Dec 08, 2020

Locked doors in aged care: resident safety or loss of dignity?

 

For those living in residential aged care, the benefits of living in a safe and comfortable environment, where you receive the care you need, must be weighed against the loss of independence that can also occur at this stage of life.

Aged care providers have a duty of care to keep residents safe, healthy and happy, and the tension between that duty and what we call ‘dignity of risk’, allowing residents to take risks as a way of preserving their wellbeing, is one of the key challenges.

Locking doors in aged care homes is a key issue that highlights this tension. 

While some say residents have the right to move freely around an aged care home and open doors are a way to preserve dignity for the residents, others say safety is the priority, and we must find ways to make locked doors acceptable for the resident.

But locked doors can upset residents who may not understand why they can’t pass through it, making them feel “trapped” and “upset”.

Kate Swaffer is the co-founder, chair and CEO of Dementia Alliance International, and is globally recognised for her advocacy of people living with dementia. She told HelloCare that when her father-in-law was living in residential aged care, he couldn’t understand why the front door was locked.

“You promised me this was my home,” he would say.

Locked doors can cause anxiety

Lee-Fay Low, Associate Professor, Ageing and Health at the Faculty of Health Sciences, The University of Sydney, told HelloCare that some people living with dementia “don’t like” locked doors.

They attempt to “escape” homes with locked doors by following visitors or staff out the front door, or they try door handles repeatedly, “knocking and pushing”. They also sometimes try leaving by other means, such as by climbing the fence, Low said.

Just as Swaffer’s father-in-law was upset he no longer had the autonomy to walk out the front door whenever he wished, Low said locked doors can make residents “feel trapped”, making them become “upset”.

But open doors mean residents can leave the home without supervision, and may do so without staff noticing, putting themselves in danger, Low said. 

A barrier to walking

Locked doors can also be a barrier to residents living with dementia who like to walk. The “challenge”, Low said, is that “residents who walk sometimes go into the rooms of others, and it upsets those other residents”.

“Residents need a safe place to walk, for example, a garden with a flat path, and perhaps with places to sit, and things to do along that path,” Low said.

A dementia expert who asked that their name be withheld told HelloCare that aged care providers have to find a balance between the rights of the person living with dementia and the rights of the other residents.

There are “pros and cons” to locking doors, the expert said.

Though Swaffer now advocates for an end to institutional care for older people, she understands “in the short term” this need for aged care homes to keep residents safe by locking some doors.

Leave the right doors open 

Residents must have access to outside areas 24/7, Swaffer said. Even if the front door is locked, the back doors can remain open, she suggested. 

Swaffer said Group Homes Australia uses this practice successfully in its homes.

Low says, “Residents need a safe place to walk, for example, a garden with a flat path, and perhaps with places to sit, and things to do along that path.”

“People who were active through their lives would not want to sit for most of the day, their body rhythms are telling them they need to move and do things.” It’s essential that those living with dementia in residential aged care can satisfy this urge to move, and so some doors must remain unlocked to allow this to happen.

The dignity of risk

“People with dementia need to have some autonomy and choice to be who they are, this ‘freedom’ is important to their psychological wellbeing,” Low said. 

“This can involve taking some risks”, such as being able to move freely about their home and not being ‘locked’ in.

When the person doesn’t have the cognitive skills to judge the level of risk “hopefully their family and paid staff would be able to balance the physical risk with the psychological/wellbeing benefits to that person to still be able to do that ‘risky’ activity,” she said. 

Finding a better way

The Interim Report of the Royal Commission into Aged Care Quality and Safety notes the “countless” stories it heard about residents losing their “basic rights to take risks, to choose what to do in their day.” 

“There is no joy in this,” the report states.

Being able to move freely around a home and not ‘locked’ inside is one of the most basic of rights, but it must be carefully balanced against safety. It’s not always an easy call.

Swaffer said that almost every time they visited her father-in-law he would ask, “Why have you put me in jail?” 

“It was gut wrenching,” she said. “We have to find a better way.”

 

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  1. I would have thought that an accessible garden area, or even outdoor courtyard, would be a minimum requirement for an aged care facility to pass accreditation.

    1. I don’t think it is legislated Skye as the standards are not written with specific requirements. Its more like best practice but even when present, access can be restricted to them, as per the article. This is more acute in memory loss units than anywhere else. Many aged care homes and operators do the absolute best they can given the resources available. Its the funding and how its spent should be changed. More money and less ambiguous language.

    1. I really hope you don’t work in aged care with the language that you used. Calling people demented is no acceptable people are living with dementia and they are not “wanders” they are more likely bored and are looking for something to do just because we don’t understand why it does not mean they do don’t have a purpose.

  2. I have worked with ‘Wanders’. They just wandered out into the garden. Big deal. Private corporate providers lock the door to save on staffing. It is really that simple. Staff cost money. Locking people up is free. So what do they do ? That is right they keep the money. Neoliberalism 101.

  3. Great article, wow. I’d like to find out just how many aged care homes lock residents in.

    I’ll have a look at the Royal Commission reports.

  4. Each individual will be different requirements, and if a person is safe enough to walk on roads and find the way back to facility then by all means allow them to.however as long as gardens and paths for safe walking, being in a locked facility is for their own safety, as they may have not the skills to walk become confused, walking on road, picked up by stranger,. Knowing family members are safe inside without others being able to abuse their condition is absolutely the best. Unless living with dementia apartments blocks can be built for people to live with others and also partners, and the assistant that come with these. I believe there is one in Tasmania.

  5. From what I have seen in Nursing Homes residents who are behind locked doors have more behaviors than those who can walk in and out of the buildings. Myself I would be horrified to be behind locked doors,
    I have noticed some NHs have all unit doors locked? why? even in hostel units,
    Access to a large open yard with gardens for vegetable growing as well as flowers, walking tracks with activity areas set up would be an appropriate setting,
    The bottom line will always come back to appropriately trained staff numbers and activity staff in all areas at all times, the choice to join activities when asked, to be able to get up, shower, and go to bed when the resident wants /non-regimented meal times.

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