SPECIAL REPORT OF THE PROTECTOR OF CITIZENS ON CONDUCTED INSPECTIONS IN SOCIAL CARE INSTITUTIONS FOR THE ELDERLY
TABLE OF CONTENTS
Inspections in residential social care institutions for elderly people 3
Privately owned homes for elderly people 4
Examples of good practice 5
BEST RESIDENTIAL INSTITUTIONS FOR ELDERLY PEOPLE 6
Subotica 7 Belgrade, Bežanijska kosa 15
RESIDENTIAL INSTITUTIONS FOR ELDERLY PEOPLE
IN BELGRADE 18
Karaburma 22 INSTITUTIONS ABOVE THE NATIONAL AVERAGE
IN TERMS OF ACCOMMODATION AND ORGANISATION 25
Mataruška Banja 37
TYPICAL AVERAGE INSTITUTIONS
IN TERMS OF ACCOMMODATION AND ORGANISATION 40
Surdulica 53 OVERPOPULATED INSTITUTIONS 59
Kruševac 63 BELOW THE NATIONAL AVERAGE 67
CONCLUDING REMARKS 72 Possible directions of improvement 74
INTRODUCTION Inspections in residential social care institutions for elderly people
In accordance with the Protector of Citizens’ power to act preventively in order to improve the work of public authorities and protect human rights and freedoms, in 2010 this institution visited and inspected the work of thirteen state social care institutions for accommodating elderly people, gerontology centres and residential homes for elderly people. Inspections were conducted by the Protector of Citizens’ team led by Zorica Mršević, PhD, Deputy Protector of Citizens for gender equality and rights of persons with disabilities, and supported by her associates. They examined the documents containing the data about the methods of providing care to the beneficiaries,1 the number, structure, and classification of beneficiaries, and had an unrestricted conversation with the employees and beneficiaries for the purpose of gathering all the information related to the methods of work and quality of service. The inspection of their work was a part of the Protector of Citizens’ annual activity plan based on a certain number of complaints from the beneficiaries of these institutions, and also the comments and suggestions submitted to the Protector of Citizens by the management and employees of these institutions.
The management was cooperative in all visited institutions; all data and documents were made available to the inspection teams without any conditions; the teams were allowed to see and photograph all the buildings; the unattended conversations with the beneficiaries and employees were conducted without disturbance. Not only has nothing been hidden from the inspection teams, but they had an impression that the visits were seen as an opportunity to highlight the most pressing problems of these institutions.
The following social care institutions for the elderly in the Republic of Serbia were visited in the period April-December 2010:
7 April - Retirement Home Bеžаniјska kоsa, Bеlgrаde
7 April – Home for Elderly People Kаrаburmа, Bеlgrаde
9 April - Home for Elderly People Vоždоvаc, Bеlgrаde
17 June - Home for Elderly and Retired People, Smеdеrеvо
18 June – Gеrоntоlоgy Centre Krušеvаc
18 June - Gеrоntоlоgy Centre Маtаruškа Bаnjа
22 July - Gеrоntоlоgy Centre Šаbаc
3 August - Gеrоntоlоgy Centre Krаguјеvаc
6 August - Home for Elderly and Retired People Dimitrоvgrаd
1 September – Gеrоntоlоgy Centre Kikindа
2 September - Gеrоntоlоgy Centre Subоticа
9 November - Home for Elderly People Surdulicа
10 December - Gеrоntоlоgy Centre Zrеnjаnin.
Some of the visited institutions are only residential homes for the elderly, while the others are also gerontology centres that provide the so-called non-institutional services in addition to the existing traditional institutional accommodation.
In Serbia, there are 41 state and 42 privately owned homes for elderly people that are officially registered. The accommodation capacity of state homes is about 7,000 people, while the accommodation capacity of privately owned registered and licensed residential homes is about 1,019 people. Some of the state homes have become gerontology centres and in addition to accommodation, they provide the so-called non-institutional services consisting of providing help to the elderly in their own homes. Currently, the state homes accommodate about 8,100 beneficiaries, and in Belgrade, where the need is greatest, there are 1,200 beneficiaries. People have to wait for a long time to be accommodated in any of these homes, in particular in the institutions with a higher standard of accommodation. There are still places in some residential homes of low standard in central Serbia. The importance of the tradition of residential homes has been noticed: in the places where residential institutions for the elderly have been working for a long period of time, they tend to be better organised.
Privately owned homes for elderly people The low standard of accommodation of the majority of state homes for elderly people is the reason for the existence of privately-owned institutions, both registered and illegal unregistered homes, as well as the so-called "shelters." However, this report does not cover such homes.
In the situation of an increasing number of elderly people in need of care and accommodation, many enterprising individuals have come up with an idea to take a lease of family houses on the outskirts of big cities and use them for opening privately owned residential homes for the elderly. Many of them do not have a license for that type of activity. They are registered as restaurants, hostels, etc. which prevents the Ministry of Labour and Social Policy from inspecting them. They are controlled only in cases of incidents, deaths, media reports about possible violence and rather widespread practice of forced accommodation of beneficiaries. Another problem is that the registration of privately owned homes requires mainly the fulfillment of construction and technical requirements. The medical and therapeutic aspect is quite often disregarded; there are no medical records of beneficiaries with the history of their disease and treatment; medical staff is usually hired under temporary, rather than permanent, contracts and there are complaints from various sources alleging abuse of the beneficiaries who are placed in such residential homes against their will. More specifically, the social welfare centres responsible for different territories have no role in such placement, and those who are placed in these homes are usually not asked for consent; the only condition for their placement is a regular payment of accommodation price, which is usually twice as high as the price of state homes.
Probably the worst type of accommodation are the so-called "shelters" for the elderly that function in the way that natural persons conclude lifelong care contracts with beneficiaries, have them certified by the court, take beneficiaries’ pensions or their land or other valuable real estate. In return, they provide beneficiaries with care. However, the elderly are often accommodated in unheated auxiliary rooms and sometimes left to slowly die of "natural causes", hungry and without adequate care.
The complaints filed with the Protector of Citizens in 2010 indicate that elderly people might be placed in these homes against their will, which then becomes a form of unlawful deprivation of liberty. This is different from state homes, because the accommodation in a state home always requires the consent of a person who will be placed in the home and the procedure conducted by the competent social welfare centre. These requirements are widely avoided in privately-owned homes or completely disregarded in case of unregistered "institutions" of that type. Allegedly, privately-owned homes do not keep medical documentation, not even the most basic one. In some cases, there is only basic documentation and nothing more. Most often there are no beneficiaries’ statements on being placed in an institution with their own consent, or evidence on being under guardianship or being placed in the home for elderly with the guardian’s consent.
Taking into consideration the indications from various sources, mostly from the complaints filed with the Protector of Citizens, as well as publicly presented views and opinions of experts in the field of social protection, it is necessary to extend the control of institutions for the elderly to privately-owned institutions that are officially registered for this activity.
Examples of good practice
The examples of the Gеrоntоlоgy Centre Subоticа with the capacity of about 700 beneficiaries and the Retirement Home in Bеžаniјska kоsa Bеlgrаde with the capacity of nearly 800 beneficiaries show that not everything is negative when it comes to state residential institutions for elderly people. Both of these institutions are large. Such institutions are usually considered inhumane and worse than the homes of smaller accommodation capacity. However, it is the fact that the largest institutions of this kind, in Bеžаniјska kоsa and Subotica, are the residential institutions for the elderly with the highest standard of service and at the same time, the most desirable for potential beneficiaries and their families in the Republic of Serbia.
After the inspection conducted in 2010, the Protector of Citizens proclaimed the Gerontology Centre in Subotica the best institution of its kind among the visited ones, because it provides a much higher standard of accommodation for elderly people, above the national average. It also admits all categories of beneficiaries without discrimination, actively performs fundraising activities in order to ensure additional funds and additional human resources through projects, has excellent cooperation with the local self-government and provides diversified non-institutional services without displacing the elderly from their households. The Centre’s staff and management show that with the proper attitude towards work, that is - consistent implementation of the regulations on residential institutions for the elderly, provision of care to the elderly and good organisation of work, impressive results can be achieved in the same system in which other social institutions of this type function much worse.
BEST RESIDENTIAL INSTITUTIONS FOR ELDERLY PEOPLE Subоticа
Bеlgrаde, Bеžаniјskа kоsа GERONTOLOGY CENTRE SUBOTICA The Protector of Citizens’ team conducted an inspection in this Centre on 2 September 2010.2 About the Centre
Institutional assistance and care for the elderly have been provided in the Municipality of Subotica since 1971, while the service of residential care has been provided since the establishment of the Centre in 1978. The Gerontology Centre in Subotica is a gerontology and geriatric institution that provides care to adults and elderly people. As part of its activities, this institution provides services for pensioners, persons with occupational disability and other adults in need of social protection. In fact, this institution accommodates beneficiaries of any age and psycho-physical condition.
The Gerontology Centre performs its activities both through non-institutional and institutional forms of protection. There are several forms of non-institutional care which include gerontology clubs, home care and household assistance services, provision of certain services to the residents of "protected housing". Home services are provided in 124 residential units within the protected housing buildings. Institutional care includes accommodation in the Home Dudova šuma, the Home for Care and the Home for Adults.
The Home Dudova šuma, with the capacity of about 265 beneficiaries, provides accommodation services to pensioners, persons with occupational disability or other persons who are eligible for this type of housing. It is a multi-storey building consisting of a boarding type unit and an enhanced care unit (fifth and sixth floors). There is a central kitchen in this building (where food is prepared for the Centre’s beneficiaries and the beneficiaries of non-institutional care services). There are also a dining room, doctor’s surgery and pharmacy.
The Home for Care is a facility that accommodates 173 persons with reduced level of functional ability, with mental, physical or combined difficulties, mentally challenged and those with sclerotic changes or dementia.
The Home for Adults accommodates 93 mentally and physically dysfunctional persons, whose remaining abilities can be maintained for a longer period in an adjusted space or even improve with adequate medical care.
The following services function within the Gerontology Centre: non-institutional protection, facilities, service provision and common affairs. The Gerontology Centre also provides protected housing in one-room flats and related services for which the institution is registered and which are in accordance with the requests of beneficiaries. Accommodation is allocated by the Republic Fund for Pension and Disability Insurance and intended primarily for the pensioners who have not succeeded in solving their housing issue during working life and their pension is now insufficient for renting an apartment.
The total area of the Gerontology Centre is 17,283 m2, and the greenery spreads on 10,398 m2 covering about 10 hectares of cultivated park with a small restaurant area, benches and fountains. One of the buildings has its own orchard with apricots and peaches.
A post office and a pharmacy are located in the building, and there is also a bar where drinks, snacks, chocolates, etc. can be bought. A supermarket is just behind the residential home. The public transport lines leading to the city centre and passing by the hospital are nearby, which is very convenient. The staff members also buy some necessities that the immobile beneficiaries might need.
There is a cable TV in all rooms in the main building and a contract has been signed with the cable company for other two pavilions, and it should be implemented soon. The high-standard rooms have TV sets, venetian blinds and the beneficiaries in that category are provided with the services of escort to the hospital. There are 20 high-standard rooms, which are mostly single, and there are 3 twin bedrooms. The sixth floor has a central air-conditioning system, the fifth floor has air-conditioned common rooms and hallways, and some individual rooms in the protected housing buildings are also air-conditioned.
The Gerontology Centre provides its beneficiaries with daily newspapers and free services of public library. Each floor has a very nicely furnished living room. In addition to individual/personal computers in the rooms, there is a common computer that may be used in the library where there is a good internet connection. The beneficiaries may attend regular pottery and weaving workshops.
Moreover, the Gerontology Centre’s vehicle fleet includes a medical vehicle, delivery vans and passenger cars.
The capacity of the Gerontology Centre is 530 people, and during the September visit the number of beneficiaries was 685. There is a waiting list of those interested in getting accommodation in these 4 buildings.
About 50% of beneficiaries are financed from the budget.
The average age of beneficiaries is 74.5 years. The elderly are accommodated in the Gerontology Centre when their household members cannot take care of them any more. It is interesting that as many as 392 or 55.8% of them lived alone before being placed in the Centre.
There are all categories of beneficiaries: dependent, independent, mentally ill and mentally challenged, but also younger persons who have no place to go, for example: a young man without arms who grew up in Kolevka or a 33-year-old person who had a car accident a few years ago fell into a coma from which he has not recovered.
There is no reception centre in Subotica so that the Gerontology Centre also accommodates persons who find themselves in a state of social need. They also accommodate treated alcoholics (currently there are 60 of them) and occasionally these people cause problems to the employees and other beneficiaries due to drunkenness.
The beneficiaries are from Subotica and its surroundings in 95% of cases, but they also come from Bačka Topola and some other towns in Vojvodina. Some of them have foreign pensions. There is no shelter for the homeless in Subotica, and until it is opened, the Gerontology Centre will receive also homeless people.
An increasing number of beneficiaries are dependent. There are fewer and fewer completely independent persons and eight out of ten so-called independent beneficiaries cannot feed themselves independently, maintain hygiene or take regularly their prescribed therapy. We can say that there is no single beneficiary who is completely independent. Only 10-20% of them can partially take care of themselves, all the others are absolutely dependent.
The beneficiaries are granted the so-called protected housing on the basis of open competition. They use the services they choose and the Centre is obliged to provide them with these services. They pay for those services by themselves and if they cannot, the costs are covered by the SWC.
An increasing number of beneficiaries come directly from the hospital, after a surgery or recovery from illness; there are many people who are mentally ill, as well as those with serious heart disease, those who have survived a stroke or similar illnesses, and their number is growing.
As regards accommodation, there are 2 organisational units; the dependent persons are accommodated on the 5th and 6th floors – there are 90-113 immobile, bed-ridden beneficiaries. There are even rooms with 13 beds on these floors. The mobile semi-dependent beneficiaries are accommodated from the first to the fourth floor.
Not only in Subotica but in all other homes, the immobile beneficiaries are placed on the top floor, because it was the prevailing architectural solution in the 1980ies since it was considered that the first impression was important and that the impression would have been depressing if the scene of bed-ridden beneficiaries had dominated immediately at the entrance. This now complicates work and life in the Centre because even when all elevators are functioning, it is necessary to carry the immobile persons from the upper floors to the hospital for check-ups, etc.
The beneficiaries can choose their roommates. It is taken care that people accommodated in twin rooms understand the same language, which does not mean that they must be of the same nationality. People also fall in love in the Centre and then they are moved to the same room. The management supports it because people function better when they are together; weddings are also organised.
In 2009, among the total number of beneficiaries who left the residential home for various reasons, the majority were those who died. In 2009, 194 persons stopped using the accommodation and 152 of them died.
Prevailing number of women
Similarly to other institutions of this kind in the Republic of Serbia, most beneficiaries are women who make up 80 to 90% of all the beneficiaries in Subotica. The "female story" does not end with the beneficiaries but extends to 336 employees, of which only 15 are men.
Dementia and depression
It is particularly important that the Gerontology Centre insists on the implementation of new achievements in its work with the beneficiaries. One segment of that work is continuous training of all employees and training of staff to work with people affected by dementia and Alzheimer's disease. They have noticed that the number of beneficiaries with this diagnosis has been increasing. According to their experience, the percentage of independent beneficiaries who seek accommodation has been reduced in the past few years compared to the number of dependent beneficiaries. Earlier, this ratio was 70:30% and now it is the other way round.
The beneficiaries with dementia in the Gerontology Centre in Subotica are neither locked nor isolated in any way. They have rooms and floors coloured differently to help them orient themselves. The staff members were in Hungary to learn about their way of dealing with demented beneficiaries. The important difference is that demented people in Hungary must not be singled out. Inclusion, and not isolation, helps to slow the process of dementia, and there is also a factor of learning from others.
The beneficiaries are affected by depression and have fear of death; only 10% of them do not complain to have come to the Centre under pressure from family members, while others consider to be treated unjustly as they had to be removed from their homes at their old age.
The beneficiaries can use the library with a renewed and rich collection of books in Serbian, Croatian, Hungarian and German, the audio library for hearing impaired people, daily newspapers and weekly magazines, a computer with an Internet connection and video equipment.
The Centre organises musicotherapy, as well as "discussion workshops" conducted by an adult educator employed in the Centre, which is a form of social therapy where people discuss and talk about various problems, resolve mutual conflicts and other problems that may arise. The problems of beneficiaries are most often related to housing, conflicts with other beneficiaries and food. Home community meetings are held once a week.
The Centre also organises physical and work therapy, which consists of white embroidery, painting on silk and glass, creating decorative pottery (they also have a clay furnace). Even paralysed people work, i.e. participate in work therapy in accordance with their ability. The Centre organises trips and exchange visits to the beneficiaries of other institutions/homes. School children often present performances for the beneficiaries. There are also video projections, visits to museum exhibitions, etc.
It should be noted that the Centre allows the beneficiaries to keep pets, which are provided with necessary veterinary, sanitary and hygienic care.
The Orthodox and Roman-Catholic priests come when needed and during religious holidays. The services are being held in the library since there is no special chapel for that purpose.
The Gerontology Centre in Subotica has 336 employees, of which 43 nurses, 3 general practitioners, 3 medical specialists hired under temporary service contract. The medical specialists are a neuropsychiatrist, a gynaecologist and a physical and rehabilitation medicine specialist. The Centre lacks an internist because they have no sufficient financial resources. The institution has 15 male employees: security guards, driver and director. A gynaecologist is necessary primarily for employees who are mainly women; medical check-ups in the workplace allow the employees better health care with minimum time used.
The expert team members (psychologist, graduate social worker, adult educator, head nurse, head physical therapist, occupational and hobby therapist), continuously monitor the needs, satisfaction and complaints of beneficiaries and adapt the programmes to changes and needs that may arise. The Gerontology Centre has a music teacher, but also an adult educator. The Centre organises discussion workshops (the beneficiaries and the employees share their thoughts about the topics they choose).
It is interesting that 51 persons are engaged through public works by the end of the year, mainly as household assistants, nursing attendants in the field, 10 geronto-housekeepers and 10 personal assistants.
The management points out that it is difficult to organise shifts, hygiene, night duty and duty during the holidays in the four buildings about a mile away from each other. The main remark highlighted by the interviewed employees and the Director is that the salaries are low for plenty of hard work.