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to classify individual homes in terms of these functions. Your Committee have had abundant evidence of the existence of homes that cater for two or more of these categories simultaneously, and which may even combine the taking in of patients with the letting of rooms to lodgers. The type of building occupied may Q. 2540. range from a specially built, properly equipped private hospital to a totally inadequate, frequently insanitary dwelling-house. The person or body of persons in virtual control of the establishment may be a committee, a medical practitioner, a qualified nurse, or a totally unqualified individual, carrying on the home as a main or subsidiary business proposition. In this connection it is pertinent to note an answer given to your Committee :-“ You cannot have an unqualified person in the case Qs. 32, 33. of a nursing home.” This aptly illustrates the present state of the Law.
6. The state of affairs existing to-day, therefore, may thus be summarised :
Throughout the country there are many institutions (the actual App. I. number could not be ascertained) of very different kinds, both as regards the type of patient catered for and the nature of the building occupied; under various conditions of ownership and management carried on mainly or entirely for purposes of gain; and grading almost imperceptibly at one end into the lodging Qs. 1883– house, and at the other into the large public hospital; but which, 1885, 2791. taken together, may be regarded as forming a legitimate industry meeting definite needs.
7. First it was necessary for your Committee to satisfy themselves as to the existence of any real need or widespread demand for the control of these institutions. On the one hand they have been informed by the Ministry of Health and the British Medical Qs. 18, 22-24, Association that no considerable number of complaints as to the 196, 269, 285. conduct of nursing homes, apart from those homes devoted to maternity cases, have reached either of these bodies.
The Ministry of Health have stated their position to be that although they are in favour of the registration and inspection of Qs. 24, 25. inaternity homes in the fulfilment of their functions in regard to public health and child welfare, they are not aware of any conditions which would make it advisable to interfere, by means of control or supervision, with what, as your Committee agree, may be regarded as a legitimate industry. They stated, how- Q. 23. ever, that if a case is made out they would have no objection to the principle of registration.
The British Medical Association take the line that while Qs. 129-135. ignorant of the existence of widespread abuses', they do not object to a scheme of registration, provided that :-(a) the registration authority shall delegate its duties to a Committee upon which both doctors and nurses shall be represented; (b) medical Qs. 136-145, records and case sheets shall not be open to the inspection of any
184-188. 233-241, 297-299, 316-322.
Qs. 146-157, lay body or its representative; (c) doctors who receive patients 242-250.
for treatment into their private homes shall be exempt from registration, or at any rate, exempt from inspection, since the medical profession is under the General Medical Council for
disciplinary purposes'. Qs. 367-377.
On the other hand the College of Nursing claim that there is a real need for inspection and supervision for the protection of the sick public and that a considerable demand exists, at least within the nursing profession, for the exercise of some form of control to ensure that at any rate a proportion of those who are
in charge of the nursing of the sick should be State Registered App. IV. Nurses. In support of this contention the College of Nursing
have submitted to your Committee statements in support of registration and inspection signed by over 300 matrons and/or owners of nursing homes.
The Society of Medical Officers of Health state that they are Qs. 3062- convinced of the urgent need for registration of maternity homes 3068, 3156.
and still more, for the registration of other nursing homes, that Cf. Qs. 974– the registration of all nursing homes is a most necessary corol977.
lary to the registration of maternity homes, and that privatelyinanaged nursing homes form the source of constant complaints to medical officers of health all over the country, but no powers exist, at present, whereby such complaints may be investigated and the matter put right.
Upon the evidence adduced before them, your Committee are of opinion that the existence of a genuine need for the registration and supervision of nursing homes is fully established. The absence of representations to the Ministry of Health in this matter is, in your Committee's opinion, due to the non-existence of
any well recognised channel for making complaints and to the fact that no official investigation has ever been held.
8. As has been stated in paragraph 4, nursing homes frequently make provision for the reception of maternity cases. Apart altogether from the question as to whether there is any public demand for control, or whether any abuses exist in connection with this class of case, justification for control will be found in the fact that maternity cases are sharply differentiated from all other cases in that the patient seeks treatment for a particular condition with regard to which, by the passing of the Maternity and Child Welfare Acts and the payments of grants in aid, the State has recognised a special liability in relation to maternity and infant welfare. Under the Midwives Acts the practice of midwifery by unqualified persons habitually and for gain is prohibited. Your Committee agree that for obvious reasons the enforcement of this prohibition is a matter of great importance, and that without the power of registration and inspection abuses cannot be effectively detected and checked.
Under certain Local Acts such powers are already exercised, and general legislation on
lines is now before Parliament.
9. On the above grounds and from the experience derived from the supervision already exercised in regard to maternity cases it remains to be demonstrated that an equivalent need exists in regard to other cases.
Your Committee have received a number of complaints of a varied nature. These complaints arise from three sources :
(1) Doctors.-Mainly directed to structural and sanitary 23. 11578; defects in the buildings used as nursing homes, and to the 2933, 3066, lack of proper provision and equipment in regard to surgical 3522.
2369. (2) Nurses.—Mainly directed to inadequate accommoda- Qs. 375–379, tion both for patients and for staff ; the provision of bad and 738-756,
1470-1544, insufficient food ; inadequacy, or even total absence, of staff ; 1919–1922 the lack of training or absence of any qualifications among 2094-2099, the staff; and even the undesirable habits of persons in 3201-3208,
3669-3684. charge. In consequence of these conditions patients may be, and often are seriously neglected.
(3) Patients. The evidence received from the patients Qs. 714-737, themselves contains similar complaints to those put forward 1790-1803 , by the nurses, though necessarily as viewed from the 1878-1907, particular standpoint of the patient.
2250-2268, 10. These complaints may best be considered under four main 3742. headings :
(i) Structural.—That by far the greater number of houses used as nursing homes have been built originally as ordinary dwelling houses and in many cases have not been adapted in any way to meet their changed requirements. Staircases are frequently steep and narrow, and since the structure of the house may make it impossible to provide a lift, the proper transportation of patients becomes exceedingly difficult. Many homes which cater for surgical cases are without any form of operating theatre, and consequently operations have to be carried on in the patient's bed-room with all the attendant difficulties in regard to lighting, heating, ventilation, and adequate disinfection. The kitchen arrangeinents are inconvenient and, it is stated, in a certain class of home frequently insanitary and without any proper provision for the storage of food. The lavatory accommodation is often insufficient and insanitary.
(ii) Accommodation.—That in a certain class of smaller and cheaper home there is insufficient and in sanitary accommodation both for patients and for nurses. The rooms used as wards are small and badly ventilated, over-crowded and frequently in a very dirty condition. There are no 57082
proper arrangements for the removal of soiled linen, refuse
(iii) Staff. That matrons are often completely un-
properly with the patients in their charge and this inQs. 333, 993. sufficiency is even greater at night. Several cases have been
reported where it is alleged that the matron or person in
(iv) Neglect of Patients.-Owing to insufficiency or lack
one case no proper provision was made for the removal of a Qs. 733, 734.
patient, who had died, from the room in which other patients
were still accommodated.
(i) That the dwelling house converted into a nursing
for nursing home accommodation and that in fulfilling this
(ii) Your Committee have been deeply impressed with the
(iii) It has been made abundantly clear to your Committee that the provision of accommodation for the nursing staff in nursing homes of all grades leaves very much to be desired. Your Committee feel very strongly that it is impossible for the nursing profession to give of its best unless its members are properly housed and adequately fed. Such conditions as have been described to your Committee not only re-act unfavourably upon the health of the individual nurses, but also cannot be conducive to the proper management and care of the patients. It is an unfortunate feature of this complaint that it cannot be said to be inapplicable even in the homes conducted by fully qualified persons
whether belonging to the nursing or medical professions. 12. In view of this your Committee find that abuses do exist and are sufficiently prevalent particularly in the cheaper class of home, and the home catering for senile chronic cases, to render some form of supervision and inspection essential. They, there