Australians are living longer, with estimates that there will be 8.7 million older people living in Australia (22 per cent of the population) by 2056. Nearly 240 000 older Australians received permanent residential care in 2016-2017, and with Australia’s population ageing, demand for care is growing. Complexity of care is also increasing, with dementia rates expected to increase to around one million by 2056.
Many Australians experience aged care services that are safe and provide quality care. Instances of mistreatment of people in aged care, however, have been identified in the recent past, highlighting potential gaps in the existing system and the urgent need for reform.
Recent high profile failures in the provision of residential aged care in South Australia, Queensland and New South Wales have been reported and investigated, and have led to a number of reviews and reforms to the governance of the sector. At the same time, the number of complaints regarding aged care has grown in recent years, with a 23 per cent increase in total complaints made to the Aged Care Complaints Commissioner between 2016-2017 and 2017-2018.
On 16 September 2018 the Australian Government announced a Royal Commission into Aged Care Quality and Safety (Royal Commission). The Royal Commission is expected to determine the extent of ‘substandard care’ being provided, and will also consider challenges associated with providing care to people with disabilities living in aged care and older Australians with dementia and complex care needs. In addition, the Royal Commission will consider challenges and opportunities associated with the expected increase in demand for aged care services over the next decade.
The mistreatment of older Australians in residential aged care facilities may take many forms, and may be direct (as with assault), or indirect (through neglect). Mistreatment in this context is often referred to as ‘elder abuse’, which is defined by the World Health Organization (WHO) as ‘a single, or repeated act, or lack of appropriate action, occurring within any relationship where there is an expectation of trust which causes harm or distress to an older person’. Further, this abuse may be ‘financial, physical, psychological and sexual … [and] can also be the result of intentional or unintentional neglect’.
For some aged care residents, and their families and carers, making a complaint about real, perceived or alleged mistreatment is a daunting prospect, with many finding the process to be complex and/or ineffective. The true prevalence of mistreatment in residential aged care facilities is not known, as issues may not be identified or complaints not made.
Communication barriers such as: cognitive or speech impairments, cultural and language barriers, or the lack of a representative or advocate also affect a resident’s ability to raise concerns or make official complaints about their care.
As the aged care sector expands to provide services to the growing number of older Australians over time, quality care and clear and efficient avenues to raise concerns and make complaints will need to be firmly in place.
About the Inquiry
Objectives and Scope
On 6 December 2017, the Minister for Health and Sport, the Hon Greg Hunt MP, referred the Inquiry into the Quality of Care in Residential Aged Care Facilities in Australia (the inquiry) to the Standing Committee on Health, Aged Care and Sport (the Committee).
As part of the inquiry, the Committee reviewed the current standard of care in residential aged care facilities, and in particular, examined:
The effectiveness of the Australian Government agencies responsible for the regulation and delivery of aged care services in Australia, including the Department of Health, Australian Aged Care Quality Agency, Aged Care Complaints Commission, and Charter of Care Recipients’ Rights and Responsibilities;
Allegations of mistreatment of residents in residential aged care facilities and associated reporting and response mechanisms; and
The adequacy of consumer protection arrangements for aged care residents, particularly those who do not have family, friends or other representatives to help them exercise choice and their rights in care.
As the Committee is not a reporting body for complaints about residential aged care, it indicated on the inquiry webpage that it was unable to investigate individual cases of abuse or neglect in residential aged care. The Committee, however, provided contact information for the Aged Care Complaints Commissioner, and relevant state and territory reporting bodies, on its webpage.
In reference to this inquiry, the Committee received personal accounts from residents, family members and carers about allegations of abuse or neglect in residential aged care. Although it was not within the inquiry scope, nor within the power of the Committee, to ascertain the veracity of the claims, the Committee appreciated the information received and understands the courage needed for individuals to speak out. Where appropriate, the Committee removed identifying and personal information received to both protect the privacy of individuals and ensure that the rights of providers are respected. The personal accounts of aged care received by the Committee provided insight into the lived experience of those in residential aged care, their families and carers, and the staff who support the sector.
On 7 December 2017, the Committee issued a media release announcing the inquiry, calling for submissions to be received by 8 February 2018. On the request of inquiry participants, the Committee subsequently extended the date for submissions to be received by 1 March 2018.
The Committee also invited submissions from: government agencies, aged care peak bodies and providers, advocacy groups, medical groups and research organisations.
The inquiry received 123 submissions and 33 exhibits, which are listed at Appendix A and B respectively.
The Committee subsequently held seven public hearings as outlined in the table below. A list of witnesses and organisations is at Appendix C.
Table 1.1: Public Hearings Held
1 March 2018
11 May 2018
24 May 2018
5 March 2018
6 March 2018
15 March 2018
26 April 2018
Previous and Current Investigations into Aged Care Framework
The Australian aged care sector has been the subject of a number of major inquiries and reviews in recent years. Each of the reviews focussed on a particular aspect of the aged care sector and contributed to debate on reform.
Australian Law Reform Commission Report
The Australian Law Reform Commission (ALRC) released its report Elder Abuse—A National Legal Response (ALRC Report), in May 2017. The ALRC Report made 43 recommendations, including:
Establishing a serious incident response scheme in aged care legislation;
Reforms relating to staffing in aged care;
Regulating the use of restrictive practices in aged care;
Reforms relating to decision making in aged care; and
National guidelines for the community visitors scheme regarding abuse and neglect of care recipients.
The ALRC Report’s recommendation for a serious incident response scheme has been adopted by the Australian Government.
Limited research on the rates of abuse of those in residential aged care was a noted issue. The ALRC received submissions which included reports of abuse by staff of aged care facilities and family members and decision makers of residents, as well as reports of neglect.
Staffing levels were also addressed by the ALRC Report, which stated that a ‘safe, qualified aged care workforce in sufficient numbers is an essential safeguard against elder abuse in aged care’. The ALRC observed concerns put to it that current staffing levels were inadequate, and may be leading to neglect.
The ALRC Report further recommended that unregistered care workers be made subject to state and territory legislation giving effect to the National Code of Conduct for Health Care Workers, and that people wishing to work or volunteer in an Australian Government-regulated aged care facility be screened.
Aged Care Legislated Review
In September 2016, the Minister for Senior Australians and Aged Care, the Hon Ken Wyatt AM MP, appointed Mr David Tune AO PSM to conduct the Aged Care Legislated Review (Tune Review) as part of changes to aged care introduced in the Aged Care (Living Longer Living Better) Act 2013. The Tune Review was released in September 2017.
The Tune Review looked at ‘the impact and effectiveness of the changes and … made recommendations for future reform to the aged care system’. Quality and safety issues relating to aged care lay outside the Tune Review’s scope.
The Tune Review received 145 submissions and made 38 recommendations. Recommendations included further steps toward a consumer demand-driven model, increasing transparency around fees, and improving the functionality and performance of the My Aged Care website.
The Tune Review also suggested changes to increase accessibility for consumers by making the My Aged Care website more understandable, recommending that:
… the government introduce aged care system navigator and outreach services to assist consumers who have difficulty engaging through the existing channels to effectively engage with My Aged Care. The services should be funded by the government and not be delivered by the government or aged care providers.
Productivity Commission Report
The Productivity Commission’s report Introducing Competition and Informed User Choice into Human Services: Reforms to Human Services (Productivity Commission Report) inquired into the provision of end-of-life services, social housing, family and community services, services in remote Indigenous communities, patient choice and dental services. The Productivity Commission Report was released in October 2017.
The Productivity Commission Report focus on end-of-life care found that reforms were needed to ‘improve the standard of end-of-life care in residential aged care facilities’, stating that ‘each year, tens of thousands of people who are approaching end of life are cared for and die in a place that does not fully reflect their choices or meet their needs’.
The Productivity Commission Report also found that ‘the quality of end-of-life care in Australia is among the world’s best, but services are not available everywhere and to everyone who would benefit’. Further, the Productivity Commission Report stated that although four out of five residents of aged care facilities die in them, residents were making potentially unnecessary trips to hospital:
… the lack of palliative care expertise and qualified staff to administer pain relief mean residents often make traumatic (and costly) trips to hospital to receive medical care that could have been provided in surroundings that are familiar to them.
Coordination between residential aged care and general practice was found to be poor, and a focus on personal consumer choice was recommended to ensure that consumers are able to receive services of their preference for end-of-life care.
Review of National Aged Care Quality Regulatory Processes
The Review of National Aged Care Quality Regulatory Processes (known as the Carnell-Paterson Review) was announced by the Minister for Senior Australians and Aged Care, the Hon Ken Wyatt AM MP, in May 2017. Minister Wyatt appointed Ms Kate Carnell AO and Professor Ron Paterson ONZM to lead the Review. The Carnell-Paterson Review was released in October 2017.
The Carnell-Paterson Review was undertaken as a response to the Oakden Report, which detailed the failures in the quality of care provided at Oakden
Box 1.1: Oakden Older Persons Mental Health Service
Oakden opened in 1982, and was a provider of specialised residential care services for older people with complex mental health care needs and people with severe dementia.
Oakden was the responsibility of the North Adelaide Local Health Network (NALHN), however, the Makk and McLeay wards became Australian Government-funded nursing home beds in 1998.
In February 2016, an Oakden resident was referred to the Royal Adelaide Hospital after ‘significant bruising to his hip’ was identified, ‘for which there was no satisfactory explanation’. The resident’s family raised concerns about his care, which were raised with the Chief Executive Officer of the NAHLN, who requested the South Australian Chief Psychiatrist, Dr Aaron Groves, undertake a review of the facility. The Chief Psychiatrist’s review was released in April 2017, and recommended the closure of Oakden due to the poor standard of the facilities, unsuitability of the design for its residents, poor maintenance, faulty equipment in use, lack of staff training and other failings.
In June 2017, the Makk and McLleay wards of Oakden were closed, and residents transferred to Northgate House and other providers in South Australia.
The failings at Oakden led to a number of reviews and reforms at the state and federal level.
Older Persons Mental Health Service (Oakden) in South Australia. The Oakden Report was undertaken by South Australia’s Chief Psychiatrist, Dr Aaron Groves, and recommended, among other things, that the facility close.
In particular, the Carnell-Paterson Review examined why existing regulatory processes had not identified the ‘systemic and longstanding failures of care at the Makk and McLeay wards documented in the Oakden Report’.
Further, the Carnell-Paterson Review sought to identify ‘improvements to the regulatory system that will increase the likelihood of immediate detection, and swift remediation by providers’.
The Carnell-Paterson Review received more than 400 submissions and made ten recommendations around centralisation of accreditation and information, a focus on consumer rights, the establishment of a serious incident response scheme, enhancements to complaints handling, and the limitation of the use of restrictive practices.
The Carnell-Paterson Review found that ‘current regulatory mechanisms do not consistently provide the assurance of quality that the community needs and expects’. Ms Carnell and Professor Paterson also stated that they ‘see the primary role of quality regulation as consumer protection’, requiring a high level of oversight of accredited facilities as well as an effective complaints commissioner.
The role of the Australian Aged Care Quality Agency (Quality Agency) in failing to find serious issues at Oakden was highlighted:
Clearly, the accreditation processes that permitted the Makk and McLeay wards at Oakden to pass all 44 outcomes under the Accreditation Standards in February 2016 were inadequate. This was a deeply concerning failure. All too often, the Review heard about accreditation by the Quality Agency that was focused on processes rather than outcomes, and appeared to be a ‘tick-the-box’ exercise.
A major recommendation made in the report was the establishment of an independent Aged Care Quality and Safety Commission to centralise accreditation, compliance and complaints handling. The new commission would include a:
Care Quality Commissioner;
Consumer Commissioner; and
In April 2018, Minister Wyatt announced the establishment of an Aged Care Quality and Safety Commission. This is discussed in Chapter 2.
ICAC Report on Oakden
In February 2018, the South Australian Independent Commissioner Against Corruption, the Hon Bruce Lander QC, released the report Oakden: A Shameful Chapter In South Australia’s History (ICAC Report).
The ICAC Report highlighted ‘systemic failings in processes and oversight’, stating that:
The problem was the regime that existed that enabled the Oakden Facility and its operations to deteriorate to such an extraordinarily poor state and to operate in that way for such an extended period of time without any meaningful intervention.
Lessons to be taken from the eventual identification of issues and closure of the Oakden facility were drawn together. The ICAC Report stated that closing the facility without fully understanding the failure to identify the deterioration of service could leave open ‘the very real possibility that similar failures could be perpetuated in the future in other settings’.
The main issues dealt with in the ICAC Report were around the proper handling of complaints, consequences of attempts to contain issues, the withholding of information, and the ‘extraordinary dangers associated with poor oversight, poor systems, unacceptable work practices and poor workplace culture’.
The ICAC Report made 13 recommendations, including strengthening the focus on staff training, making expectations of staff responsibilities clearer, increasing the frequency of community visitor inspections, and reviews of clinical governance.
Senate Standing Committee on Community Affairs
On 13 June 2017, the Senate referred an inquiry on the effectiveness of the Aged Care Quality Assessment and accreditation framework for protecting residents from abuse and poor practices, and ensuring proper clinical and medical care standards are maintained and practised to the Senate Standing Committee on Community Affairs (Community Affairs Committee). The Community Affairs Committee was required to report by 18 February 2018, however, the reporting date was extended to 28 November 2018.
The Community Affairs Committee released an interim report on 13 February 2018, which focussed on ‘the critical care failures in the Makk and McLeay wards of the Oakden Older Persons Mental Health Facility (Oakden) in South Australia’.
The interim report found that ‘the Oakden facility failed to provide an appropriate model of care’, and that the Community Affairs Committee was ‘deeply concerned that warning signs in relation to resident health were not heeded, such as unexplained bruising, medication mismanagement and falls, and that complaints from family members and community advocates were ignored’.
The Community Affairs Committee extended its inquiry to make it focus on the assessment and accreditation framework, and clinical and medical care standards.
Aged Care Amendment (Staffing Ratio Disclosure) Bill Inquiry
On 22 August 2018 the Parliament referred the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 to the Committee for inquiry.
The Committee has called for submissions by 4 October 2018 and is expected to conduct an inquiry which will include issues related to staffing and staffing ratios for aged care.
On 16 September 2018, the Prime Minister, the Hon Scott Morrison MP, announced that he had asked the Governor-General to establish a Royal Commission into Aged Care Quality and Safety (Royal Commission).
The Prime Minister stated that ‘increased audit work’ commissioned by the Government had led to the closure of ‘almost one aged care service per month since Oakden, with an increasing number under sanction to improve their care.’
The Prime Minister also stated that while changes to aged care policy in relation to quality and safety were already taking place, there are still areas of concern in regard to the quality and safety of aged care services. The Prime Minister stated:
Despite the further reforms underway, including the coming establishment of a new Aged Care Quality and Safety Commission, there clearly remains areas of concern with regard to the quality and safety of aged care services. For this reason, our Government has decided to establish a Royal Commission into Australia’s aged care system.
The Royal Commission will consider issues of:
‘Quality and safety including the extent of substandard care;
How to best deliver care services to people with disabilities residing in aged care facilities including younger people;
How to best deliver care to the increasing number of Australians living with dementia;
The future challenges and opportunities for delivering accessible, affordable and high quality aged care services, including people’s desire to remain living at home as they age, and aged care in rural, regional and remote Australia;
What the Government, the aged care sector, Australian families and the wider community can do to strengthen care services to ensure quality and safety;
How to allow people greater choice, control and independence and how to improve engagement with families and carers;
How to best deliver sustainable aged care services through innovative care and investment in the aged care workforce and infrastructure; [and]
Any matters that the Commissioners believe is relevant to their inquiry.’
The Royal Commission is expected to provide an interim report by 31 October 2019 and its final report by 30 April 2020.
Chapter 2 outlines the current system for the delivery of aged care in Australia, and discusses the changes to the current system which will take effect on 1 January 2019.
Chapter 3 examines allegations of mistreatment of residents in residential aged care facilities, and the reporting mechanisms in place to respond to these incidences. This chapter also highlights the experience of residents, families and representatives, as well as staff, in making complaints or raising concerns.
Chapter 4 addresses issues of consumer rights and protection, including for those who do not have family, friends or representatives.
Chapter 5 discusses the changing nature of Australia’s population, the next generation of residential aged care consumers, and innovation in aged care facilities.