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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. 1883house, 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. maternity 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.




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Qs. 146-157, lay body or its representative; (c) doctors who receive patients 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.

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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 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 convinced of the urgent need for registration of maternity homes. and still more, for the registration of other nursing homes, that the registration of all nursing homes is a most necessary corollary to the registration of maternity homes, and that privatelymanaged 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 the same 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 Qs. 1578, 2540, 2932, defects in the buildings used as nursing homes, and to the 2933, 3066, lack of proper provision and equipment in regard to surgical 3522.


Cf. 23642369.

(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, 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.

2193-2203, 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 arrangements 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 insanitary 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


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proper arrangements for the removal of soiled linen, refuse and excreta In the rooms provided for the nursing staff there is considerable over-crowding. This may happen even in the better class homes. In some cases the rooms are quite unsuitable for use as bed-rooms and their restricted size prevents the provision of a sufficient number of beds. Consequently, night nurses may have to sleep not only in the beds but, owing to the inadequate supply of linen, even in the sheets just vacated by the day nurses. No off-duty rooms or sitting-rooms are provided. No room is set apart as a theatre, or if it is, it is also used for other purposes.

(iii) Staff. That matrons are often completely unqualified. There are frequently no qualified nurses and the nursing is carried on by house-maids. The number of nurses available during the day-time is quite insufficient to deal properly with the patients in their charge and this insufficiency is even greater at night. Several cases have been reported where it is alleged that the matron or person in charge is frequently drunk. In other cases there is no staff at all beyond the keeper of the home and perhaps her husband or a relative.

(iv) Neglect of Patients.-Owing to insufficiency or lack of qualification in the staff, patients particularly of the senile chronic type, are stated to be left entirely to administer to their own wants although often quite incapable of doing so. That they frequently develop bed-sores due to prolonged neglect. They are rarely washed. The bed linen is changed at very infrequent intervals, even when soiled. The rooms are verminous. No adequate protection is taken to prevent dissemination of contagious or infectious diseases, and frequently patients are unable to obtain any assistance when they require it. The food is scanty and often quite unsuitable, and has to be supplemented by the patients themselves or their friends. Elderly and senile patients, practically put away in a cheap home by relations who take little or no further interest in them, suffer great indignities, are very unhappy and too frightened to make any complaint. In one case no proper provision was made for the removal of a patient, who had died, from the room in which other patients were still accommodated.

11. After making due allowances for the different sources from which your Committee have received evidence they consider that three facts clearly emerge :

(i) That the dwelling house converted into a nursing home with its many structural deficiencies which cannot. be overcome, is, at any rate, in acute surgical cases a very poor and expensive substitute for the specially built, adequately equipped and staffed, hospital. It is of course true that at the present time there is a considerable demand

for nursing home accommodation and that in fulfilling this
demand nursing homes serve a useful purpose. In stating
this opinion your Committee do not intend to criticise the
work carried out by well run nursing homes, for it is clear
that in many cases the owners or managers of these homes
are making the very best of structurally unsuitable buildings.
Your Committee desire to emphasise their opinion that the
future trend of development in regard to the provision of
accommodation for the paying patient should run more along
the lines of the provision of specially built and equipped
private hospitals and homes and of the extension of the
paying ward system in the existing big hospitals.

(ii) Your Committee have been deeply impressed with the
urgent need for registration and supervision in that class of
nursing home which caters for the poor senile chronic. It
has been stated in evidence that it is impossible adequately
to nurse and accommodate, in a private room, a patient Q. 3236.
under £5 a week. Unfortunately there exists a large class
of elderly persons who although they are capable of making
some payment are quite unable to find a weekly sum of this
order. Your Committee consider that the general applica-
tion of registration and inspection will do much to alleviate
the bad conditions and suffering undergone to-day by patients
of this class, but they desire strongly to emphasise their
opinion that this change cannot be regarded as a cure for
these evils, but merely as a palliative. They feel that the
problem can only be properly solved by the re-organisation
of the Poor Law system, and with regard to the class of
patient dealt with in this sub-paragraph by the provision
of proper paying accommodation by local authorities to meet
their needs.

(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

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