This is what a nursing home looks like inside: "Families don't even know half of what goes on here."

BarcelonaAt eight in the morning, half a dozen elderly people are already in the dining room. The geriatric assistants have cleaned, washed, and combed their hair and seated them at the table, which is set for breakfast with a tablecloth, cups, and plates. However, an hour later, no one has brought them anything to eat, and the elderly remain in the same place, patiently waiting for someone to serve them. The geriatric assistants are too busy helping other elderly people get out of the way.

The geriatric assistants finally distribute breakfast at nine-thirty in the morning, although they still haven't helped some elderly people get up, who remain in unwashed beds with dirty diapers. "I feel sorry for them having to eat breakfast like this, covered in shit and piss, but we can't do more," one worker explains. There are two geriatric assistants to care for 28 people. "The bosses tell us to have the grandparents whom the family visits in the morning removed first so they can see them dressed and seated. It's a disgrace. The families don't even know half of what goes on in here."

This journalist worked as a cleaner for four days in a senior citizens' home in Barcelona without identifying herself as a reporter. I also interviewed some of the senior citizens' care workers by phone without them knowing I was there and could therefore verify the information. The search for the job It was relatively easy. Several nursing homes were interested in hiring me, and some requested that I start within 24 hours, which highlights the lack of staff in the sector. This is the story of what I've seen and heard. "They're people, not cars! You can't work like that," complains a nursing home assistant who has just finished washing an elderly man and thinks she's talking to a cleaner, not a journalist. The nursing home that hired me belongs to a company that made €1.9 million in profit in 2021, as ARA has been able to verify in Spain. It's a large center, with around 150 places, 95 of which are privately funded, according to data from the Generalitat (Catalan government).

The first floor is where the elderly in the worst condition are concentrated: they barely speak, they have to be fed, and many are confined to wheelchairs. In fact, the situation is quite similar throughout most of the residence. Most residents wear diapers, and even those who appear physically fit are impossible to maintain a conversation with: they have dementia.

Data from the Generalitat (Catalan government) confirm that this is not exceptional, but rather the widespread situation in almost all nursing homes in Catalonia. Of the 42,467 nursing home places that receive some form of public funding, 58.9% are occupied by people with dependency level 2, meaning they need help performing basic activities of daily living such as eating or using the bathroom. 41% have dependency level 3, meaning they require the continuous presence of a caregiver. The average age of residents is 86.5 years. Therefore, the user profile has changed radically: there are no longer people with a certain degree of autonomy.

"I've told you a thousand times not to get up, that you'll fall. I can't take you to the bathroom now, I'm with someone else," a nursing home worker shouts at an elderly woman in a wheelchair who is trying to get up in the dining room and has been asking for someone to take her to the toilet for a while. "She keeps getting away from me," the woman complains. "If she gets away, she'll pee in her diaper. I'll clean you up afterward," the caregiver replies as she continues to care for another elderly woman.

Low Wages

The residence's facilities are striking. They are tastefully decorated, there is a small garden, a spacious reception room and a gym, and the dining rooms and bedrooms have natural light. The staff is a very different matter. Geriatric assistants, cleaners, laundry staff, kitchen staff... all of them—the majority are women, many of them immigrants—complain that they can't keep up. You don't need to ask them; it's a recurring topic of conversation among them.

There's also a constant shortage of someone at work. Low wages and working hours that make work-life balance difficult make absenteeism common. The base salary for a geriatric assistant, according to the collective agreement, is around €1,100 gross per month. Add to this around €20 for every holiday or Sunday worked. At this residence, the geriatric assistants work seven hours a day, six days a week, and only work one weekend a month.

"The manager says we'll dry the grandparents with sheets if there are no towels," complains a nursing home worker. Once again, there are no clean towels left in the closet. The nursing home has a laundry room, but only three people are working there. "Yes, yes, I know there are no towels left. I was washing them," replies one of the workers anxiously as she hurriedly folds towels and bibs. All residents use a bib for eating. "The newer ones that aren't torn should be taken to the fifth floor, because the grandparents will find out there; they don't have dementia," the worker tells this reporter.

Breakfast is around 9:30 a.m., lunch at 1:00 p.m., afternoon tea at 4:00 p.m., and dinner at 7:00 p.m. Afterwards, the grandparents go for about fourteen hours without eating anything, except for those with diabetes, who are given juice. Meal times are organized around the geriatric care workers' work schedule. Those on the afternoon shift finish work at nine:00 p.m., and by that time, in theory, all the elderly should have had dinner and be in bed.

"Come on, my queen, open your mouth," says a geriatric assistant sitting on a stool in front of a wheelchair-bound grandmother, to whom she is giving porridge. On the first floor, thirty-five elderly people need food put in their mouths. There are seven more who eat on their own, but they also require assistance. Normally, there are four geriatric assistants on this floor, but tonight only three are working. One didn't show up. "It's not the way we should be. We have to feed them almost from a funnel," says a caretaker, who seems completely overwhelmed. Within an hour, all the elderly should have had their dinner. By seven-thirty, they're already starting to go to bed.

The geriatricians take the grandparents to their bedrooms one by one, while the rest wait in the dining room, with no one watching. An hour and a half later, there are still elderly people who haven't gone to bed for the same reason that it takes so long to get them out of bed in the morning. And as expected, some of them fall asleep. A woman falls asleep in the dining room with her head on a table. Another, with her head tilted, drool dripping onto her chest.

"I know you're very busy and don't have time to talk, but can you come here for a moment?" an elderly woman, also waiting to be put to bed, asks this journalist. Having a conversation with her is complicated; she has dementia, but she seems to understand that the workers here are very fast and don't have time for much conversation. At night, there are fewer staff: four geriatric assistants to care for 150 people. There are about 38 elderly people per caregiver.

ARA has interviewed geriatric assistants from other senior homes, both private and public but under delegated management, and they all describe similar situations. A book was even published in 2021, Caregivers, by researcher Ernest Cañada, which collects the testimony of a dozen geriatric assistants who reinforce the same point: nursing homes are short on staff. The president of the Catalan Professional Association of Directors of Dependency Care Centers and Services (ASCAD), Andrés Rueda, himself denounces this: "We would need 50% more geriatric staff to care for the elderly properly, without frills."

The Generalitat's regulations establishing minimum staff ratios in nursing homes date back to 2014 and have not been updated since then, despite the fact that the level of dependency among users has only increased. In fact, in 2014 the government lowered the ratios. Previously, they were slightly higher, according to sources from the Department of Social Rights. This was intended to reduce costs in a time of cutbacks.

Current regulations establish that there must be 25 geriatric assistants for every 100 elderly people with a dependency level of 2. This does not mean that all these geriatric assistants work simultaneously, as they must cover all shifts and at least 365 days a year. The ratio is even lower: the regulations state that three assistants are sufficient for 150 elderly people. de facto The ratio of nursing home staff in each of Catalonia's senior citizen residences. The answer is that the Department of Social Rights doesn't have that information. It only knows the ratio for the 16 residences it directly manages, although there are a total of 951 centers in Catalonia. Neither public ones with delegated management nor private ones with subsidized places are required to report to the administration how many people they employ. Compliance with the ratio is only checked on the day an inspection is carried out. According to the law, the Generalitat must inspect residences "at least once a year."

However, the Secretary of Social Affairs and Families of the Catalan Government, Lluís Torrens i Mèlich, assures that the staff ratio is not a problem and that the Generalitat has no intention of increasing it. "We have not detected a shortage of professionals during the inspections," he argues. However, it is striking that in the 16 nursing homes managed by the Generalitat (Catalan government), the ratio of nursing home staff is double the regulations: almost 50 assistants for every 100 elderly people, according to the Transparency response.

"Even if we wanted to increase the ratio, we wouldn't find staff," Torrens explains. There are few people willing to work in such a poorly paid and demanding sector. According to him, the solution would be to pay geriatric assistants better and increase their productivity with technological advances, such as robotic beds that reposition elderly people so they don't suffer and don't need a person to do it. But all this requires money.

The Catalan government currently pays a maximum of €2,002.56 per month for each of its residential care places, both for dependency levels 2 and 3. A figure that the sector complains has long since become obsolete. For example, in the Basque Country, the price of a residential care place is around €3,300 per month. Furthermore, the regulations there are much more restrictive: 75% of dorm rooms must be single—in Catalonia, single-occupancy dorms are an exception—and centers cannot have more than 150 beds. Here, the largest residence has 308.

"If we had to pay €1,000 more per subsidized care place, we would need an additional €400 million. This would increase the dependency budget by more than 20%, and for the moment, it's unfeasible. There's no money. Our budget is only enough," replies the Secretary of Social Affairs and Families.

In 2022, the Generalitat (Catalan government) allocated almost €1,036 million to finance subsidized and public residential care places, and to provide benefits for their payment. This year, it plans to increase the price of subsidized care places by 4% retroactively to January 1, so the investment will be even greater. Furthermore, demand continues to rise. There are currently 11,872 people on the waiting list in Catalonia for a public or subsidized residential care place.

There's another factor: 65% of nursing homes in Catalonia are private, and many of the public ones are also managed by companies. This isn't the case in other countries: in France, 52% of nursing homes are publicly managed, and in Sweden, 83%, according to a 2020 study. One of the report's authors, gerontologist Mayte Sancho, highlights that the money allocated to elderly care is directly related to the social value placed on it. And, of course, unfortunately, in our country, it's getting less and less.

The cleaner finishes her shift at 9:30 p.m. Before that, she has to take the trash cans out to the street. In this nursing home, five trash cans are filled every day, mostly with dirty diapers.

If you are aware of irregularities at any senior citizen's home in Catalonia, you can send us information to this email address:investigacio@ara.cat