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(iii) The sanitary arrangements.

(iv) The accommodation for patients and nursing staff.
(v) The adequacy of the staff both as to numbers and

(vi) The preparation and storage of food both for patients
and staff.

(vii) General domestic arrangements such as the cleanliness of the rooms, the supply of linen, &c.

(viii) The arrangements for disinfection and the prevention. of the spread of infection.

(ix) The arrangements in the event of a fire.

It is true that a medical officer is fully qualified to inspect many of these matters, and it is equally true that a sanitary officer and a trained nurse are better qualified to inspect others, but it is doubtful whether any of these officers are properly qualified, single-handed, to inspect all these services. On the other hand numerous inspections by different officials, whose functions may or may not overlap, can only result in friction and the unnecessary duplication of work.

23. There is a growing recognition of the importance of food services and your Committee consider it important that supervising authorities should give this matter their earnest attention. Medical men or women are qualified to prescribe and nurses who have taken the proper curriculum are trained to prepare articles of invalid diet; but neither doctor nor nurse can be considered normally to be expert in the preparation of ordinary meals. Nor

is there any guarantee in the ordinary nursing home that the Cf. Qs. 2816, many details essential to the attractive service of a meal receive 2933. anything like sufficient attention.

24. Your Committee have heard a considerable body of evidence directed to the qualifications and previous training of both matrons and nursing staff. Suggestions have been made Qs. 58-84, that the matron and all the nursing staff should be fully qualified 328-333, 457, 480-502, trained nurses; that a certain fixed percentage of fully qualified 1121-1125, nurses should be laid down; that only the matron should be com- 1241, 1242, pelled to be fully qualified; and lastly that no rigid rules can 2004-2011, possibly be laid down in this matter. There is much to be said 2169-2174, 2587-2590, for the argument that the public pays for expert nursing and 2783-2788, consequently expects to receive it. Patients are frequently quite 2872, unaware that the uniformed individuals in charge of them are. 3142-3146, 3159-3166, in many cases, quite unqualified girls with no real training in 3214-3219, their profession. On the other hand it cannot be overlooked that 3239-3247, in a certain type of case, it is not necessary to employ a fully 3287-3294, 3438-3440, qualified nurse or even a nurse at all. The immense diversity 3547-3549. in the requirements of patients and in the nature and size of

Qs. 65-78, 2614.

Nursing Homes makes it extremely difficult to fix even a minimum percentage of trained nursing staff that could be universally applicable. Even the provision that there need only be a fully qualified matron fails in, say, a Home where a qualified medical man takes in one or two patients who really require no nursing at all in the strict sense of the term.

The whole question of nursing staff depends necessarily on the supply of trained nurses; although it may be quite true that certain nursing homes find no difficulty in obtaining the necessary staff to-day, if, in future, they are required to carry a larger proportion of qualified nurses on their staff the well-recognised difficulties of the larger institutions in recruiting suitable staff will become even more acute. Your Committee are of opinion that there is a definite shortage of qualified nurses and that the attention of the Ministry of Health should be drawn to this aspect of the problem.

25. Undoubtedly the ideal condition would be that every person actually in charge of and responsible for a nursing case should be a fully qualified trained nurse and that the person in control of such nurses should herself be fully qualified. This would allow of the use of unqualified nurses for the performance of such small duties as would normally be performed by ward- or house-maids. Your Committee cannot too strongly urge that this ideal should be kept constantly before the supervising authorities and their inspecting officers; but your Committee fully realise that in many cases, at any rate to-day, inspecting officers will have to be content with conditions that fall short of this ideal and that in practice individual cases must be judged on their merits.

It must be borne in mind that there are to-day Nursing Homes under the control of matrons who have had long experience, who conduct their Homes in a satisfactory manner, but who are not fully qualified trained nurses. Although the aim of the supervising authority should be directed in the future towards the elimination of Homes under the control of unqualified persons, Your Committee do not recommend that already existing Homes of this class should be refused registration on the sole grounds that the owner or matron is an unqualified person; provided that some person fully qualified either as a doctor or a nurse and who is also in charge shall be actually resident in every Home.

This state of affairs makes it all the more important that an officer entrusted with the duties of inspection should be of considerable standing and possessed of wide experience.

Your Committee recommend that, subject to possible exemptions by the supervising authority in special circumstances, in every nursing home which comes into being and applies for

registration after the introduction of a Bill on the lines recommended in this report, the matron or other person in charge of the nursing in the home shall be a fully qualified nurse.

26. Your Committee recommend that nurses' certificates of Qs. 518-536, 1166-1185, training should be produced for inspection on demand to 1189-1191. inspecting officers and in suitable circumstances to the patient or the patient's friend. In these circumstances they do not consider that it should be necessary to make regulations compelling the public display of such certificates, as they fully realise that rules of this kind would detract from the home-like conditions that the owners of many nursing homes endeavour to preserve.

27. Similar arguments apply to the public display of the rules Qs. 283, 1098-1100, and regulations drawn up by the supervising authority, and to 3157, 3158, the exhibition of brass plates outside registered nursing homes. 3350. Your Committee are opposed to any form of compulsion in this matter. They consider that these rules and regulations should be available whenever called for whether by inspecting officers, patient's, or persons visiting patients, but that under an efficient system of registration it should not be necessary to compel their display in public. They also consider that every nursing home should similarly have available and disclose to inspecting officers and patients information as to the numbers of fully qualified nurses and unqualified nurses therein employed.

28. After giving due weight to the relative importance of the many different functions to be performed by the inspecting officer and the desirability of limiting the number of inspections, your Committee consider that the most effective inspection would be that carried out by the Medical Officer of Health with the assistance of other technically trained officers on his staff, such as the sanitary officer and a fully-trained and experienced nurse of the matron class.

Your Committee do not consider, however, that it would be at all advisable to tie the hands either of the supervising authority or the medical officer of health in this respect, but it must be remembered that the responsibility to the supervising authority should rest solely with the medical officer of health.


29. One of the main fears in the minds of those witnesses who Qs. 1166demur to the principle of inspection and supervision is that the 1185, privacy of the patient and the home-like atmosphere of the 3310, 3311, nursing home is likely to be destroyed by the frequent visit of 3356, 3400, officials, and the existence of innumerable and irritating regula- 3401, 3405, tions. It is pointed out that many patients go to nursing homes 3814-3818, mainly to obtain privacy and rest, and if the patients are to be subjected to inquiries into their private affairs and hedged about with restrictions one of the essential features differentiating a


Qs. 136-145,

nursing home from a publicly-controlled institution will be removed to the detriment of all concerned.

30. It has been suggested that inquiries might be made by 184-188, 233, inspecting officers into the medical records and case sheets of 234, 297-299. individual patients. Such inquiries would not unnaturally be deeply resented both by the patients and their medical advisers. Your Committee desire to emphasise the fact that the making of such inquiries could not possibly fall within the duties of an inspecting officer.

Qs. 2791, 2792.


31. Supervising authorities must clearly be empowered make byelaws in regard to the records to be kept by persons in control of registered homes, but in the circumstances your Committee consider it of great importance that the records required to b. kept should be the absolute minimum compatible with the proper administration of a scheme of registration, and the public health requirements of the country.

32. On the other hand, several matrons or owners of nursing homes have expressed their opinion that a well-conducted home has nothing to lose and everything to gain by registration and inspection. From the evidence your Committee have heard as to the practical working of such a system in regard to maternity Cf. also 2409. homes, it is clear, that once the supervising authority is satisfied as to the conduct of the home and its standard of efficiency, subsequent inspections are reduced to a minimum. The activities. of the inspecting officer are directed mainly to the border-line homes where the standard of efficiency is in doubt.

Your Committee do not consider that, if the supervising Cf. Qs. 2842- authorities are the County Council and County Borough Council, there is any real danger of interference with, or over-inspection of, properly conducted establishments.



33. Many doctors take in single patients for treatment in their private houses; frequently such cases require no actual nursing but merely normal home-life and the sympathetic companionQs. 324, 325, ship of intelligent persons. It is submitted by certain witnesses 3287-3294, that the term "nursing home" cannot properly be applied to cases of this type and that registration is not required, would do no good, and would be strongly resented by the medical profession. There are a number of nursing homes and private hospitals directly controlled by medical men, and often having Qs. 146-167, a medical officer resident therein. Strong representations have 242-249, 281, been made by the medical profession that, although there would 1580-1583, be no objection to simple registration, such homes, particularly 2373-2377, those with a resident medical officer, should be entirely exempt 3098-3109, from inspection. If registration is considered necessary, it is 3311-3315, suggested that the registration authority should place on the register any home controlled by a qualified medical practitioner



3401, 3591-3595.

who can submit to them certificates from two recognised medical men that he is a fit and proper person for the conduct of such an establishment. This system, it is pointed out, is already in Q. 246. operation in certain areas which have obtained powers for the registration and inspection of maternity homes.

34. Your Committee feel that there is much to be said for this point of view, but, on the other hand they have had evidence Qs. 1789put before them which indicates quite clearly that in certain 1803, 1862-1868, cases there is very decided room for improvement in nursing 2250-2267, homes under the direct control of a doctor. They feel that if an 3669-3683. individual doctor decides, for purposes of gain, habitually to take in patients, whether into his private house or into a nursing home, he does so with the full knowledge that he is taking up a definite trade and entering into competition with other persons who have to comply with such regulations as may be enforced. In these circumstances your Committee cannot see their way to recommend any general exemption from registration or inspection in respect of any premises covered by the definition of a nursing home on the sole grounds that such premises are under the direct control of a medical practitioner, resident or otherwise.

From this it would follow that the present practice of exempting maternity homes in such cases should no longer be permitted

35. Your Committee, however, recommend that in any legislation arising out of their inquiry certain institutions which would otherwise fall within the scope of the definition should be Cf. Qs. 158expressly excluded, namely, any Hospital or other premises 167. maintained or controlled by a Government Department or Local Authority, or the Board of Control or any body of persons constituted by special Act of Parliament or incorporated by Royal Charter. Your Committee consider that discretionary powers Cf. Q. 572. should be allowed to the supervising authority also to exempt, if they so think fit, any hospital or similar institution not carried on for purposes of profit, provided that such exemptions are brought under reconsideration each year.

36. If powers are granted to local authorities to make orders witholding registration or cancelling any registration previously granted, clearly some provision for appeal against such orders must be made. By the Midwives and Maternity Homes Bill now before Parliament, appeals may be made to a Court of Summary Jurisdiction. Under the Nursing Homes (Registration) Bill. 1925, provision is made for the determination of any such appeal by a referee to be appointed by the Minister of Health. From the attitude taken up by a number of witnesses and on general considerations, your Committee recommend that the latter course should be followed.

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