SISTERS OF ST JOHN OF GOD CARE AND ACCOMMODATION STRATEGY REGIONAL LEADERSHIP TEAM FOLLOWING CONSULTATION WITH

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1 SISTERS OF ST JOHN OF GOD CARE AND ACCOMMODATION STRATEGY REGIONAL LEADERSHIP TEAM FOLLOWING CONSULTATION WITH REGIONAL TREASURER REGIONAL FINANCE MANAGER LIAM AND MARIA LONG L&P TRUSTEE SERVICES NOVEMBER 2014 Sisters of St John of God Irish Region Page 1

2 TABLE OF CONTENTS 1. THE CHALLENGE THE BRIEF...5 The Objectives of the Project are: MEMBERSHIP AND CARE PROJECTIONS...6 Sisters in Nursing Care...8 Sisters in Assisted Living Plus...9 Sisters in Assisted Living...9 Sisters Living Independently Summary of Sisters Living Arrangements / Projections FUTURE PREFERENCES FOR ACCOMMODATION LOCATION REVIEW OF MAJOR PROPERTY LOCATIONS HEALTH CARE CONSIDERATIONS SUMMARY CONCLUSIONS APPENDICES I & II Sisters of St John of God Irish Region Page 2

3 1. THE CHALLENGE 1.1 In 2013, St John of God Irish Region (the Region) identified with the following statement issued by CORI. 1.2 At this moment in time, as Religious, we find ourselves in a new experience in Ireland. It is one we are challenged to welcome with gratitude and also with a new sense of responsibility. It requires us to create and provide appropriate spaces/places that exude an ethos of living faith and strong ethical awareness for older religious in various stages of dependency and experience of vulnerability. (CORI) 1.3 We acknowledge the importance of recognising the potential of older persons to contribute to and enrich society in many diverse ways given their talents, experience and wisdom and the many years of healthy life expectancy that most can enjoy. Older people need to be viewed not as a burden, but as a huge resource for society. 1.4 Prior to this report, over the previous number of years, the Region / Province had carried out numerous different consultations to facilitate planning for the future. As a result of these consultations, a number of developments were undertaken as follows: o St John of God House was built in Kilkenny in 2000 providing a 10 bed purpose built Assisted Living Accommodation. o The Convents in Wexford (2006/7) and Kilkenny (2003/4) were refurbished. The quality of the living accommodation was improved significantly, however, not to a level that would lend itself to nursing care. o The house at Aut Even was refurbished for independent living (2004). o From the early 1990 s and onwards, a number of 3 and 4 bedroomed houses were purchased to facilitate independent living. 1.5 It must be noted that the standards required of healthcare providers are always improving and these standards are increasingly open to monitoring by external agencies. The Region would wish to plan for accommodation and care of the highest standard possible within the constraints pertaining. 1.6 At this point in time, therefore, it has been deemed appropriate that, taking all factors into consideration, a more long term strategic view should be taken and a comprehensive care and accommodation strategy be developed to provide guidance and some degree of clarity for the future of the Region. Sisters of St John of God Irish Region Page 3

4 1.7 Timing was good in that CORI promoted a survey (2013) which it anticipated would assist its membership to collaborate and plan for the future care and accommodation needs of Religious in Ireland. This survey, carried out by L&P, involved the projections of membership and the different types of facilities needed by various Congregations for care and accommodation. However, the St John of God Regional Leadership Team (RLT) decided to build on this process by using the definitions and some of the survey questions, as well as their own additional questions. Data from the SJG survey is utilised in this document to assist in the planning process and the results of the national survey (CORI) were used as comparators for our own data. 1.8 As L&P worked through this process with the various groups, a request was made by the RLT for a more in depth analysis to be made of the data relating to the Region. In conjunction with L&P, the RLT undertook to develop a Care and Accommodation Strategy which would ensure that the membership was provided for in an appropriate manner. This would take into account internal and external factors such as the property available to the Region and the demands that may be imposed on the Region as a result of the provision of care. Sisters of St John of God Irish Region Page 4

5 2. THE BRIEF FROM THE REGION 2.1 The overall goal of the Region is to provide appropriate and sustainable accommodation / care for our Sisters, as an increasing number of Sisters require assistance, care and nursing in day to day living. 2.2 The Objectives for this Project are: 1. To know what are our specific accommodation/ care needs over the next 20 years 2. To work out an ACCOMMODATION / CARE STRATEGY that will be appropriate and sustainable for the next 20 years 3. To make recommendations to the RLT In furthering these objectives, we need to determine the following: a) the type of accommodation needed b) the location the geographical area - where the accommodation is needed c) the number of units needed d) the location that is best - within a given geographical area e) the availability of services that meet the spiritual needs of the Sisters f) the level of access available to the wider community in any given location 2.3 L&P s response to this request was to recommend that consideration of the membership could not be carried out in isolation of the other resources of the Region; therefore, any review process would need to take into account: Membership the current membership profile; and future projections taking into account age and care needs. Property the current use of property within the Region possible adaptations to the property; and other options such as purchase and / or new build. 2.4 The brief did not extend to reviewing the financial resources of the Region and the Region s ability to finance any recommendation made. There was, however, discussion about financial implications of building and refurbishing at each stage of the process. 2.5 This study provides an overview of the membership and property resources of the Region as at the end of 2013 / early Liam and Maria Long, Consulting Engineers, were appointed as the Property Consultants to this review process in conjunction with L&P. 2.7 In September 2014, the RLT made the significant decision that, where possible, the Region would provide care for its members up to and including nursing care, within an SJG facility. Sisters of St John of God Irish Region Page 5

6 3. MEMBERSHIP AND CARE PROJECTIONS 3.1 L&P reviewed the current membership of the Region and prepared a projection of the likely future membership profile using proven life expectancy tables. Due account was taken of the particular ethos and circumstances of female religious organisations in Ireland. 3.2 The total membership of the Region reported at 31st December 2013 was 131 Sisters ranging in age from just under 50 to over 90. It is acknowledged that as this report comes to a conclusion, the numbers have already altered. However, for the purposes of membership projections, data as at 31st December 2013 was utilised and the future assessment from that base is as outlined in the table below. 3.3 With the total number of Sisters in the Region at 131, the average age is currently 75 years. 3.4 The largest volume of Sisters is based in Wexford (61), primarily in the Convent (27) but with 12 other Communities also located in County Wexford. 3.5 Kilkenny has a slightly smaller number of Sisters (46). They are primarily based in the Convent (28) but with a further 6 Communities located in the county of Kilkenny. We note, however, that Kilkenny has a slightly larger number of Sisters living in Care or Assisted Living. Sisters of St John of God Irish Region Page 6

7 3.6 A further 24 Sisters are located between Waterford, Dublin, Laois, Offaly, Clare and the UK. 3.7 We began this process with 4 categories of accommodation need. At the time of the initial questionnaire late in 2013, based on their accommodation needs, Sisters were categorised as follows: Specialised Nursing Care Sisters receiving specialised / skilled nursing care e.g. Alzheimer s disease, renal dialysis. Nursing Care Sisters in receipt of nursing care within a care facility (within SJG Convent or in a private nursing home). Assisted Living Sisters living within a Community which provides support services such as catering and cleaning, laundry, transportation and assistance with some personal care / taking medication. Independent Living Sisters living alone or within a Community having the ability to live an independent lifestyle and with no requirement for support services or care. 3.8 As part of the review process, consideration was given to the categorisation of care provided within the two main Convents. It was accepted that in reality, differing levels of care are being provided within the Convents. The RLT undertook to review the categorisation to more accurately reflect the care needs of the Sisters within the Region. This resulted in a change of the membership care need categories, to assist in more accurately identifying the accommodation requirement. These are the definitions that will be used throughout the remainder of this document. Nursing Care Sisters in need of nursing care. Assisted Living Plus Sisters in need of care and significant support services (catering, cleaning, laundry, transportation). Limited need for nursing care, e.g. management / supervision of medication. Assisted Living Sisters in need of support services such as catering, cleaning, laundry, transportation and assistance with some personal care. Independent Living Sisters having the ability to live an independent lifestyle and with no requirement for support services or care. Sisters of St John of God Irish Region Page 7

8 Membership Classification as at 31 December Sisters in Nursing Care When we projected the various categories into the future, it is estimated that the current number of Sisters (10) receiving Nursing Care / Specialised Nursing Care, will remain at a similar level for the next 15 years approximately, reducing thereafter. Sisters of St John of God Irish Region Page 8

9 3.10 Sisters in Assisted Living Plus The number of Sisters in the Assisted Living Plus category is currently 17 and is projected to remain between 17 and 15 for the next 15 years. These are the Sisters that are currently receiving a level of care that is believed to be beyond Assisted Living standard. It is felt that these Sisters may have difficulty in obtaining NTPF / Fair Deal financing (public funding) if they are to be cared for in a Registered Nursing Home. However, this will not be known until tested. The Nursing Care estimates may be conservative, meaning that some of the Assisted Living Plus Sisters could possibly be categorised as in need of Nursing Care Sisters in Assisted Living The Assisted Living category of Sisters, primarily Sisters living in a Community environment with support services but little or no care provision, is the largest category of Sisters currently numbering 26. This category is anticipated to remain at a similar level for the next 15 years. Sisters of St John of God Irish Region Page 9

10 3.12 Sisters Living Independently The largest reduction will be in the category of Sisters living independently and it is anticipated that they will number approximately 12 in 15 years time Summary of Sisters Living Arrangements / Projections These previous tables provide a good indication of the accommodation needs of the Region up to and including the next 25 years. It is clear that there will be a significant reduction in the need for certain types of accommodation in the Region. However, what this also shows is the level of accommodation required for each category of need If we combine the Nursing Care and Assisted Living Plus categories of membership, this indicates the membership that will require a level of care into the future that involves at least some nursing care. This has obvious implications in terms of suitability of property and also staffing levels. The knock on effect is that there will need to be significant capital expenditure and increased operational costs. Sisters of St John of God Irish Region Page 10

11 4. FUTURE PREFERENCES FOR ACCOMMODATION LOCATION 4.1 Of the Sisters surveyed, the majority (76%) have indicated a preference for future care within an SJG Care Facility with the minority indicating no preference regarding the location of their future care. 4.2 This figure is way above the expectation of CORI membership groups (37%) for care within their own Congregations. We anticipate that part of this is due to the fact that some Congregations have already stated they will not be providing nursing care into the future and therefore, their membership did not choose this as an option. Future Care Preference Total CORI % SJG % Within Own Congregation Care Facility 37% 76% Within another Religious owned Care Facility 3% 1% In another registered Care Facility 18% 0% No preference for Care Provision 8% 22% Currently in Assisted Living / Nursing Care 35% 26% 4.3 Other factors may be because there had been a previous commitment to care for membership internally. There may also be a heightened expectation for internal care in religious groups with a nursing tradition. 4.4 What is also interesting is that 80% of those surveyed in the Region indicate that they would have a preference to remain within their current local area, primarily Wexford and Kilkenny. Generally speaking, those outside Wexford and Kilkenny had no preference for location of nursing care. Sisters of St John of God Irish Region Page 11

12 5. REVIEW OF MAJOR PROPERTY LOCATIONS 5.1 Whilst the Regional statistics were being calculated and projected, it was agreed that reviews of the major properties would take place in order to establish the following: Suitability for current use; Suitability for future use in light of the changing profile of the Region (age and numbers); Other factors (legislative requirements, integration with other properties, possible sale, etc). 5.2 The properties reviewed and considered included Wexford Convent (and land) and Kilkenny Convent (and land). From an external perspective, it appears both properties reviewed have such depth of history within the Region that it was impossible to say if either property is more or less important than the other. 5.3 Both Convents present challenges in relation to fire safety and there is a concern about their suitability for non-ambulant Sisters. 5.4 Consideration was given to the future use of Ballyvaloo as a Community property. However, for a variety of reasons, but primarily location and the reluctance to carry out major refurbishment on a new building, this was ruled out at this juncture but could be considered at a later date. 5.5 Attached to this document is a copy of a discussion document which was utilised during this process. As part of this document, the various pros and cons of each property are listed. In summary, both Convents are protected structures and therefore are subject to limitations for refurbishment. 5.6 It was felt that in both cases, the properties could be adapted in a minor or major manner (with various costs attached). In assessing spatial requirements for a modern nursing care building, it became evident that it would not be feasible, or even possible, taking planning constraints into account, to adapt either Convent to the appropriate level. 5.7 This would not rule out the possibility of refurbishing the two Convents for Assisted Living. However, if this option were followed, it is likely that the number of bedrooms would have to be significantly reduced. 5.8 There is a concern about the ability to deliver an appropriate level of care in the confines of the two Convents. Furthermore, the Region may have exposure to external monitoring and regulation from bodies such as the Health Information and Quality Authority (HIQA) and the HSE. Sisters of St John of God Irish Region Page 12

13 5.9 The legal position with regard to the definition of nursing homes needs to be considered. The Health (Nursing Home) Act 1996 would have exempted Religious groups providing care for their own membership from their regulatory regime. The 1996 definition reads: Nursing home means an institution for the care and maintenance of two or more than two dependent persons...excluding premises in which the majority of persons being maintained are members of a religious order However, the exemption for Religious groups has been omitted from the later legislation. The Health Act 2007 repeats the above definition but has removed the exemption for Religious groups This is a grey area. However, we are aware that HIQA have begun to visit other religious run care units to establish the level of care being administered / received. To date, we have not heard of any conditions being imposed on religious run care units. We would, however, be concerned that any religious run care unit could be subject to this type of inspection at any time, indeed the indications are that it is very likely to happen in the not too distant future. The legislation appears to require this to happen The implications of this into the future could be the following: Significant upgrade of property necessitated;* Additional staffing required; and / or Possible forced closure. * In view of comments on the two Convents above, this would essentially mean new build Consideration was given to the two main campuses, i.e. the two Convents and their surrounds. The Kilkenny site has seen some development with St John of God House built in 2000 leaving limited remaining land. Wexford Convent has an advantage in being also the location of the Heritage Centre, the original foundation Convent with all the associated history. There is ample land to further develop on the Wexford site if the Region wishes to do so Obviously, a green field site could also be chosen at either location, should the desire be for a new development. However, it was felt that any development would need to take place close to the original sites as well as close to churches and other facilities in town. Sisters of St John of God Irish Region Page 13

14 6 HEALTH CARE CONSIDERATIONS 6.1 The options that the Region has to provide for health care are as follows: a) To remain as is, which we believe is not an option for two reasons: i. The acknowledgement by Leadership that it is not feasible to bring current facilities to acceptable standards for appropriate care. ii. The possibility of an external agency requiring closure of one or both Convents. b) To provide nursing care in an appropriate setting managed by the Region. c) To obtain nursing care in the private nursing home sector and seek Nursing Home Support Scheme, commonly known as the Fair Deal, where appropriate. 6.2 Our research of the Fair Deal shows that the level of support for Wexford is in the region of weekly while Kilkenny Nursing Homes range from This is generally accepted as the cost of care in a Nursing Home whether this is paid for by the Fair Deal or privately on a resident s behalf. 6.3 Should the Region decide to provide their own care, in a registered nursing home, this is the level of support that could be expected for each registered bed where a resident would qualify for NTPF / Fair Deal. 6.4 We have made enquiries with HIQA, on a no names basis, about a possible new build which accommodates only religious (with a view to opening it up to others at a later date if the numbers reduce). HIQA have indicated that the provider would have the right to register a number of beds with themselves, and would also have the right to use these beds for their own membership. If at any time in the future, the provider wishes to increase the number of registered beds and review their admission policy, they would submit an application to vary the registration. We would hope that this stance would continue. 6.5 It should be noted that it is difficult at this stage to envisage how any new structure would be designed to accommodate a level of care that will be mixed (dual usage), particularly if there is a desire to register the portion of the property that will provide nursing care. Consideration will need to be given to liaising with HIQA prior to developing plans to any advanced stage to ensure that these plans would be acceptable to HIQA and suit the needs of the Region. Sisters of St John of God Irish Region Page 14

15 6.6 There is a difficulty in establishing what Sisters may or may not be entitled to under the Fair Deal scheme. Whether the individual will be entitled to Fair Deal is dependent on two issues: a) The Care Needs Assessment is the most important part of the process and without this, an application will go no further. This is carried out by appropriate healthcare professionals (nurse) appointed by the HSE and can occur when in hospital or at home. It may involve a physical examination and takes into account the following: i. The individual s ability to carry out day to day activities including bathing, shopping, dressing and mobility. ii. The medical, health and personal social services being provided / available to the individual. iii. The family / community support available to you. iv. Your wishes and preferences. Quite often, an individual s private medical practitioner or the local public health nurse will refer an individual for review if they feel they are in need of assessment for entry into a nursing home and the individual is open to the suggestion. b) The Financial Assessment looks at the individual s income and assets (house, etc.) in order to decide on an appropriate level of contribution to care and the HSE then pays the balance. E.g. if the cost of care is 1,000 and the contribution from the individual is 300, the HSE will pay the balance of care cost. A maximum of 80% of an individual s income is taken for care, in other words, an individual can retain 20% (to a maximum of 20% of the State Non- Contributory Pension 219 or 229 for 80+) of their income for personal use. This amounts to per week ( for 80+). In no situation will an individual pay more than is required for the cost of their care. When looking at other assets, this takes into account rental income, commissions, dividends and interest and of course, property although in the case of a private family home, only 7.5% of the value of the asset can be taken for the first 3 years (22.5% in total). It is important that, where possible, no Sister would hold an asset in her own name on behalf of the Region as this could be taken into account. If an individual is deemed not to be in a position to complete an application for themselves (if they are suffering from ill health, physical or mental disability) a Specified Person can apply for their care needs / State support. It would be preferable if the same person were to assist all Sisters, whether it will be for your own care unit or a private nursing home. Sisters of St John of God Irish Region Page 15

16 7 SUMMARY CONCLUSIONS 7.1 Following a period of discernment and deliberation and having considered the following: The wishes of the Membership; The desire of the Leadership Team to provide for the membership wishes; The membership projections; and The existing property resources that the Region holds. 7.2 The findings are as follows: There is a desire by the Region to provide nursing care for membership in an SJG facility There is agreement that the current position of providing nursing care within the two Convents is not suitable and cannot continue because of: a. The increasing level of care required by the Sisters; and b. The limitations within the existing Convent facilities (having been extensively reviewed by property professionals) There is real concern that the regulatory bodies (HIQA and HSE) could intervene in our current care arrangements and require us to dramatically improve accommodation standards, with the threat of possible forced closure otherwise The provision of care and nursing care into the future, is based primarily on the current membership and projections, based on the experience of SJG Sisters and other religious congregations The cost involved in building a new facility compares favourably to the refurbishment of existing properties. In any case, it has been determined that it would not be feasible to refurbish our existing properties to the standard required for nursing care as noted in 5.6 previously The provision for nursing care in one location should minimise the level of staff required and the need for multiple managers (to supervise nursing / care staff). 7.3 The strategic decisions taken by the RLT, as a result of all of the deliberations and research, are that the Region will provide: Nursing Care, in a suitable SJG environment, for the Sisters who currently need nursing care in the Region Care and accommodation for Sisters who have been recognised as being at the level of Assisted Living Plus care Accommodation and services for the Sisters in the Region that need Assisted Living Accommodation for the Sisters requiring Independent Living in the short and medium term. Sisters of St John of God Irish Region Page 16

17 7.4 Therefore, in view of the above, the Care and Accommodation Strategy is as follows: Build a property, on the site at Wexford Convent which will provide for Assisted Living Plus and Nursing Home Care for approximately 30 Sisters. The new building should have separate access. The expectation is that Sisters requiring nursing care will avail of the new facility in Wexford except in exceptional circumstances. This property should be designed in a manner that makes it attractive to all Sisters but particularly suitable for Sisters that are non-ambulant and / or less physically active Ensure that the Wexford and Kilkenny Convent accommodation is to a standard that provides for Assisted Living (with little or no care provision). This may require some adaptations to each Convent for Community living which would result in a reduction in the number of Sisters that could be accommodated at both locations. Due to the age and the preserved nature of both properties, they will require ongoing maintenance Give consideration to what might be required to provide for the needs of those Sisters requiring to live independently and purchase / rent suitable single living accommodation, if necessary. In the design process of the new build at Wexford, consideration will also be given to incorporating some element of sheltered housing accommodation The management / governance of the various properties will require strong leadership. The Leadership Team may need to give consideration to a combination of lay and religious management if the personnel resources are not available internally to manage the various properties and the resulting staff Develop a strategy of property usage / disposal that will require active management to ensure that the Region is not carrying an oversupply of property along with the obvious financial costs. This will involve the categorisation of all properties for short, medium and longer term use. Consideration will also need to be given to a. vacating of Convent buildings when they reach a certain level of occupancy; b. the appropriate usage of St John of God House, Kilkenny; c. delineation of boundaries between Convent / Parish property; and d. ancillary surrounding lands. Sisters of St John of God Irish Region Page 17

18 7.4.6 Develop a Care Policy in the Region that: b. clearly defines the varying levels of need / care; c. how the Region proposes to provide for the needs of the Sisters; and d. how a Sister will be assessed for suitable accommodation / care provision when her situation changes. This policy may include the use of a new property for respite from regular Communities / Convents when the need arises Finally, give consideration to the possible future use of Ballyvaloo as an accommodation source should the ministry activity diminish. Whilst we recognise that this is currently a vibrant and viable ministry, the cost of replacing Sisters with lay staff will have a significant financial impact on the viability of this ministry. 7.5 A financial exercise will be carried out to establish the following: The cost of provision of the necessary accommodation; The cost of ongoing provision of services (to include lay management); The availability of financial resources; and A strategy for the disposal of excess property in the coming years. It is noted that the financial implications of establishing and managing a registered nursing home have been examined by the RLT in arriving at the decisions of this document. 7.6 The above decisions are made by the RLT based on discussions and research between them, the Regional Treasurer, Regional Finance Manager, Liam & Maria Long and L&P. These discussions involved review of current and future projections of membership age profile and care needs. They also included significant review of the existing Convent structures and their suitability and feasibility for adaptation in conjunction with the future care needs of the membership. Appended to this report are the following: I A copy of the PowerPoint presentation detailing all of the projections specific to the St John of God Irish Region as well as general CORI projections, dated September II A copy of the discussion document which was prepared for a full day review meeting in July 2014 including pros and cons of Kilkenny and Wexford properties as well as a new build property. NOVEMBER 2014 Sisters of St John of God Irish Region Page 18

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