Bev Howlett lives in an aged care residence in the Melbourne suburb of Williamstown — but she doesn't feel like she lives in a nursing home.
The 70-year-old comes and goes as she pleases. Her room has a door that opens directly to the outside.
She can garden. She can smoke. She can go shopping. No-one stops her.
"It's good," she said. "You feel free."
She has lived at Wintringham Williamstown Hostel for over a decade. She met her fiancé there; they now have adjoining rooms.
The residence embraces an open-door policy for all. She can't imagine any other way.
"I feel sorry for the other ones who are locked indoors and can't get out," she said.
"If you're locked in, you feel like you're in jail. And we haven't done anything wrong."
'Quite happy to stay indoors'
Controlling the movements of residents is the industry standard for nursing homes.
It is done primarily for one simple reason: to keep residents safe.
At aged care homes like BlueCross Ashby in Melbourne's north-east, about 70 per cent of residents live with some form of dementia.
The doors are kept closed. There is a keypad lock system in place for a handful of residents who know the code.
Everyone must sign out when they leave.
Residents at the nursing home do not seem to mind the restrictions.
Sammy Licata, 84, has lived at BlueCross Ashby for three years. He still drives, and knows the keypad code to get to his car in the parking garage.
He still has to sign out, and pass a staffed desk before he can leave.
"They gotta keep the door locked, so that people can't go out," he said. "I think it's a good idea."
Fellow resident Nancy Gurciullo, 85, moved into BlueCross Ashby seven months ago. The closed-door policy does not bother her.
"I'm quite happy to stay indoors," she said.
"My daughter takes me out if I want to go out. I phone relatives and have conversations with them."
'There is so little research'
"It's a tricky one," said Bridget Howes, a dementia care specialist with BlueCross.
"The balance that's at play is people's autonomy and people's safety.
"We do obviously have some duty to protect people and look after them."
The biggest concern is "unexplained absences", when residents leave a facility without staff knowing.
They can get lost. They can fall down. They can get hit by cars.
The consensus that unexplained absences lead to greater harm of aged care residents underpins the closed-door policy in nursing homes around the world.
The statistics behind unexplained absences in nursing homes were the basis of a recent review published in the Journal of the American Medical Directors Association (JAMDA).
"I was absolutely blown away that there is so little research," said Marta Woolford, one of authors from Monash University, which published the review.
The researchers found there was almost no evidence to back up the widespread belief that unexplained absences lead to a greater potential for harm.
The statistics do not support the view that residents face a greater risk of injury or death due to unexplained absences, and there are almost no statistics that prove that "locking in" aged care residents makes them safer.
"If we are going to put [in place] those quite restrictive measures, we really have to know what the risks are. And we just don't know that. The evidence isn't there," Ms Woolford said.
Other measures are also put in place to prevent to prevent unexplained absence, including restraints and, in some cases, drugs.
The researchers said those measures all had a cost.
"We're really focussing on the physical safety, and we're examining only that," said Ms Woolford.
"We haven't looked at the cost of emotional distress of being locked in."
'Home 'til stumps'
The open-door aged care home in Williamstown is one of seven residences run by Wintringham, originally founded to provide aged care for homeless men and women.
The Williamstown hostel is mixed — half of the residents are formerly homeless, and half are from the local community.
Wintringham founder Bryan Lippman said the hostel's motto was "a home 'til stumps".
"That's what we try to create — a home. And you don't lock yourself into a home," he said.
"I think if a person is in a locked facility, it will unnecessarily stress them."
Eighty-eight-year-old Faye Rush, who moved into the home four-and-a-half years ago from the local community, appreciates the open-door approach.
"Being in a nursing home, it frightens people that you're going to be locked up," she said.
"Here we're not locked up, and so it's much freer. And not so scary."
Even at aged care homes such as BlueCross Ashby, there is recognition that for some residents, feeling locked in can have a detrimental impact on their wellbeing.
"As a general rule of thumb, for ourselves we want autonomy, we want freedom and choice. But we tend to, with our loved ones, we want them to be safe," said Bridget Howes from BlueCross.
"I think as people come into aged care, we've really got to get that balance right."
- Photo: Nancy Gurciullo, 85, has been living at the BlueCross Ashby nursing home in Lower Templestowe for seven months after transitioning from a retirement home. Here the doors are locked in order to keep residents safe. Ms Gurciullo's husband died from dementia in a nursing home at the age she is now. "When he retired we had intentions of going on a holiday, but it didn't occur. I think about him always but I appreciate that God took him out of his sufferings because he didn't know me anymore." (ABC News: Jane Cowan)
- Photo: "I don't think at all. I get up in the morning, have a shower, go to breakfast and make the best of what there is of the day." Ms Gurciullo says she never planned for how she would live at this stage of her life. "I just went along with it as I got older." (ABC News: Jane Cowan)
- Photo: Ms Gurciullo visits with another nursing home resident. She didn't know anyone here at first, but made friends during an initial stay for respite. "My health is good and I'm kind to people. If I can help them I do." (ABC News: Jane Cowan)
- Photo: Ms Gurciullo participates in a seated exercise class with other residents, many of whom have limited mobility. (ABC News: Jane Cowan)
- Photo: Ms Gurciullo's lost her sense of smell and can no longer taste her food. "I enjoy it just the same," she says, at lunch in the dining room where residents take the same seats each day. (ABC News: Jane Cowan)
- Photo: The nursing home has a hairdresser where residents can get their hair styled, which some do weekly. (ABC News: Jane Cowan)
- Photo: Ms Gurciullo talks with BlueCross clinical care co-ordinator Victor Rodrigues. "I'm quite happy to stay indoors. My daughter takes me out if I want to go out. I phone relatives and have conversations with them." (ABC News: Jane Cowan)
- Photo: Ms Gurciullo gets a cup of tea from the cart mid-morning. "It's really sad seeing so many people here with dementia," she says of the home, where 70 per cent of residents have some form of the disease. (ABC News: Jane Cowan)
- Photo: Ms Gurciullo waits for customers at the kiosk she runs once a week. As a younger woman she ran a fruit shop, and then bottle shops, with her husband. "I've been a bit out of sorts lately," she says. "I was on a patch for dementia and it was upsetting me. I could not sleep. But I've offered to look after the kiosk for as long as I can." (ABC News: Jane Cowan)
Watch the story tonight on Lateline at 9.30pm on ABC News or 10.30pm on ABC TV.