Speech at the parliamentary committee concerning the living conditions of adults housed in CHSLDs
Members of the National Assembly and members of the Committee,
Thank you for your invitation to contribute to the mandate for this initiative. The brief we have addressed to you is consistent with the angle chosen by the Committee, housing in CHSLDs. Before presenting some of our findings and suggestions, I would like to make three comments.
My first comment concerns the importance considering residential care for seniors in a continuum of services, including home support, access to hospitals and temporary residential care. By adopting this comprehensive vision, it is recognized that not all seniors who require it are housed in a CHSLD, due to a shortage of places. The impact of this reality on the organization and quality of services and respect for seniors' rights must not be hidden, neither in the CHSLDs, nor in intermediate resources, nor in seniors' residences, nor in home support services.
My second comment concerns work in CHSLDs and, more specifically, their staff. Despite the deficiencies we observe during our investigations, I must mention that we often find good will, expertise and dedication among CHSLD staff. Several of the issues we bring up in our brief go beyond their abilities and good will.
My third comment concerns the findings and analyses contained in our brief. They are mainly based on problems we identified during our investigations. The Québec Ombudsman does not draw conclusions merely on allegations and hearsay, but after a methodological investigation that verified the facts alleged. Over the past five years, the Québec Ombudsman intervened in 128 of the 202 CHSLDs in Québec, a proportion of 63%. In all, 75% of the complaints and reports that we concluded were substantiated concerned the quality of care and services (36%), the physical environment and the living environment (23%) and respect for rights (16%). For 2012-2013 alone, 56 CHSLDs in Québec (28 %) were the subject of one or more substantiated complaints and reports.
Our brief covers each of the challenges taken on by the Committee. In view of the time allotted to me, I will share a few observations related to three of these challenges: accessibility of CHSLDs, services and care, and monitoring their quality.
Regarding the challenge of accessibility of CHSLDs, it is documented that population aging is accentuating and that the wait is already inordinately long to obtain access to a CHSLD. Given that the number of places is stagnant, and even decreasing, we have questions about the actual accessibility of CHSLD places for the next generation. We make three suggestions to the Committee. They concern the conditions of access to residential care, including temporary housing, the quality and clarity of communications with seniors and their families in this regard, and finally, the impact of the foreseeable increase of the demand for public residential care on the supply of services.
Regarding the challenge of services and care, assistance in activities of daily living is the greatest source of dissatisfaction for residents housed in CHSLDs. While maintaining and strengthening the capacities of the people accommodated are one of the guiding principles of the ministerial orientations for a quality living environment, our investigations reveal that patient attendants' daily work plan leaves little leeway to respect these conditions, even though they are the basis of an appropriate response to the needs.
In several CHSLDs that were investigated, we observe, for example, that the staff are unable to take time to sit down and assist the residents during meals or to interact with them personally in a timely manner. We make the same finding for hygiene care and the only weekly bath. Residents also deplore the long wait for a response to call bells. Arrangements in the organization of work are not always designed to favour a maximum staff presence during peak periods. To support the implementation of a living environment adapted to the special needs of the housed residents, it is not possible to skimp on a better organization of work and increased staff engagement so that they adapt their methods to respond better to the residents' basic needs.
I will now discuss the challenge of monitoring the quality of services and care. In its consultation document, the Committee questions the adequacy and capacity of the seven mechanisms it identifies to ensure quality services and care in the CHSLDs. In our opinion, these mechanisms are theoretically adequate – and certainly numerous enough. What concerns us is the lack of proactivity and consistency, and the weaknesses in acting on recommendations, even once they are accepted. Moreover, when problems are identified in these mechanisms, the delays are much too long to correct them. I take the example of the difficulties we observe in quality control when temporary residential care places are purchased under agreements between the CSSS or the agencies and private resources. The phenomenon is growing, due to the delays in access to the CHSLDs.
The Québec Ombudsman has repeatedly identified deficiencies in these temporary residential care resources regarding the training of the workforce and on-site clinical supervision. These deficiencies do not ensure appropriate and safe care delivery for the residents. The users need and have a right to the same quality of care and services, regardless of the type of residential care where the public network refers them while waiting for a place to become available in the CHSLD of their choice.
The Québec Ombudsman has no inherent reservations regarding the principle of agreements for the purchase of residential care places. However, it has noted – and continues to note – its concern regarding the recognized insufficiency of the control of quality monitoring. Indeed, several CSSS and agencies do not adopt adequate procedures to favour an informed and sound choice of private partners. In our opinion, the following factors related to the organization of work should be given better consideration: the private partners' staff evaluation and hiring criteria, the skills and competencies of this staff based on the profile of the clientele, the staff ratios in relation to the number of residents in this specific environment, and the clinical supervision tools.
We look forward with interest to the concrete actions resulting from the in-depth review undertaken by the MSSS regarding the process of evaluation visits to the CHSLDs, which henceforth would be conducted regardless of the public or private status of a body and considering the purchases of places in private resources. The implementation of this new approach is scheduled for this spring 2014.
In the context of the future increasing reliance on private partners, it is also more essential for the CSSS and the agencies to assume their responsibilities for monitoring the quality of services provided to the users they refer to their private partners. This is why we suggest that the Committee request Minister of Health and Social Services institute a quality assurance policy associated with an action plan, in light of this consultation, and to include in its concerns the examination of procedures favouring the informed choice of private partners, including the quality control procedures to which they would be subjected.
In conclusion, meeting the nine challenges adopted by the Committee requires a comprehensive vision, an integrated action plan, including adequate quality control, and sustained action.
For this purpose, it is essential for all network players, particularly the institutional CEOs, to adhere to and concretely appropriate the living environment concept. Their strong leadership must make the difference. The problems to be solved and their causes are well known.
Leadership must focus on problem solving without losing sight of the human dimension, by far the most essential dimension that must be considered both by managers and staff members at all levels.
Several solutions have been raised within the context of the initiative for this mandate. They are added to the recommendations we made in our annual reports over the past few years. It is now time to implement these recommendations consistently within a comprehensive perspective that includes home support services, access to hospitals, and temporary residential care.