t mos t

5 7

authorities had to draw u p a list of local voluntary groups for

t he first time d u e to th i s legislation is indicative of t h e scan t

liaison i n existence in some areas, prior to its enactment.

A Char ter for Voluntary Social Services i s current ly being

prepared a n d co-ordinated b y t h e Depar tmen t of Social

Welfare (as promised in t h e Programme for Economic a n d

Social Progress). In addition to drawing u p the Charter, i t is

intended to prepare a White Paper on the topic.

T h e Commit tee t a k e s t h e view t h a t t h e concep t of

pa r tne rsh ip between t h e voluntary a n d s t a tu to ry sectors

needs urgent development a n d expresses t h e hope t ha t t he

forthcoming Char te r a n d White Paper will go some way

towards filling the policy vacuum in which voluntary bodies currently operate.

3.2.3. Involvement of Voluntary Groups In the Dun Laoghaire Area

Voluntary and statutory groups co-ordinate locally to provide a

range of services for elderly people. These m a y b e broken

down into three main groupings, a s follows:-

services for elderly people provided by voluntary groups

on behalf of, or funded by statutory agencies (examples

i n c l u d e t h e two v o l u n t a r y h o m e h e l p service

committees in t he area; the twelve voluntary meals-on-

wheels groups, and five of the seven day care centres in Community Care Area 1);

services for elderly people offered independent ly b y

voluntary groups (examples include some social clubs,

active r e t i r emen t a ssoc ia t ions , v o l u n t a r y g r o u p s

providing hospi ta l or home visitation or befriending services);

service for elderly provided jointly by s ta tu tory a n d

voluntary groups (examples include voluntary housing

assoc ia t ions , services for elderly people or t h e

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community a s a whole supported b y s ta te employment

s chemes e.g. t h e "Options" communi ty informat ion

cen t r e i n Ballybrack o r t h e "Choices" bef r iending

service for elderly people in Rathsallagh).

Bo th of t h e s e g roups a r e s taf fed v ia Vocat ional

Education Committee a n d FAS support a n d gran t aid.

While offering a good service to the local communities,

s u c h s c h e m e s a r e l imited i n t h a t the i r s t a f f i s

constantly changing (new personnel every 6-12 m o n t h s

and their continuity is not assured).

.2.4.Voluntary Involvement Resulting from the Pilot Project

Voluntary Statutory Forum

The voluntary-statutory forum h a s already been referred t o i n

1.3 above. The idea of t he forum w a s t h a t over time, each

sector of voluntary activity would nominate one person t o

represent their interests on a forum of both voluntary a n d

s ta tu tory personnel, e.g. one representative on behalf of 12

meals-on-wheels groups; one representative for t he Society of

St. Vincent De Paul conferences, etc., so t ha t there would b e

a representa t ive group of t h e voluntary sector who were

readily contactable and with whom statutory representatives

would have regular meetings.

The above model of a formalised voluntary/statutory liaison

mechan ism w a s subsequently amended to allow for various

groups to participate in a working forum on t h e bas i s of a

sha red in teres t a n d common goal e.g., housing provision.

S u c h a l iaison mechan i sm would have necessi ta ted t h e

appointment of a key co-ordinator which was n o t possible in

the circumstances.

An outcome of t h e forum process was the development of a

two-way referra l system between voluntary a n d s t a tu to ry

personnel involved with elderly persons a t district level. This

arose a s a result of the personal contact made with all known

5 9

voluntary groups working -with elderly people in the Dalkey,

Dun Laoghaire, Sallynoggin and Glasthule areas. These groups

were introduced to a n identified public health nurse working

full-time in liaison with elderly people.

This was seen a s one way of building confidence a n d of generating a n actual working relationship to underpin t he formal liaison s t ructure mentioned above. The response to th is was good and in the first 6 months after the initial contact, about 40 referrals were made, e.g. voluntary group requesting a nurse or occupational therapist's advice and help or a public health nurse requesting a voluntary group to visit a lonely elderly person.

Transport Services

A first s tep taken w a s to t ry to document existing heal th board, local authority and voluntary sector transport in the area. This proved extremely difficult. The local authority does n o t have a fleet of vehicles sui table fo r t h e transportation of people. The health board does, of necessity, have a n extensive network of vehicles a n d t r anspo r t arrangements b u t could not provide any further services to voluntary bodies. Despite meetings with key personnel involved, it h a s not been possible to draw u p a total schedule of services provided.

A panel of voluntary drivers to transport elderly for once-off journeys was established. It w a s found, however, t ha t very

many of the requests for this service were to take people on

regular recurring trips, to at tend health centre or hospital

appointments. This was not seen a s appropriate to voluntary

private drivers. A major obstacle which arose w a s t h a t the

statutory onus is on the vehicle owners to provide insurance

cover for their own vehicle a n d t h u s group insurance

indemnity cannot be obtained for private cars.

6 0

Carer Sitting Service:

The Steering Committee identified supports for family carers

a s one of five priority areas of need within the project area.

Following discussion in t he local committees it w a s felt t h a t

one type of practical support appropriate to t he voluntary

sector was tha t of a voluntary service to give those caring full-

time for a n elderly relative a break for a few hours once a

week or once a month, a s arranged.

The D u n Laoghaire local committee undertook to recruit volunteers to provide such a service. Initially the home help service was identified a s the logical grouping to take on this role. Whilst the home help service were supportive of t he idea, their workload was such tha t they could not b e of much pract ical ass i s tance . Considerable progress w a s m a d e nonetheless. Office space a n d a phone line w a s made available by the health board, and a voluntary co-ordinator was identified who agreed to "vet" those requesting t he service a n d those offering to act a s "sitters" and to match the two groups. Volunteers were recruited. An induction/training session was prepared and advertising leaflets were prepared.

Despite these achievements, the committee decided no t to implement th is service unt i l t h e i ssue of public liability insurance for such volunteers w a s negotiated with the E.H.B or with other relevant parties. This did not happen during the life-time of the project.

Recruitment of Voluntary Helpers

It came to t he a t tent ion of one of t h e project local committees t ha t the staff shortages a n d lack of suitable t r anspor t were factors which caused wheelchair-bound patients to be excluded from admission to Leopardstown Park Day Centre. The transport factor h a s now been resolved by the provision of a suitable ambulance and driver.

6 1

In view of t h e fact t h a t t h i s i s t h e only high suppor t day

centre in the catchment area, a n d t h a t in essence those who

should most benefit from i t s services (i.e. pat ients with least

mobility) were be ing exc luded , t h e commit tee fe l t i t

appropriate to make representation to change this.

When evident tha t lack of f inance precluded the appointment

of fu r the r staff, t he committee negotiated a n d arranged for

vo luntary s t u d e n t p lacement i n t h e d a y centre , thereby

increasing the staff/volunteers:patient ratios in t he day centre

a n d enabling acceptance of wheelchair-bound patients o n i ts admission lists.

Voluntary Involvement in Brookfield Lawn Day Centre

Volun tee r s played a k e y ro le i n t h e e s t a b l i s h m e n t ,

development and running of t h e Brookfield Day Centre a n d

their role and involvement h a s been described in 2 .4 above.

3.2.5.Difficulties Encountered in Co-ordination between Voluntaiy and Statutory Bodies

A n u m b e r of diff icult ies were identif ied i n respec t of vo luntary /s ta tu tory liaison dur ing t h e course of t he Pilot Project;

(1) Absence of a mechanism by which to achieve representative involvement of the voluntary sector.

The P r o j e c t s experience confirmed t h e a l ready identified

absence of a satisfactory mechanism by which representative

involvement of t h e vo lun t a ry sec tor c a n b e obta ined .

Volun ta ry sec tor p e r s o n n e l repea ted ly highlighted t h e

impossibility of a token one or two individuals' ability to speak

for t he whole range of voluntary groups t h a t exist. It w a s

regarded a s being a s unreal is t ic a s expecting one or two

indiv iduals to r e p r e s e n t all s t a t u t o r y groupings . This

6 2

fundamental difficulty a n d absence of known working models of representation (at local/regional or national levels in t h e Irish context) led to t h e D u n Laoghaire local committee proposal for voluntary/statutory liaison a t district level which h a s been described above.

(ii) Unsuitability of mechanism by which volunteers were

targeted and recruited.

The initial contact with voluntary groups occurred a t local

ra ther t h a n a t regional level a n d this created the difficulty in

finding a voluntary representative with a general overview of

service issues and voluntary/statutory partnership.

(iii) Numeric imbalance in sectoral representation.

The Project committees were extremely top-heavy with

heal th board personnel a n d h a d only 2 or 3 members from

the voluntary sector/active elderly/informal caring networks

a s representat ives on each committee. The co-option of

f u r t h e r voluntary personnel w a s regarded a s making t he

committees too cumbersome for efficient functioning.

(vi) Timing of meetings unsuitable for volunteers.

Many volunteers are free only outside office hours. Staff in statutory bodies a re often reluctant to attend night meetings a n d can also encounter difficulties in being available during the normal working day for duties additional to their ordinary workload.

(v) Problems of bureaucratic administrative practices

Delays i n decision-making, t ime-lags between decision making and consequent action, reticence to enter into formal contractual arrangements with voluntary bodies and delays in payments sanctioned, were all difficulties encountered by the

project in relation to the establishment of Brookfield Day

Centre.

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Also, project participants on committees b y virtue of their statutory responsibilities sometimes felt constrained in their comments/recommendations and actions by their loyalties to the i r p a r e n t bodies, while voluntary sector personnel conscious of their autonomy, were often frustrated by t he resultant inaction or apparent fudging of issues.

(iv) Difficulties in accessing background information

Many voluntary group representat ives h a d little or n o

knowledge of the organisation, procedures of s tate or semi-

state bodies or of other voluntary organisations. This often

leaves volunteers feeling excluded, frustrated and unsure how

b e s t t o m a k e the i r con t r ibu t ion a s voluntary sector

representat ives. The project ' s experience confirmed th i s

si tuation which was repeatedly articulated by volunteers

during the course of the project. In a n effort to rectify this,

one project sub-committee undertook to prepare a loose-leaf

folder of voluntary, heal th a n d housing agency structures,

services a n d contact personnel for the Borough of D u n

Laoghaire. This attempt collapsed when they were not able to obtain all the required information.

(vii) Communication problems:

Use of jargon and professional terminology was seen by some

voluntary sector members a s a problem. They felt excluded

and unable to participate fully in discussions because they

were u n s u r e of some of t h e terminology being used by professionals.

(viii) Problems of insurance cover

As stated above the Pilot Project highlighted t he fact t h a t voluntary effort can b e hampered by t h e absence of appropriate insurance cover (whether motor insurance or public liability).

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While possible solutions were suggested (affiliation with t h e

National Social Services Board umbrel la scheme for public

liability cover a n d a specially negotiated scheme for cover for

t h e voluntary ca r pool), these did n o t materialise during t h e

course of t h e project. The Project Committee takes t h e view

t h a t i t r u n s counter to t h e spir i t of par tnership a n d co­

ordination t h a t the o n u s for providing insurance indemnity

for services rendered by volunteers, falls onto the voluntary

sector . In a n increasingly litigation conscious society, i t

would seem unfortunate t ha t some groups/individuals willing

t o offer their services graciously a r e n o t spared the financial

c o s t s a n d worry of hav ing t o m a k e n e w i n s u r a n c e arrangements .

3.2.6.Recommendations for Improving Voluntary/Statutory l iaison

The Steering Committee makes a n u m b e r of suggestions a n d

recommenda t ions in respect of developing t h e voluntary

sec tor a n d fostering effective vo lun ta ry / s ta tu to ry liaison. These a re se t ou t below: -

The effective involvement of t h e voluntary sector in a co­

ordinated approach with the statutory sector requires:

a flexible approach to arranging meetings outside of

normal working hours to facilitate volunteers who have their own work commitments:

a c lear ar t iculat ion of w h a t i s expected f rom t h e

vo lun t a ry sector i n t e r m s of accountabi l i ty a n d responsibility:

a n agreed policy between b o t h sectors o n i ssues of

confidentiality and procedures to b e adopted;

t h e fostering of a n e thos of respect, co-operation a n d mutua l t rus t between the two sectors;

6 5

t h e avoidance of mere token representat ion of t h e voluntary sector on committees.

Statutory /Voluntary Liaison Officers

Statutory Bodies (Health Board a n d Local Authority) should

each appoint a n officer to ac t in a liaison capacity with

voluntary groups. The time allocated for this liaison work

should be sufficient to allow regular planned meetings with

voluntary groups wishing t o make representat ions a n d

submissions or to explore developmental ideas or to register

complaints about specific issues. It should also allow for

regular consultation with voluntary bodies in respect of policy development.

Funding of Voluntary Bodies

Funding from statutory bodies to voluntary groups should be based on clearly defined criteria and should be paid on time, taking into account the voluntary agency's accounting system.

Contractual Arrangements with Voluntary Bodies

Statutory bodies should encourage voluntary bodies to enter into contractual arrangements for the provision of specific services according to agreed criteria involving defined targets a n d a specific time-scale. The level of statutory involvement (e.g. nursing, physiotherapy, transport) should be specified a t the outset.

Developing the Voluntary Sector

Health Boards should appoint full-time Development Workers

(1 per Community Care Area) to work with and develop t he

voluntary sector. This Development Worker should have a s

p a r t of the i r brief t h e development of representat ive

involvement of the voluntary sector in local co-ordination

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mechanisms. A specific budget should b e allocated for t h i s purpose.

Voluntary-Statutory Forum

The Eas te rn Health Board should establ ish (as p a r t of t h e Care Team s t ruc ture in Community Care Area 1) a forum for voluntary/s tatutory liaison a t district level o n a pilot basis . An officer of the heal th board should be deployed o n a full-time bas is for this purpose.

Care Team

The n u m b e r of voluntary sector representatives o n the Care

Team in Community Care Area 1 should b e increased f rom one to four.

Charter for Voluntary Social Services

T h e Char ter for Voluntary Social Services being prepared b y

t h e Depar tmen t of Social Welfare shou ld inc lude viable arrangements for:

(i) insurance for voluntary groups providing a service t o the public; and

(it) con t r ac t s be tween vo lun ta ry g r o u p s a n d s t a t u t o r y authorities.

3.3. THE EASTERN HEALTH BOARD CARE TEAM STRUCTURE

3.3.1. Structure of Care Teams

The Years Ahead Report (Depar tment of Hea l th 1988)

recommended t h a t hea l t h b o a r d s shou ld appo in t a co­

ordinator of services for t h e elderly in each community care

a r e a . T h e E a s t e r n H e a l t h B o a r d e n d o r s e d t h i s

recommendat ion i n i t s policy documen t Services for the

Elderly (Eas tern Heal th Board 1989) a n d appoin ted a

6 7

medical Co-ordinator of Services for the Elderly i n each community care area.

The Board also constituted a care team in each community care area comprising of:-

A Community Physician (who will act a s Co-ordinator of Services for the Elderly);

A Public Health Nurse;

A Community Psychiatric Nurse; A Medical Officer; A Hospital Matron;

A representative from the local branch of the Irish College of General Practitioners;

A Community Welfare Officer;

A representative from the Voluntary Organisations; A Housing Official of the local authority; A Consultant Geriatrician;

A Consultant Psychogeriatrician; An Administrative Officer.

The Eas te rn Health Board policy document stipulated t h a t t h e Care Team i n each community care a rea would b e required to:

develop a n d implement appropriate preventative, heal th education and health promotion programmes for the elderly in their area;

ensure tha t the needs of the elderly are identified and t h a t a register of elderly a t r isk is established a n d maintained;

p lan for and ensure the provision of a comprehensive

range of services a n d suppor ts for the elderly in a

community setting including services provided from a n institutional base;

identify the various housing needs of the elderly a n d ensure tha t these needs are met;

6 8

ensure t h a t t h e provision of all services i s co-ordinated,

a s between t h e various services a n d service providers,

bo th statutory a n d voluntary;

ensu re t h a t appropriate advice a n d suppor t i s m a d e

available to carers of t h e elderly; monitor t h e ongoing provision of services. (Eastern

Health Board 1989 p p 6 - 7).

3.3.2. Establishing the Care Team in Community Care Area 1

The Care Team s t ruc ture a n d funct ions were quite similar t o

those of t h e Pilot Project Steering Committee. Some of t h e

personnel proposed for t h e Care Team were already involved

i n t h e Pilot Project a n d there w a s inevitably going t o b e some

overlap. However, t h e Care Team s t ruc ture w a s pa r t of overall

Health Board policy a n d t h e Pilot Project w a s d u e to end i n

1990 (subsequently extended to 1991). The Pilot Project a n d

the Care Team t h u s were seen a s operating simultaneously a n d

in a complementary manner .

In December 1989 t h e f i rs t meeting in respect of t h e Care

Team for Community Care Area 1 took place in D u n Laoghaire

unde r t h e direction of t h e Director of Community Care a n d

Medical Officer of Health t o identify t h e people listed above

Who would be invited t o become members of t he Care Team.

During t h e next few mon ths a large n u m b e r of meetings were

held a n d t h e proposed format for t h e working of t h e Care

Team w a s discussed. The following procedures were agreed;

(I) M e m b e r s w o u l d b e m a d e a w a r e of t h e w o r k

commitment t h a t would be involved (the minimum time

t h a t should be s e t aside was regarded a s one day pe r

month).

(ii) a n introductory planning workshop would be held to

initiate the Care Team in the area.

6 9

The protocol agreed for t h e proposed workshop w a s a s follows:

(i) members would describe their work with the elderly a n d identify their needs;

(ii) current policies of t he Eastern Health Board would b e

discussed a s well a s the role of the Care Team, a s stated

in the Eastern Health Board policy document;

(iii) a suggested target for the Care Team for 1990 would be agreed on by the members;

(iv) i ssues arising from the experience of t he pilot project

co-ordination project to date would be discussed and ,

where possible a n d appropr ia te , included i n t h e

programme of work of the Care Team;

(v) t he pilot project development worker would be invited to attend the planning meeting.

Invitations were sen t ou t in September 1990 and the first Care Team meeting was held on 7th November 1990. Because of the urgency to p u t the Care Team in place, t he workshop proposal was not implemented.

There were a number of problems associated with setting u p the Care Team :-

(i) Staff were no t released from other duties for some time

to under take the extra work emanating from the Care Team.

(ii) The concept of various disciplines working together was difficult for some members of t he team.

(iii) The identification of new roles for different disciplines

was much more readily accepted by some than others.

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(iv) The delegation of dut ies i n respect of t h e Care Team b y

senior staff t o j u n i o r staff presented some problems.

Some members of t h e team found i t difficult to m a k e

decisions without referring back t o senior staff.

(v) Funding of specific projects was no t possible a s the Care Team itself h a d n o budget.

(vi) The t ime allotted t o Care Team meet ings w a s s h o r t

making it very ha rd to achieve any progress.

(viii) Too many t a sks were given to the Care Team without resources.

T h e Care Team s t ruc ture i s a n important bas is on which to

consol idate a n d bui ld inter-disciplinary a n d inter-agency

working. The groundwork tha t w a s done b y t h e pilot co­

o r d i n a t i o n p r o j e c t i n t e r m s of improved in fo rma t ion

e x c h a n g e , b e t t e r c o m m u n i c a t i o n , improved m u t u a l

unders tanding of roles a n d functions should be consolidated

b y t h e Care Team. The Care Team s t ruc ture should also

facilitate a more comprehensive assessment of needs i n t he

D u n Laoghaire a r e a a n d the prioritisation of local (as distinct

from overall Health Board) needs and related policies.

3.3 .3 . Recommendations for the Development of the Care Team i n Dun Laoghaire Community Care Area 1.

T h e Project Steer ing Committee recommends t h a t t h e Care Team in Community Care Area 1 should:

(i) d e v e l o p a n d i m p l e m e n t t h e c o n c e p t of t h e

voluntary /s ta tu tory forum which w a s formulated by t h e

pilot co-ordination project;

(ii) complete t h e compilation of t he information package for

family carers which was commenced under t h e auspices of

t h e pilot project;

7 1

(iii) develop f u r t h e r t h e concept of a ca re r s relief service

which w a s instigated by the pilot project;

(iv) engage i n ongoing monitoring of t he t ranspor t n e e d s of

t h e elderly;

(v) increase t h e voluntary sector representation on t h e Care Team from one to four members;

(vi) explore t h e role of social p rogrammes in suppor t ing

elderly persons in t he community;

(vii) promote t h e concept of task-focused voluntary /s ta tu tory

committees for specific periods of time.

SUMMARY

This section of t h e report h a s discussed two key aspects of local

service organisations for t he elderly - voluntary/statutory liaison

a n d the concept of t he Care Team for t h e Elderly a t Community

Care Area level. The experience of t h e D u n Laoghaire Pilot

Project Committees in respect of voluntary/statutory liaison have

b e e n descr ibed a n d s o m e of t h e i s s u e s ar is ing f rom t h a t

experience have b e e n identif ied. Some of t h e diff icult ies

experienced in respect of developing t h e Care Team concept in

Community Care Area 1 have been outlined. The final section of

t h e Report p resen ts a summary of t h e recommendations m a d e

b y t h e D u n Laoghaire Pilot Project Steering Committee in

respect of t h e organisation and development of services for t h e elderly.

SECTION 4 7 2

SUMMARY OF RECOMMENDATIONS

The final section of t h i s report p resen ts t h e m a i n recommendations

arising o u t of t he experience of t h e D u n Laoghaire Pilot Project. Some

of these recommendations apply locally b u t m a n y have regional a n d

nat ional application. The recommendations a re se t ou t u n d e r eight headings:-

Housing a n d Related Issues

Community/Hospital Liaison

Day Care Services

Voluntary Statutory Liaison

Care Team Structure in Eastern Health Board Board Community Care Area 1.

Health Board Administration

Family Carers of Elderly Persons

Innovative Development in Service Co-ordination.

HOUSING AND RELATED ISSUES (2.2.)

Need for Additional Housing for the Elderly (2.2.2.)

The Project Steering Committee considers t h a t there i s a need for a n

extra housing capital provision t o D u n Laoghaire Corporation from t h e

Depar tment of t he Environment i n order to deal with t he bui l t -up

demand for housing for elderly people.

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Disabled Persons Housing Grant Scheme (2.2.3.)

The following recommendat ions a r e m a d e by t h e Steer ing

Committee in respect of t he operation of the Disabled Persons

Grant Scheme in Dun Laoghaire Borough.

(i) The a m o u n t of t h e g ran t should cover t h e full cost of approved works, including architects' fees.

(ii) The Disabled Persons Housing Grant should be subject to a means test.

(iii) All local authorities should be required to cover the costs of

a n y works deemed necessary on non-vested local authority dwellings.

(iv) Local authorities should draw u p a panel of approved local

contractors for carrying ou t work approved for the Disabled Persons Grant.

Accommodation for Homeless Persons (2.2.4.)

The Project Steer ing Committee considers t h a t there i s a substantial need for more emergency hostel-type accommodation in the Borough to cater for the growing numbers of elderly a n d middle-aged who find themselves homeless.

Refurbishment of Local Authority Dwellings

The Steering Committee recommends tha t the Department of the

Environment substantially increases the allocation to Dun Laoghaire

Corporation u n d e r t h e Remedial Works Scheme so t h a t t h e

upgrading of local authori ty dwellings occupied by elderly a n d middle-aged persons can be expedited.

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Maintenance of Local Authority Dwellings

T h e S teer ing Commit tee r e c o m m e n d s t h a t D u n Laoghaire Corporation should increase t h e n u m b e r of skilled t radesmen available for house maintenance and, also, increase significantly the allocations for house repairs and re-decoration.

Private Rented Dwellings

T h e Steer ing Committee r e c o m m e n d s t h a t D u n Laoghaire Corporation continues to make every effort to seek improvements i n t h e housing conditions of elderly t e n a n t s i n formerly rent -controlled dwellings b y ensuring a rigourous enforcement of the Housing (Private Rented Dwellings) (Standard) Regulations 1984.

Improvements to Private Dwellings

The Steering Committee recommends t h a t the Department of the

Environment should increase the allocation to Eastern Community

Works Ltd. unde r the Task Force on Special Housing Aid for the

Elderly Scheme so a s to expedite t he programme of work and to

reduce the existing waiting list for improvements.

Maintenance and Management of Voluntary Housing Schemes (2.2.6.)

The Steering Committee recommends t h a t Department of the Environment Grants to Voluntary Housing Associations should be increased significantly and tha t special allocations should b e made to approved associations to help defray management costs.

Liaison with Voluntary Housing Associations (2.2.6.)

The Steering Committee cons iders t h a t there is a need to

designate a n officer in each local authority to liaise with voluntary

bodies applying for grant assistance. Such a n officer would have responsibility for co-ordinating the responses of all local authority personnel involved.

7 5

T h e Steer ing Commit tee recommends t h a t t h e local au thor i ty

Housing Officer b e ass igned t h i s overall co-ordination role i n

respect of voluntary housing associations applying for grant aid.

Design of Housing Accommodation for the Elderly

The Steering Committee recommends t h a t a formal link should b e

establ ished between local author i ty archi tects a n d hea l th boa rd

occupational therapis ts so a s to ensure optimum design in respect

of elderly persons' dwellings.

The Committee also recommends t h a t a National Resource Centre

on Housing Design should b e established t o give all in teres ted

groups a n inpu t into housing design for specific users . These would

i n c l u d e local a u t h o r i t i e s , v o l u n t a r y h o u s i n g a s s o c i a t i o n s ,

occupational therapists, disabled persons and elderly tenants .

An Agreed Definition of Sheltered Housing

The Committee recommends t h a t a n agreed definition of shel tered

h o u s i n g b e worked o u t between local authorities, hea l th boards ,

relevant government depar tments a n d voluntary groups. S u c h a n

agreed definition would facilitate service planning and, particularly,

would clarify t h e na tu re a n d financing of ancillary suppor t services for such housing.

COMMUNITY/HOSPITAL LIAISON IN RESPECT OF THE ELDERLY (2.3)

The Steering Committee makes t h e following recommendations in

r e spec t of developing a n in tegra ted r ange of hosp i t a l a n d

community-based services for t h e elderly in t h e D u n Laoghaire Area.

Geriatric Departments

A geriatric depa r tmen t should be established in S t . Michael 's

Hospital, D u n Laoghaire a n d a Consul tant Physician in Geriatric

Medicine should b e appointed to t h e hospital. A Day Hospital

7 6

should also b e established in St . Michael's a n d S t . Vincent 's Hospitals.

Waiting Lists

The Steering Committee considers t h a t t he waiting lists for w h a t a re termed elective procedures (e.g. h ip replacement, ophthalmic surgery) should be reduced a s a matter of priority.

Emergency Admissions

The Steering Committee considers t h a t greater efforts should b e made to help elderly pa t ien ts avoid having to seek admiss ions through the casualty depar tments of hospitals except i n extreme circumstances.

Hospital Discharges

Discharges of elderly p e r s o n s f rom hospi ta l require ca re fu l planning and organisation a n d t he following recommendations are made in this regard:-

A community liaison n u r s e should attend a case conference prior to discharge.

A care plan should be drawn u p prior to discharge involving the medical eo-ordinator of services for the elderly, the G.P., the public health nurse, the physiotherapist, the occupational therapist and the social worker a s appropriate.

The community-based physiotherapist, occupational therapist a n d social worker should liaise with their hospital-based counterparts.

Attendance a t casualty departments by elderly persons should be notified to the G.P. and to the community care services.

7 7

An interim care unit should be established to cater for people who a re no t ready for immediate home care on discharge from hospital. (It is noted tha t the proposed multi-purpose unit for Dalkey encompasses such a scheme).

Where a person is being discharged to long-term institutional care (statutory or private) from a n acute hospital, a medical report a n d a comprehensive nursing report should be sen t simultaneously to the relevant nurse manager in t he long-stay institution. This also pertains to a patient being discharged from long stay care back into the community.

Rehabilitation

The Steering Committee recommends t h e es tabl i shment of a Rehabilitation Unit for elderly persons There are 3 9 rehabilitation beds required in Community Care Area 1. The possibility of us ing a n existing rehabilitation service in the area could be explored.

Long-Term Care

The Steering Committee recommends t h a t t he building of t h e proposed mult i-purpose u n i t in Dalkey should b e expedited in order to provide urgently needed beds for long-term care!

Transport

The Steering Committee recommends tha t a t ransport committee should be established in each district with representatives from the hospitals a n d t he community, from the voluntary a n d s tatutory sectors in order to co-ordinate a n appropriate transport system for elderly persons in need of care services.

Community-Based Social Work Service for the Elderly

The Steering Committee recommends tha t the Health Board should appoint community-based social workers for the elderly.

7 8

Speech Therapy Service

T h e Steer ing Commit tee r ecommends t h a t a communi ty-based

speech therapy service for t h e elderly b e established. A par t - t ime

service i s now operational a n d could be expanded.

DAY CARE SERVICES (2.4

The Steering Committee considers t h a t there is a n urgent need for

addit ional day cent res for t h e elderly mentally infirm in order t o

mee t recommended n o r m s of provision of th i s service.

The Committee also recommends t h a t 3 additional high suppor t day centres be provided in t he area;

Components of Effective Day Care

The Project Committee h a s identified a n u m b e r of factors which

a r e important for t he effective runn ing of day centres, a s follows:

There should b e adequate guarantied funding for t he runn ing of t he day centre.

Transpor t to t h e centre should be adequate and appropriate to t he levels of disability of clients.

Premises s h o u l d b e adequa te ly a n d sui tably f u r n i s h e d , attractively decorated a n d well-heated.

The day cent re supervisor is a key p e r s o n and should b e

adequate ly r e imbursed a n d suppor t ed by a managemen t

committee. Careful selection of a suitable candidate is crucial.

The day cen t re staff shou ld b e adequa te to provide t h e

services offered by t h e day centre a n d a reas of responsibility should be clearly defined.

7 9

Volun tee r h e l p e r s s h o u l d h a v e a p p r o p r i a t e i n d u c t i o n sessions.

The management committee should b e broadly-based a n d

should include voluntary a s well a s statutory personnel.

The d a y centre should develop s t rong l inks with t h e local

community so a s to ensu re suppor t for t he centre in t e rms of

both funding and local involvement.

Day centre programmes should have a n adequate stimulative content depending o n t h e needs of the clients.

Day c e n t r e s u p e r v i s o r s a n d d a y c e n t r e m a n a g e m e n t

committees should hold regular meetings with their counter­

pa r t s i n other day cen t res i n order to exchange ideas a n d experiences.

VOLUNTARY-STATUTORY LIAISON (3.2.)

The Steering Committee makes the following recommendations in respect of voluntaiy/statutory liaison:

Statutory/Voluntary Liaison Officers

Sta tu to ry Bodies (health board a n d local authority) should e a c h

appoint a n officer to act in a liaison capacity with voluntary groups.

Funding of Voluntary Bodies

Funding from statutory bodies t o voluntary groups should be based

o n clearly defined criteria, a n d should b e paid on time, taking in to

account the voluntary agency's accounting system.

Contractual Arrangements with Voluntary Bodies

Sta tu tory Bodies should encourage voluntary bodies to enter in to

con t rac tua l a r rangements for t h e provision of specific services

8 0

according to agreed criteria involving defined targets a n d a specific time-scale.

Developing the Voluntary Sector

Health Boards should appoint full-time Development Workers (1

per Community Care Area) to work with a n d develop the voluntary sector.

Charter for Voluntary Social Services

The Char te r for Voluntary Social Services being prepared b y t h e

Depar tment of Social Welfare should include viable a r rangements for :-

(i) i n su rance for voluntary g roups providing a service to t h e public: a n d

(ii) contracts between voluntary groups and statutory authorities.

Voluntary-Statutory Forum

The Eas te rn Health Board should establ ish (as pa r t of t h e Care

T e a m s t r u c t u r e i n C o m m u n i t y Ca re Area 1) a f o r u m f o r

Voluntary/Statutory liaison a t district level on a pilot basis.

EASTERN HEALTH BOARD CARE TEAM/COMMUNITY CARE AREA 1(3.3.)

T h e Steer ing Commit tee r ecommends t h a t t h e Eas te rn Heal th

Board Care T e a m in Communi ty Care Area 1 should take o n board t h e following tasks:-

develop a n d implement t he concept of t he voluntary-statutory

f o r u m wh ich w a s formula ted b y t h e pilot co-ordinat ion projec t :

publ i sh a n d dis t r ibute t h e information package for family

carers which w a s compiled u n d e r t h e auspices of t h e pilot project ;

8 1

develop fu r the r t he concept of a carers relief service which w a s instigated b y the pilot project;

engage in ongoing monitoring of t h e t ranspor t needs of t h e elderly;

inc rease t h e voluntary sec tor representa t ion o n t h e Care Team from one t o four members;

explore t h e role of social programmes in support ing elderly persons in the community;

p romote t h e concept of t ask- focused vo lun t a ry / s t a tu to ry committees for specific periods of time.

HEALTH BOARD ADMINISTRATION

The Project Steering Committee recommends t h a t t he concept of

management b y geographic a rea should b e applied in respect of t h e

elderly a n d t h a t one officer should b e designated a t central Health

Board level to have overall responsibil i ty for t h e p lann ing a n d organisation of services for t h e elderly.

The Health Board should designate one person a t district level t o

l iaise w i th agencies, profess ionals , volunteers a n d families i n

respec t of co-ordinating care a r rangements for individual elderly persons.

FAMILY CARERS OF ELDERLY PERSONS

Family carers of elderly persons should receive greater recognition

t h a n is currently t he case. Eveiy effort should be made to ensu re

protection of full-time ca re r s in t e rms of income, social welfare enti t lements a n d suppor t services.

8 2

The Steering Committee, therefore, recommends a s follows:-

Liaison between t h e Department of Social Welfare and Health

Board personnel should occur a s a mat te r of policy when

eligibility for t he carer 's allowance is being established.

The criteria for eligibility for t h e carer 's allowance should b e

revised b y t h e Department of Social Welfare in consultation with t he Department of Health.

The facility for f ree travel for pe r sons aged over 6 5 years

should b e revised t o enable family carers of incapacitated elderly persons to accompany t h e m free of charge.

INNOVATIVE DEVELOPMENT IN SERVICE CO-ORDINATION

The Steering Committee considers t h a t innovative developments in

local service co-ordination should b e encouraged and recommends

t h a t staff of s ta tu tory bodies should be relieved of some of their existing duties for th i s purpose.

Inter-disciplinary education a n d training should be provided for all those involved in a n innovative co-ordinated approach.

Innovative developments in respect of service provision for t h e

elderly should include the concept of a 'single stop shop' with a

range of services - housing, health a n d social-being provided in one , location.

8 3

REFERENCES

Browne, M. (1992), Co-Ordinating Services for t h e Elderly a t Local

level: Swimming Against t he Tide. A Report on Two Pilot Projects,

National Council for the Elderly, Dublin.

Eas tern Health Board (1989) Services for the Elderly. Eas te rn

Health Board, Dublin.

Department of Health (1988), The Years Ahead: A Policy for the

Elderly. The Stationary Office, Dublin.

Kennedy D. (1990), Dublin Hospital Initiative Group Interim

Report, Department of Health, Dublin.

8 4

APPENDIX 1 COMMITTEE PERSONNEL IN THE DUN LAOGHAIRE

PILOT PROJECT

Dun Laoghaire Steering Committee Membership (1987- 1991)

Mr. J o h n Byrne. (Chairperson from May 1990)

Sr. Patricia Byrne. (Co-opted May 1990)

Ms. Kay Cahill.

Dr. Denis Keating

Dr. Sheila Lynch. (Co-opted J u n e 1990)

Dr. Sheila MacEvilly. Co-opted J a n u a r y 1990)

Ms. Aileen McNicholas. (Committee Secretary)

Ms. Frances Mullins. (Co-opted J a n u a r y 1989)

Mr. Cormac O'Broin. (Co-opted April 1989)

Dr. Darina O'Flanagan. (Co-opted April 1989, resigned December 1989)

Administrative Officer. Housing & Environment, Dun Laoghaire Corporation.

-Public Health Nurse, E.H.B. Community Care Area 1. (Chairperson, Blackrock Local Committee).

Superintendent Public Health Nurse,E.H.B., Community Care Area 1.

Consultant Physician in Geriatric Medicine, St . Vincent's Hospital, Dublin.

Director of Community Care & Medical Officer of Health, E.H.B. Community Care Area 1.

Medical Co-ordinator of Services for Elderly, E.H.B., Community Care Area 1. (Chairperson, Dun Laoghaire Local Committee).

E.H.B. Administrative Staff, Services for the Elderly, St. Mary's Hospital.

Irish Private Nursing Homes Association Representative.

Voluntary Sector Representative, Regional Council, St. Vincent d e Paul Society.

Senior Registrar in Community Medicine. (Chairperson. Blackrock Local Committee 1987 - 1989).

Ms. Norah Owens. (Resigned J a n u a r y 1989)

Voluntary Sector Representative, St. Vincent de Paul Society.

8 5

Dun Laoghaire Steering

...contd

Dr. Pat Quinn. (Resigned J u n e 1990)

Mr. George Ramming. (Co-opted April 1989, resigned J a n u a r y 1990)

Mr. Seamus Shields. (Chairperson from April 1988 to April 1990)

Mr. Liam Gaffney, (resigned 1988)

Ms. Ailish Walsh (resigned 1988)

Ms. Cathy Lanigan.

Membership (1987- 1991)

Director of Community Care, E.H.B. Community Care Area 1.

Voluntary Sector Representative, Active Retirement Association. (Chairperson, Dun Laoghaire Local Committee 1988 - 1990).

E.H.B. Co-ordinator of Services for the Elderly.

Former Housing Officer, Dun Laoghaire Corporation.

Irish Private Nursing Homes Association Representative.

Project Development Worker.

8 6

Dun Laoghaire Local Committee Membership (1987 - 1991)

Sr. Patricia Byrne. ( January 1989 to October 1990)

Ms. Val Cave. (Co-opted September 1990)

Ms. Mary Collins. (Co-opted August 1989)

Ms. Liz Cooney.

Ms. Marie Egan.

Ms. Patricia Fallon. (Committee Secretary)

Sr. Una Lennox.

Ms. Patricia Lynes. (Co-opted J a n u a r y 1988; resigned February 1989)

Dr. Sheila MacEvilly. (Co-opted November 1988 Chairperson from J u l y 1990).

Ms. Aileen McNicholas. (Liaison person between steering a n d local committees)

Mr. Tom Murphy. (Co-opted May 1988; resigned August 1990)

Ms. Pauline Nolan. (Co-opted November 1990)

Ms. Nora Owens. (Co-opted February 1989)

Public Health Nurse, E.H.B. Community Care Area 1,

Voluntary Sector Representative D u n Laoghaire Active Retirement Association.

Voluntary Sector Representative, Dun Laoghaire Old Folk's Association.

Public Health Nurse, E.H.B., Community Care Area 1.

Housing Official. Dun Laoghaire Corporation.

Physiotherapist, initially a t Leopardstown Park Hospital and subsequent in E.H.B. Community Care Area 1.

Home Help Organizer, E.H.B. Community Care Area 1.

Family Carer.

E.H.B. Area Medical Officer a n d later appointed Medical Co-Ordinator of Services for Elderly, Community Care Area 1.

E.H.B. Administrative Staff, Service for t he Elderly, St. Mary's Hospital.

Voluntary Sector Representative, D u n Laoghaire Active Retirement Association.

Public Health Nurse. E.H.B. Community Care Area 1.

Voluntary Sector Representative, St. Vincent de Paul Society.

8 7 Dun Laoghaire Local Committee Membership (1987-1991)

...contd.

Mr. George Ramming. (Chairperson to J u n e 1990; resigned December 1990)

Rev. Richard Rountree (Co-opted October 1989).

Ms. Niav O'Daly, (resigned 1989)

Dr. Paul Lacey (resigned 1988)

Voluntary Sector Representative, Active Retirement Association, St. Vincent de Paul Society.

Voluntary Sector Representative, Rector, Church of Ireland, Dalkey.

Social Worker, St. Columcille's Hospital, Loughlinstown.

Representative of Irish College of General Practitioners.

Ms. Cathy Lanigan. Project Development Worker.

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Blackrock Local Committee Membership (1987 - 1991)

Ms. Mary Balmaine.

Sr . Patricia Byrne. (Chairperson f rom April 1990)

Ms. Ann Clyne. (Co-opted April 1990; resigned October 1990).

Dr. Darina O'Flanagan. (Chairperson resigned December 1989)

Ms. J e t Dunleavy

Ms. Patricia Fallon (Resigned February 1991)

Mr. Tom Haugh (Co-opted December 1990)

Ms. Kathleen Holohan (Co-opted November 1990; Secretary f rom J u n e 1989)

Ms. Aileen McNicholas (Liaison person between steering committee a n d local committee).

Ms. Cathy Neagh

Dr. Maura O'Dwyer (Died J u n e 1990)

Ms. Karen Peile

Ms. Brid Tedders

Ms. Cathy Lanigan

Public Health Nurse, E.H.B. Community Care Area 1.

Public Health Nurse, E.H.B. Community Care Area 1.

Family carer.

Senior Registrar in Community Medicine, E.H.B., Community Care Area 1.

Home Help Organiser, E.H.B. Community Care Area 1.

Physiotherapist, initially a t Leopardstown Park Hospital and subsequently in E.H.B., Community Care Area 1.

Voluntary Sector Representative, Blackrock Active Retirement Association.

Housing Official, Dun Laoghaire Corporation.

E.H.B. Administrative Staff, Services for the Elderly, St. Mary's Hospital.

Medical Social Worker, St. Michael's Hospital, Dun Laoghaire.

Family Doctor, Blackrock area.

Community Occupational Therapist, E.H.B.. Community Care Area 1.

Voluntary Sector Representative, St. Vincent de Paul Society.

Project Development Worker.

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APPENDIX 2

PROJECT SUBMISSION ON NURSING HOME LEGISLATION

14th February, 1991

Dr. R. Barrington, Principal Officer, Department of Health, Hawkins House, Dublin 2.

Re: Code of Practice - Nursing Homes.

Dear Dr. Barrington,

I enclose submission from the D u n Laoghaire Pilot Co-Ordination Project o n t h e forthcoming Code of Practice u n d e r t h e Nursing Homes Legislation.

I also s e t o u t hereunder , recommendations which are outside the scope of t h e Code of Practice, b u t which t h e Committee feel a r e related to it:-

1. Choosing a Nursing Home

1.1 Agree a n i n f o r m a t i o n l e a f l e t f o r t h e p r o s p e c t i v e res iden ts / fami l ies o n "choosing a n u r s i n g home". It i s suggested t ha t the Department of Health, t he Health Boards in conjunction with t he Nursing Homes Association and other re levant in teres ted pa r t i e s would design a n d agree t h i s leaflet. Suggest criteria to u s e in deciding the degree of t h e ma tch between any given home a n d the na ture and degree of ca re required. (Liaison shou ld b e m a d e with t he D u n Laoghaire Local Commit tee of t h i s Pilot Project on t h i s sub jec t , a s they a r e cu r ren t ly p u r s u i n g a series of 15 information leaflets for family carers of elderly).

2. Charter of Resident's Rights.

2 .1 Health Boards to liaise with t he Department of Social Welfare, r es iden t s a n d families t o e n s u r e a min imum disposable income for e a c h r e s i d e n t f o r 'personal comforts ' pos t payment of nursing home fees.

3. Medical Care.

3 .1 Prior to entry into a n u r s i n g home, prospective residents shou ld b e offered t h e oppor tun i ty of a s s e s s m e n t by a Consul tant in Geriatric Medicine within a month of s u c h a request being made.

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4. Staffing

4 .1 A minimum of one Registered General Nurse (as distinct from a Registered Nurse) m u s t b e on du ty a t all times. (This i s a r e c o m m e n d a t i o n f o r t h e n u r s i n g p e r s o n n e l o n t h e Committee)

4 .2 Agreement shou ld b e r eached between t h e Registration Authority (i.e. the Health Boards), the Nursing Homes a n d the Nursing Bodies regarding t h e ra t io of R.N. s pe r pa t i en t category a n d the corresponding n u m b e r of care a t t endan ts pe r R.N. necessary to provide adequate patient care.

4 . 3 Staff ratios (i.e. all categories of staff) to be agreed between the individual nurs ing home a n d the Registration Authority a t t he time of issuing a n d renewing registration for the home in quest ion. A rat io of one R.N. t o four care a t t endan t s i s suggested a s appropriate.

4.4. The Department of heal th , t h e Health Boards and Nursing Groups, e.g. An Bord Altranais to encourage good nursing care p rac t ice b y p ioneer ing a n d developing s taff exchange programmes in and between nurs ing homes (and hospitals) for training.

4.5. The onus to encourage and facilitate up-date staff training and motivation correctly falls o n hea l th authori t ies and large organisations; it would no t b e reasonable to expect individual n u r s i n g homes to necessar i ly have ei ther t h e resources a n d / o r expertise in th i s regard.

5. Related issues and proposals nrislnp

5.1 A mechan i sm to b e a r ranged (e.g. wi th the Law Society) whereby res idents / famil ies /proprie tors have recourse to a n external impartial legal adviser - to establish a procedure for referral of difficulties t o s u c h a n impartial legal adviser. Nursing Homes to arrange a Solicitor if key person/resident cannot.

5.2. Dept. of Health/Health Promotion Unit /Ir ish Nursing Homes Association to contract ou t t o a group of relevant professionals (e.g. Physios, O.T.'s Speech Therapis ts , Mus ic /Ar t /Drama Therapis ts , others. . .) t h e compilation of st imulation a n d resource materials for u s e in nurs ing homes and with groups of frail elderly.

5.3. A r ange of mater ia ls , ideas , resource addresses t o be compi led for t h e d i f f e r e n t ca t ego r i e s of r e s i d e n t s ' dependency. It should n o t be automatically assumed t h a t Occupat ional Therap i s t s o r o the r professionals have the neces sa ry ski l ls ex officio to do this. It is a difficult and

9 1 developing new area warranting input of both short and long-t e r m research resources . The benef i t s accruing should improve the quality of life of staff a n d residents alike and may also resul t in financial benefit in s o f a r a s stimulating and ma in ta in ing res iden t ' s independence m a y effect s taff ing levels (required for heavily dependent residents).

5 .4 Introduce awards as incentive t o good care practice:

Proposal 1: Joint-sponsored 'nursing home of the year award' Proposal 2: Joint-sponsored 'resident of t he year award'

5 . 5 The adoption of t he Code of Practice be recommended not alone for the private nurs ing homes b u t for all Health Boards e n g a g e d i n t h e p rov i s ion of r e s i d e n t i a l c a r e fo r f ra i l /vu lnerable pe r sons , par t icular ly s u c h homes where nurs ing care is provided by or on behalf of any Health Board.

5 .6 Health Boards to provide suggested outline/recommendations to those involved in t he Inspectorate of Nursing Homes, to include:-

any staff engaged in inspecting nurs ing homes to have received prior training to do so, e.g. be familiar with t he relevant legislation, regulations, code of practice etc.

minimum of two inspectors t o visit and assess a nursing home a t any time.

The Committee welcomes the introduction of a Code of Practice for Nursing Homes a n d it i s hoped t h a t t he enclosed submission and t h e above recommendations will b e covered by the Group drafting t h e Code.

Yours sincerely,

J o h n Byrne, Chairperson, D u n Laoghaire Pilot Co-Ordination Project o n Services for the Elderly a t Local Level.

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DUN LAOGHAIRE PILOT CO-ORDINATION PROJECT NURSING HOME CODE OF PRACTICE.

- SUB-HEADING SUGGESTIONS

1. Pre-admission: issues arising41

1.1 Ensu re a s ses smen t of elderly person 's immediate, medium a n d long-term needs. Families to b e encouraged to explore all available care options and decide on appropriate choice of care in t he light of resident's needs, care options and finance available, and personal preference.

1.2 Ensu re liaison with hospital, community services, resident, family, a s appropriate.

1.3 Clarity a s to medico/social/legal situation in issues relating t o t he nurs ing home- e.g., valid will; appointing agents, trustees, attorney if resident no t compos mentis.

2. Information brochure o n the nursing home.

Each nurs ing home to provide information literature to t h e public on request to include the following items:

2 . 1 Proprietor's name; nurs ing home name, address , tel. no. & contact person.

2 .2 Location a n d sketch m a p indicating neares t available public t ransport & social amenities.

2 . 3 Cost of different levels of care detailing services offered a n d what constitutes 'extras". [If reticence to include costs in brochures exists for reasons of commercia l competi t ion, i t i s sugges ted t h a t s o m e indication of cos ts b e m a d e e.g. >£160, £200,>£250,>300 and tha t detail of costs be made available o n request].

2 . 4 Level of resident-nursing/mental dependence to which the home caters.

2 . 5 Physical characteristics of home;

2 .6 Nature of recreational a n d social stimulation activities available to residents.

2 .7 Stated daily routine within the home.

2 .8 Visiting arrangements.

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3. Admission procedure & review mechanism.

3.1 Admission procedure: Initial information material to be made available; Introductory visit prior to a n y commitment being given b y either party; r ight to family/ f r iend/advocate visit with t h e potential resident by way of support.

3 .2 Trial period e.g. initial three months of residence (read in conjunction with 4.8).

3 . 3 Review mechanism: initial review af ter 3 weeks; subsequent 3-monthly reviews, or a s deemed necessa ry / reques ted b y res ident / fami ly . (see also 8.4, medical review a f t e r 6 months).

3 .4 Opt ion to h a v e s taf f m e m b e r , r e s iden t , key s u p p o r t person/advocate for resident a n d medical adviser present a t the review, is desired.

4. Legal Contract of Care:

4.1 A contractual agreement to be a right.

4 .2 Contract of Care to be agreed prior to admission; contract to be reviewed after se t timescale a s mutual ly agreed (i.e. review of care; review of costs).

4 .3 Terms and conditions of residence to be stated e.g., finance, type of accommodation, services, philosophy of care and cost specific to the individual named in t h e Contract; itemised list & account of "extras".

4 .4 Admis s ion cond i t i ons ; b r i n g i n g i n p e t s , f u r n i t u r e , possessions, inventory of valuables; house rules, r e tu rn of valuables/assets e.g., furniture post death.

4 .5 State if a Charter of Residents Rights a n d a Residents' Council operate in the home.

4 .6 Discharge procedure: issues/circumstances t h a t would lead to termination of contract of care; period of notice; notification of relatives; arrangement of alternative care/accommodation, (agree transfer arrangements a t end of trial period if decision is to move from the nursing home).

5. Philosophy of Care

There may be need for different philosophies of care for residents with different levels of mental a n d / o r nursing dependency.

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General principles:

5.1 The aim of t h e n u r s i n g home to ensure t he bes t possible quality of life of each individual resident give their physical a n d / o r mental abilities.

5.2 The quality of life of res idents to be t h e main focus a n d orientation of t h e care system within t h e home (rather t h a n e.g., the needs of administration). Internal 'house rules' to b e kept to a minimum.

5 .3 The nurs ing home is t h e residents' "home" for a s long a s they live there; a s s u c h it i s more t h a n a commercial enterprise or a contractual care-giving institution.

5 .4 Residents to be involved in policy decisions within the home effecting their lives.

5 . 5 Staff a n d c a r e s y s t e m / p r o c e d u r e s t o fos ter r e s iden t ' s autonomy, independence, individuality, dignity a n d personal freedom in s o f a r a s th i s does no t infringe the safety a n d rights of other residents.

5 .6 The stated philosophy of care to embody a n agreed Charter of Residents' Rights.

5 .7 Confidentiality to b e observed.

6. Charter of Residents' Rights

6 . 1 Charter of Residents' Rights t o b e incorporated in the Contract of Care.

6 .2 Charter may include the following:

right to respect , dignity, privacy, personal autonomy a n d freedom of political, emotional, cultural religious and sexual expression.

6 . 3 right to receive the level of nurs ing care and services agreed in t he Contract of Care in a manne r which embodving t h e nursing home's stated philosophy of care.

6 .4 right to have a say in decisions in the nursing home affecting one 's daily life e.g. t ime w h e n woken, meal-times, dai lv routine.. . a n d in decisions affecting one's fu tu re care [self-determination].

6 . 5 right to be listened to.

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6 . 6 right to a mechanism or procedure (e.g.. Residents' Council, if appropriate) whereby residents c a n air grievances/disputes; seek information/clarification o n policies affecting their lives. Right to meet t he proprietor given reasonable notice.

6 . 7 r ight t o a p rocedure /mechan i sm whereby a n y unresolved compla in t s c a n b e referred to t h e inspectora te a n d / o r registration authority.

6 . 8 r i g h t of a c c e s s t o in fo rmat ion concern ing one ' s own medical /nurs ing condition, if requested.

6 . 9 r igh t t o privacy especially for med ica l / nu r s ing / i n t ima te procedures (e.g., if in shared room u s e of screens for intimate personal /nurs ing care).

6 . 1 0 right t o entertain visitors i n privacy and to provide light refreshment /beverage.

6..11 right of association within and outside the home.

6 . 1 2 right to b e addressed in t he manner of one's preference.

7. Physical features

Design: especially for new buildings:-

7 .1 The layout, decor a n d furn i sh ing of t h e home should b e designed to minimize confusion a n d maximize independence a n d mobility.

7 .2 sa fe ty f e a t u r e s shou ld b e u s e d e.g., non-s l ip flooring; app rop r i a t e b a t h r o o m equipment , grab-rai ls ; f i re-safety precautions; suitable alarm/communication.

7 . 3 The design fea tures should seek to balance residents ' need for privacy a n d individual freedom with opportunities for involvement and group integration.

7 .4 Where possible, dependent residents should b e located in ground-floor accommodat ion with a p leasan t a n d visibly stimulating outlook.

7 .5 Efforts should be made to enhance the physical areas of t he home a s m u c h a s possible e.g.. create a water feature; include green a reas in t h e design; landscape the garden to facilitate act ive ga rden ing b y t h e less mobi le /whee lcha i r -bound resident .

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7 .6 E n s u r e suf f ic ien t s u i t a b l y a d a p t e d toilets , showers & bathrooms e.g., ratio a s per nurs ing home regulations.

7.7 Ensure cleanliness.

7 .8 E n s u r e adequa te hea t , light, ventilation a n d freedom from noise pollut ion & unp leasan t / an t i - soc i a l h a b i t s of o ther residents. Ensure adequate locked storage and hanging space per resident.

7.9 Pood issues include:

Hygiene; storage; food nutri t ional balance; quantity; quality; variety; presentation.

food shou ld b e adequa te , nut r i t ious , varied, attractively presented , in keeping wi th individual res ident ' s medical d ie ta ry r e q u i r e m e n t s (and pe r sona l preferences , where possible).

7 . 1 0 Fluids; issues include:

hydra t ion , con t inence ca re , quan t i t y , t i m e s available, resident 's preferences. Residents ' i npu t in above decision; meal - times....

8. Medical care:

8 .1 Every resident in a nurs ing home should make contact with a n d agree a medical ca re a r r angemen t wi th a General Practitioner of their choice.

8 .2 It i s des i rable t h a t Genera l Prac t i t ioners u n d e r t a k e a comprehensive medical review of each of their nurs ing home pa t i en t s a t l eas t every s ix-months (viz. general physical condit ion, men ta l condit ion, s ight a n d hear ing checks). Part icular a t ten t ion should b e given t o investigation a n d m a n a g e m e n t of i ncon t inence a n d t h e promot ion of continence where possible.

8 . 3 Risk- taking n e e d s t o b e ba lanced aga ins t respec t for residents' personal autonomy, dignity a n d choice.

9. Special needs of the terminally ill.

9.1 The need for privacy for t h e dying res iden t a n d the i r family/close friends should b e accommodated.

9.2 W h e n a r e s i d e n t i s dying, family m e m b e r s or c lose fr iends/advocate of t h e dying resident should be contacted. The need for suppor t to relatives, staff a n d other residents should be recognised and met.

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9 . 3 T h e proprietor should e n s u r e res idents ' access t o p roper p a i n c o n t r o l w h e r e n e e d e d , l i n k i n g w i t h G e n e r a l P rac t i t i one r s , h o s p i c e m o v e m e n t soc ia l w o r k e r s a n d b e r e a v e m e n t counse l lo r s , p a s t o r a l c a r e w o r k e r s a n d ministers of religion, a s appropriate.

9 .4 Appropriate arrangements should be made for t he laying o u t of t h e dead. Mortuary facilities should b e provided within t h e nurs ing home where possible.

1 0 Spiritual care.

10.1 Nurs ing h o m e s t o provide facilities for religious services a n d / o r visiting by ministers/clergy if required by residents.

10.2 A r o o m / q u i e t a r e a wi th in t h e home to b e reserved for quiet /reflect ion/prayer should residents wish to avail of t h i s (this could double u p for mortuary facilities if necessary).

1 1 Stimulation of residents i n nursing h o m e s i s s een as crucial in - avoiding and countering institutionalisation.

- paramedical sessional i n p u t s required e.g., occupational therapist ; physiotherapist, chiropodist; [See t h e proposal (in cover letter) t o have resource a n d reference materials a n d collated by suitably qualified personnel on a contract basis e.g. via the Health Promotion of t h e Dept. of Health].

- involvement of relat ives; visi tat ion & s t imula t ion b y voluntary groups; organisation of outings.

- proprietors should encourage and facilitate involvement of res idents in t he local social activities. Transport would n e e d t o b e provided t o m a k e s u c h involvement a possibility.

1 2 Staffing:

12.1 In t h e selection of staff a t l eas t two references should b e t a k e n u p , w h e r e pos s ib l e f r o m p rev ious employers . Applicant's curriculum vitae should be checked.

12.2 Staff deployment should t ake account of periods of h igh demand.

12.3 Min imum staff cover s h o u l d b e designed to cope wi th residents ' anticipated problems a t any time.

12.4 Where res idents require lifting a t least two members of staff should be on duty a t all time.

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12.5 Staff skills should ma tch the residents ' needs a s identified i n t h e Contract of Care a n d the homes philosophy of care.

Staff update training/stimulation/motivation

12.6 Staff induc t ion a n d on-going or ienta t ion a n d individual supervision should b e carefully considered a n d planned in detail by the nurs ing home.

12.7 Staff training should include a n understanding of the needs of mentally a n d physically frail old people.

1 3 References drawn o n i n drafting 1 -12 above

13.1 Klna, Lady Avebuiy (Chair) (1984). Report of a Working Party sponsored b v the Department of Health and Social Security. (Centre for Policy on Ageing).

13.2 Nat ional Associat ion of Heal th Author i t ies (1988) T h e Registration & Inspection of Nursing Homes - A handhook for heal th authorities. N.A.H.A. Supplement 1988.

13.3 O'Connor, J (1986). "It's o u r home". The quality of life in private a n d voluntary nu r s ing homes". National Council for t h e Aged.

NOTE: [See cover letter for issues arising outside t h e scope of Nursing Home Code of Practice, but which are related t o it].

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APPENDIX 3

PROJECT SUBMISSION ON INTERIM REPORT OF DUBLIN HOSPITAL INITIATIVE GROUP

Mr. D. Kennedy, Room 629, Department of Health, Hawkin's House, Dublin 2. 6 t h December 1990.

Dear Mr. Kennedy,

I write to you a s Chairperson of t he Steering Committee of t he D u n Laoghaire Pilot Project o n Services for t h e Elderly. This i s one of two pilot co-ordination projects which were established in 1987 a t t h e invitation of the then National Council for t h e Aged (ad advisory body t o t h e Minister for Health). The project pa r tne r s a r e t h e Eas te rn Health Board, D u n Laoghaire Corporation a n d Voluntary Groups in the Dun Laoghaire Borough catchment area.

T h e a im of the projects i s to develop a n d evaluate t h e concept of co-ordination of services for t he elderly, in t e rms of both planning a n d provision, a t local level. As co-ordination is t he major focus of t h e project we felt it appropriate to respond to t he Dublin Hospital Review Body Report.

The Steering Committee broadly welcomes th i s report and concurs wi th your group in identifying geriatric services a s t he section of hea l th services currently requiring urgent resourcing and a s being t h e key to improving health care services in Ireland.

We identify the resourcing a n d development of active and dynamic hospital-based geriatric depar tments with a vibrant outreach into t h e community a s being the keystone of comprehensive health care services for elderly. Neither hospital no r community services c a n f u n c t i o n efficiently a n d effectively u n l e s s developed in close association with each other.

In order to achieve the above within the Project catchment area we recommend tha t resources b e made available a s a prioritv. for t h e following staff appointments:

1. A Consul tant in Old Age Psychiatry t o b e appointed to t h e Sou th County Dublin ca tchment , wi th dedicated hospi ta l assessment / rehabi l i ta t ion a n d extended care beds in t h e c a t c h m e n t served. Th i s a p p o i n t m e n t shou ld a l so b e supported by aJDay Hospital assessment service.

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2. An additional Consultant Physician in Geriatric Medicine to be appointed in t he South Eas t Dublin a rea with full back-up team having a major commitment to St . Michael's Hospital with secondary rehabilitation a t Leopardstown Park Hospital. Subject to this appointment we consider t ha t the pilot s tudy of communi ty /hosp i t a l co-ordinat ion proposed in t h e Kennedy repor t , shou ld b e es tab l i shed between EHB Community Care Area 1 a n d St. Michael's Hospital, D u n Laoghaire. A s i s t e r pilot s t udy could also b e useful ly under taken between EHB, CCA 2 and t h e Royal Hospital, Donnybrook. (The above recommendations subject to t he detail of the ac tua l proposals submitted b y t he respective groups to you and to the Department of Health).

3. We further recommend the introduction of a comprehensive community social work service for elderly persons. There i s currently no communi ty social work service available to elderly people; t h e only service available is hospital-based (with home visits being a n exception). We recommend tha t a community-focused geriatric social work service be piloted within Dublin South East . Subject to t he establishment of a Department of Geriatric Medicine in St . Michael's Hospital, Dun Laoghaire, we would strongly argue for the appointment of a n additional social worker to St. Michael's Hospital, Dun Laoghaire, to b e p a r t of t he Geriatric Team there with a definite outreach into the community.

The following services a n d procedures, though hospital-based, also impinge on health services for elderly within t he community and a s such we make the following recommendations aimed a t improving hospital/community liaison:

4. We recommend t h a t all elderly pa t ien ts have access to geriatric consultat ion screening within 2 4 - 4 8 hou r s of admission, if required, (decision on need for same to be the responsibility of t he admitting consultant).

5. Improved access to elective surgical procedures is urgently needed. Lengthy waiting lists are all too common and include the following current waiting times:

cataract operations: 7 months - 2 years (Eye & Ear Hospital) cataract operations: 6 months (St. Vincent's priority

given elderly patients on waiting list),

hip replacements: 1 - 2 years (Adelaide Hospital) hip replacements: 8 - 9 months (Cappagh Hospital)

This situation is particularly unacceptable for elderly patients.

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6. Similarly, waiting time incurred in attending hospital Out-Patient Departments often las ts several hours; a si tuation particularly unsuitable for elderly patients. Review of OPD appointment procedures is urgently required.

7. Transport: Frail/immobile elderly require t ransport t o and from hospital O.P.D. clinics; this is largely unavailable and is no t sufficient to meet the growing needs of hospital out­patient and day care services.

8. Communication between hospitals , general practit ioners, public heal th nurse , etc, particularly in relation to pat ient discharge, is not always ideal and needs to be strengthened a s a matter of urgency.

9. Assessment and rehabilitation facilities need to be augmented to reach the recommended norms set by the Department of Health for these services viz a viz current and projected populations trends.

10. Extended care beds are urgently needed in South East County Dublin where there i s less t h a n a quar ter of the cur ren t na t iona l bed ra t ios pe r 1,000 elderly pe rsons in t h e population.

11. Close liaison between hospitals and the recently established EHB Care Teams for the Elderly in each Community Care Area is vital in order to avoid inappropriate discharge of elderly patients into the community.

12. Review of the u se of day-hospital procedures (as opposed to in-pat ient procedures) should be unde r t aken especially where frail elderly persons living alone, are concerned. A procedure requiring the patient to fas t from midnight for a n early morning appointment/hospital procedure and discharge tha t day, may be very suitable for young, basically fit patients, b u t is likely to be unsuitable for frail elderly persons without family or emotional support, or even transport to get to and from the hospital.

I hope tha t the experience of the Project a s outlined above will b e d rawn on in formulation improved hospi tal /community liaison policies and procedures.

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On behalf of t h e Steering Committee may I again welcome t h e Hospital review Body Interim Report a n d hope t h a t your group's final report , inclusive of t he above recommendations, will b e implemented with delay. Yours sincerely,

JOHN BYRNE Chairperson, Steering Committee, Dun Laoghaire Pilot Co-Ordination Project on Services for Elderly @ Local Level.

c.c. Dr. Roiy O'Hanlon, Minister for Health.

c.c Mr. D. McCarthy, Secretary, Dublin Hospital Review Group.