The horror stories began circulating in early March. At a care home on the outskirts of Madrid, death had started to stalk the residents after the coronavirus had floated through the facility’s yellow and purple-painted common rooms. “You would wake up in the morning to WhatsApp messages telling you that five more people had died,” said Maria, the relative of an 83-year-old who lives at the privately-run care home, called Vitalia Leganés. “The next day it would be three [more] people had died.”
The information came not from official sources, but from relatives scrambling to piece together what was happening inside the home. On the orders of the regional government, Vitalia Leganés had shut its doors to visitors in early March. Frantic calls to staff and officials went unanswered, even as sleuthing by relatives suggested the death toll was spiking; family members believe as many as 100 of the home’s 266 residents have died of the virus.
Similar situations have played out across Spain, where one of the world’s deadliest outbreaks of the coronavirus has crashed into the reality of an ageing population, killing more than 18,000 care home residents and pitting relatives against a care industry controlled largely by international investors. It’s a battle set to sweep Europe, where the share of places in privately-run care homes has outpaced public offerings in recent years.
Amid claims of unchecked deaths, shortages of protective equipment for staff and failures to adequately isolate suspected Covid-19 cases, care homes across the continent are now in judicial crosshairs. In Italy, police have carried out inspections at some 600 care facilities while prosecutors in Sweden have opened a preliminary investigation into a home where 27 of the 96 residents are believed to have died of the virus. Prosecutors said their preliminary investigation into the Berga care home in Solna centred on possible violations of the Work Environment Act, which maintains working standards and safeguards workers against accidents and occupational illness.
In Spain, more than 27,500 people have died of the virus, according to the health ministry, an official figure that counts only those have tested positive for Covid-19. But authorities have hinted that the death toll could be as much as 35% higher, after the virus stampeded through the country’s more than 5,400 elderly care homes.
“The army found seniors that had been completely abandoned, some dead, in their beds,” Defence Minister Margarita Robles told broadcaster Telecinco after the military was deployed to disinfect care homes in March. In the Madrid region, the epicentre of the country’s outbreak, officials estimate that the virus has killed 5,909 people in homes for the elderly and disabled, with the vast majority of cases suspected, but not tested. In Catalonia, it is believed to have claimed the lives of 3,409 care home residents.
The grim statistics have rocked Spain, a nation that has long prided itself on its deep reverence for the elderly. Prosecutors have launched 140 investigations into care homes across the country, sifting through complaints from relatives of those in care and workers at the homes for evidence of potential crimes such as manslaughter due to negligence, abandonment and mistreatment. Prosecutors have so far declined to name who or which homes are being investigated.
But the tragedy has reignited a debate about the way the care sector operates in Spain – and now the question is: who should be held accountable? Around 70% of care homes in the country are privately-run, with many residents receiving public funding to help cover the costs. The rest are public or run by non-profit organisations. For Maria’s relative at the privately-run Vitalia Leganés home, this translates into a cost of 1,956 euros a month – around average in the Madrid region – for a room at the home. Her relative sold his home, adding the proceeds to a monthly pension of just under 600 euros and a subsidy of 400 euros a month from the regional government to cobble together the monthly fee.
Relatives of those at Vitalia Leganés had long complained about chronic understaffing at the facility, even staging a protest in 2018. “You can’t have a care home with four people working the night to care for 266 residents,” said Maria, who asked that her last name and other identifying details be withheld to protect her relative, who remains in the care of Vitalia Leganés. “Virus or no virus, there wasn’t enough staff.”
A spokesperson for Vitalia Home confirmed around 70 deaths at the facility, attributing the loss of life to a failure in the healthcare system; at the height of the crisis, from March 18 to April 4, care homes were left to fend for themselves as overwhelmed hospitals refused to take in elderly patients or send care homes the proper medication, he said. “Care homes tried to treat them the best they could. But they didn’t have the resources or the medications.”
Compounding the issue was the many staff who became infected, he said, leaving the company scrambling to hire more staff. But he declined to provide a concrete figure of how many staff were affected. All the while, care homes were pushing for their residents to be admitted to hospitals: “It was really difficult. Everyone has the right to be treated at a hospital.”
He added that care homes are working on lodging a formal complaint against the government over what he described as “abandoning the elderly”. He denied that there had been issues with staff shortages prior to the crisis, pointing to the strict staffing guidelines set out by the regional governments that oversee care homes.
Prior to the pandemic, a steady stream of grievances had painted a dire picture of what was happening inside care homes. Leftwing Más Madrid politician Pablo Gómez Perpinyà, speaking to the regional assembly last month, listed complaints dating back to 2016: “Family members who find their elders ‘literally bathed in faeces’ … seniors forced to wait for hours to go to the bathroom or to have a drink of water. One nurse on duty for 340 residents, mistakes in handing out medications and falls that are never explained,” he said. He was unequivocal about the cause: “It’s a low-cost model that has prioritised business over health.”
Foreign investors have flocked to Spain’s elderly care sector in recent years, lured by life expectancy rates that rank among the highest in the world and the long waitlists for spaces in public care homes. “The sector is booming,” said Juan de Dios Punzano, a consultant who specialises in elderly care. Between 2015 and 2017, more than 2 billion euros in investment poured into the sector in Spain, according to a study by real estate firm CBRE.
Despite a decade-long freeze in public funding, profit margins in the sector normally range from 25 to 40%, depending on the size of the facility and location, said Punzano. With care homes bound by regional government agreements that set out ratios detailing the minimum number of staff needed per resident as well as other protocols, most look to economies of scale and tightening costs such as electricity and suppliers to boost their bottom lines. “There are residences that cut staff, they don’t care,” he said. “But if you’re a legal operation, you don’t get rid of staff.”
In 2018 the sector saw a turnover of some 4.5 billion euros, growing by 3.4% on the previous year and marking its fourth consecutive year of growth, according to Spanish consulting firm DBK. The sector has also become increasingly consolidated, with the five biggest groups controlling 23% of the market in 2019, a rise of nearly 2% compared to one year earlier.
Spain’s biggest operator is DomusVi, acquired by London-listed private equity investor ICG Europe VI in 2017, followed by Orpea, in which Canada’s pension plan bought a 15% interest in 2013. The two firms count more than 30,000 spaces in Spanish care homes between them. Canada’s pension plan referred all questions about the coronavirus crisis to Orpea, who said the situation in Spain was tending to normalise. “The Covid-19 struck Spain very suddenly and in particular the big cities where Orpea is located,” it said in a statement, adding that it had coped by providing its staff with “full protection” since the start of the epidemic in mid-March and has kept families and authorities informed of the situation.
Vitalia Home, acquired in 2017 by CVC, one of the world’s largest private equity firms, ranks third in terms of places in care homes. The website for Vitalia Home boasts annual revenues of 200 million euros. CVC did not respond to a request for comment.
Other prominent players in Spain’s care home industry include Florentino Pérez, one of Spain’s richest men who splits his time as the president of football club Real Madrid and the CEO of one of Spain’s largest construction companies, Grupo ACS. The portfolio of the publicly-traded construction group, which in 2019 counted American asset manager BlackRock among its shareholders, includes more than 60 care homes in Spain that are run through its services division, Clece.
Two of DomusVi’s care homes were named last week in a criminal complaint filed in a Madrid court by a group representing relatives of those in care homes. Seizing on a Spanish legal provision that allows civilians to potentially bring issues to trial, the group said in a statement that the complaint had been compiled after weeks of hearing testimonies from families with loved ones in care and care home workers. The number of deaths in Madrid care homes “represent nearly 50% of the lives claimed in care homes across the country, an alarming figure”, the complaint noted.
It accuses the directors of 10 private and public care homes as well as the leader of the Madrid regional government, Isabel Díaz Ayuso, and the region’s health minister, Enrique Ruiz-Escudero, of manslaughter due to negligence, degrading treatment, corruption and refusing to provide assistance. Neither Madrid’s regional government, nor DomusVi or ICG responded to a request for comment.
For years the Unión General de Trabajadores, a workers’ union whose members include care home staff, have called on regional officials to keep closer tabs on the sector, pointing to the ease with which the staff-to-resident ratio can be exploited. “It’s not a good criteria – it depends also on how those workers are organised into shifts and the level of need among residents,” said Gracia Álvarez, a union representative.
These long simmering issues were exacerbated by the virus. Care home workers – most of them women – found themselves on the front lines, their defences hampered by a severe shortage of protective gear, the constant fear of becoming vectors for the virus and the challenges of isolating patients in spaces designed for communal living. At times those who fell ill faced pressure to keep working as homes struggled to find replacement staff, said Álvarez. Data compiled by the union suggests that at least 1,955 care home workers across the country have tested positive since the start of the crisis.
In Madrid, the regional government – led by the conservative People’s Party – intervened last month in 14 hard hit care homes, including Vitalia Leganés. “We all made mistakes,” Alberto Reyero, the head of social policy for the region, admitted. “Care homes are not prepared to deal with a health crisis of this magnitude, they don’t have the appropriate materials.”
Among the region’s 475 elderly care homes, 28% do not have a doctor on staff, while 22% only have access to a doctor in the mornings, he said. “Care homes are made for caring, not curing.”
At Vitalia Leganés, where the regional government intervened in early April, the families said they’ve seen little change. Maria was relieved last month to hear her relative had been moved to another facility after he was one of the few who tested negative for the virus. “His cognitive abilities have declined a bit, so he’s having a lot of trouble understanding what is happening,” she said. But her solace was short lived; she was recently told he would be moved again after he tested positive for the virus. “It’s like a horror film … How did he get infected?” she asked. “He’s been confined to his room for a month.”
Maria and other relatives have joined forces, reaching out to various ministries and patient advocates in a bid to better grasp what is happening. “We’ve contacted everyone we could think of. We still don’t know what is happening inside,” she said. For weeks they’ve pushed for more to be done to tackle the deadly threat they believe continues to lurk among the care home’s common rooms. “Nobody is doing anything,” she said, “100 people may have died and nobody is doing anything”.
Ultimately, she laid much of the blame on the regional government, accusing them of handing over some of society’s most vulnerable to private entities with little follow up. “What we would like to see, eventually, is a change in how residences are run. You can’t have care homes in the hands of construction giants, vulture funds or companies,” she said.
“A care home shouldn’t be a place to turn a profit.”
Reporter: Ashifa Kassam
Editor: Basia Cummings
Photography: Jon Jones
Design: Oliver Bothwell
Additional reporting: Ella Hill
This article was corrected on 19 May 2020 to reflect the distinction between Vitalia Home and Vitalia Group.