Ehpad: For the Defender of Rights, “the response of the public authorities is not up to par”

A year and a half after the publication of your report on the fundamental rights of elderly people in nursing homes, you are analyzing its follow-up. Has the situation improved?
Frankly no, we still see violations of the rights of residents in nursing homes. The follow-up that we will present tomorrow was drawn up on the basis of the complaints that we continue to receive and the responses given by the ministries and public bodies to the recommendations that we had addressed to them. We have seen an increase in reporting. The Defender of Rights had investigated more than 900 complaints in connection with elderly people in nursing homes during the six years preceding the 2021 report. We have since received 281 more. This does not necessarily mean that the situation is worse than before, because speech has been released. But this shows that the phenomenon persists: in 43% of cases, it is cases of abuse, in 30% of limitation of visits, in 12% of restrictions on the freedom to come and go. The shortcomings concern both the private and the public, the private for-profit and non-profit sectors.

We have seen an increase in reports

Have your 64 recommendations aimed at improving the conditions of care for residents been followed?
The Ministries of Health and Solidarity, Autonomy and People with Disabilities did not provide explicit feedback on the 34 recommendations addressed to them. The response of the public authorities is not commensurate with the attacks denounced, nor the urgency. Eighteen months after the first report, the results are extremely worrying: 9% of our recommendations have resulted in action, 55% have been announced but are struggling to materialize, and 36% remain without reply.

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What do you ask first?
Our main recommendation is to set a minimum coaching ratio. It takes at least eight caregivers and facilitators for ten residents in nursing homes. In France, the ratio is 6 to ten, where the northern countries are ten. If we do not progress on this, in fact, we are mistreating. We are still told of the forced bed rest of the elderly, two days a week, residents who, for lack of human resources, stay in their pajamas all day, are only entitled to a shower every two weeks, have dinner at 5.30 p.m. adapting to the schedules of the staff or to whom we put protections so as not to have to accompany them to the toilets when they are not incontinent. We need to recruit massively.

But old age professions lack attractiveness…
If you restore a normal supervision rate in nursing homes, the caregivers will return to work there. They say it: they chose this job because it made sense. If we put them in a situation where they can no longer work properly, they prefer to turn to other sectors. By setting a staffing ratio of eight and increasing salaries, you will be able to recruit.

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At least eight caregivers and facilitators are needed for ten residents

Now that the pandemic is ebbing, have the attacks on residents’ freedoms diminished?
If life has returned to normal for the entire population, without restrictions linked to Covid, this is not always the case for the elderly in nursing homes. Some establishments reconfine the residents, in their room or on their floor, as soon as they have a few positive cases, restrict visiting rights, prohibit outings, force them to leave the door of the room open to monitor respect for distances. I recommended, in 2021, adopting a specific legal framework for nursing homes to guarantee the necessary and proportionate nature of the attacks on freedoms linked to the pandemic. This has not been followed at all: health measures continue to be enacted in the form of protocols and recommendations, without legal basis. The elderly are not in detention! We must put an end to violations of their freedom to come and go. Otherwise, it is discrimination.

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After the revelations about the Orpéa group, has the government taken measures to fight against abuse?
Our 2021 report and Mr. Castanet’s book have raised awareness, not just of the public authorities, but of society as a whole. If mistreatment is now defined by law, the reporting system is not yet developed. Professionals continue to wonder about what we put under the term abuse, about what to do, about the obligation to report it. Despite our recommendations, there is still no reliable measurement tool shared by all regulatory and control authorities. It is necessary to set up a real mechanism of “medico-social vigilance”with training in well-treatment and the fight against abuse for staff.

The elderly are not in detention!

The public authorities have nevertheless launched a vast plan to control nursing homes…
It’s a start, but it’s not enough. The ARS and the Departmental Councils still do not have a common repository as a basis for control. The duration of the procedure is long. And the human resources are lacking: the government may have planned the recruitment of 120 additional positions for two years, it is insufficient to cover the 7,500 nursing homes. We also recall the need to develop on-site investigations, and in an unexpected manner.

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How to improve relations with residents and their relatives?
Families do not necessarily dare to denounce acts of mistreatment for fear of reprisals: We already have 7% of withdrawals among the 281 complaints received over the past eighteen months. We recommend setting up a mediation system in each Ehpad: sometimes it is enough to talk to each other to unblock a situation. The Defender of Rights has already settled, in this way, 37% of the reports it had received since the first report. It is also necessary to implement annual satisfaction surveys and strengthen transparency. It is very good that the HAS has created the first reference system intended for the evaluation of the quality of medico-social establishments. The Ministries of Health and Solidarity have also promised to publish ten key indicators on each establishment sheet. But we are still waiting for their publication.

Families do not necessarily dare to report acts of abuse

There are still some interesting local initiatives…
Sure. Institutions are doing extraordinary things. Our report does not aim to do Ehpad Bashing. I find it very unfair to point the finger at the staff when they are asked, for example, to do fifteen toilets in two hours. The organization, the budgetary constraints, generate a systemic mistreatment. It is absolutely necessary to reflect on the place of the elderly in society. The rights and freedoms of residents cannot be an adjustment variable for the lack of human and financial resources of nursing homes.

What is the purpose of this follow-up report?
I am asking for a national plan commensurate with the challenges, a strong signal from the public authorities. The bill tabled in mid-December by the presidential majority starts from a good intention. It includes some interesting elements, on the collection of worrying information or the right of access, but seems a poor substitute for the old age law that we were promised. France is one of the European countries with the highest proportion of elderly people in nursing homes (8.8% of people aged 75 and over). It really is time to take action. We will be extremely attentive to the follow-up that will be given. Respect for the rights of vulnerable people is at the heart of my concerns.

Ehpad: For the Defender of Rights, “the response of the public authorities is not up to par”