In response to an increasingly ageing population, aged care in Australia is evolving towards a more consumer-driven, market-based system.
Aged care regulation and quality is currently delivered by three Australian Government departments and agencies: the Department of Health, the Australian Aged Care Quality Agency (Quality Agency) and the Aged Care Complaints Commissioner (Complaints Commissioner).
The current system of aged care was viewed by some as not working efficiently or to the benefit of the consumer. Residents, their family members and carers expressed concerns at the complexity of the current residential aged care system. Members of the medical profession were of the view that the funding of aged care services was in need of updating to reflect current best practice.
Another area of concern was the accreditation system for residential aged care services. A number of inquiry participants stated that the current accreditation system, carried out by the Quality Agency, was too focussed on process and not enough on the consumer or the delivery of high standards of care.
The regulation of aged care in Australia is undergoing major reform, with the proposed formation of a new and independent Aged Care Quality and Safety Commission (the Commission) and a new set of Accreditation Standards. The Commission will merge the Quality Agency, Complaints Commissioner and aged care functions of the Department of Health.
Responsibility for the quality and safety of residential aged care facilities is currently shared between three Australian Government departments and agencies, with the Department of Health responsible for the funding, regulation and policy oversight of Australian Government-funded aged care services. Accreditation is carried out by the Quality Agency, and the Complaints Commissioner resolves concerns about aged care services.
The Aged Care Act 1997 (Aged Care Act) is the primary piece of legislation governing aged care services in Australia, and resources are allocated through the Aged Care Funding Instrument (ACFI).
The services that must be provided by an aged care provider are set out in the Schedule of specified care and services for residential care (the Schedule), in the Quality of Care Principles 2014 (Quality of Care Principles). The Schedule also sets out where fees may apply. Other relevant legislation includes the User Rights Principles 2014 (User Rights Principles) and the Complaints Principles 2015 (Complaints Principles).
The Australian Government provides the majority of funding to aged care, which was approximately $17.2 billion in 2017-2018.
The Department of Health
The Department of Health approves aged care providers, allocates and manages aged care places, establishes quality standards, takes enforcement actions against providers and administers the mandatory reporting function for assaults in aged care facilities.
Residential aged care services must be operated by an ‘approved’ organisation in order to qualify for Australian Government funding. The Department of Health considers applications against criteria set out in the Aged Care Act. An approved organisation then has the ongoing responsibility to ensure it continues to meet these criteria, and a failure to do so may result in a loss of approval.
The Department of Health also manages the allocation of residential aged care places using a competitive process to ensure that places allocated are based on need and match the suitability of the provider of care.
The aged care functions of the Department of Health will move to the new Aged Care Quality and Safety Commission from 2020.
Aged Care Complaints Commissioner
The Complaints Commissioner was established on 1 July 2016. The Complaints Commissioner is a statutory office holder working under the Aged Care Act and the Complaints Principles.
Complaints about the quality of aged care services funded by the Australian Government may be made to the Complaints Commissioner. Anyone can make a complaint.
The Complaints Commissioner’s primary functions are to:
Resolve complaints about aged care services;
Educate people and aged care providers about the best way to handle a complaint and the issues it raised; and
On request, provide information to the Minister in relation to any of the Complaints Commissioner’s functions.
Australian Aged Care Quality Agency
Established in 2014, the Quality Agency is an independent statutory agency with responsibility for accrediting and reviewing aged care services and home care services.
The Quality Agency is also responsible for the registration of the assessors who conduct accreditation, and delivers training and education to the aged care sector. The role of the Quality Agency is to hold providers of Australian Government-subsidised aged care services to account against applicable standards.
Residential aged care services are reviewed in accordance with the standards and the Quality Agency Principles 2013. Compliance of providers with the standards is monitored by the Quality Agency, which stated that:
Where issues are identified with the performance of a provider, the Quality Agency sets out specific areas for improvement and a clear timetable for making those improvements. The Quality Agency then informs the Department of Health, allowing it to consider what further regulatory action is appropriate in those circumstances.
Charter of Care Recipients' Rights and Responsibilities
The Charter of care recipients’ rights and responsibilities – residential care (the Charter) sets out the rights and responsibilities of care recipients, including the use of personal, civil, legal and consumer rights, the right to quality care, the right to live without discrimination or victimisation and the right to make a complaint. The Charter is contained in Schedule 1 of the User Rights Principles. A new single charter of care recipients' rights and responsibilities is in development.
Aged care services must be delivered in a ‘manner that is consistent with the rights and responsibilities of care recipients that are specified in the Charter’.
The Department of Health advised that the Charter ‘provides the right for care recipients of residential aged care to be treated with dignity and respect, and live without exploitation, abuse, neglect, discrimination or victimisation’.
The Charter sets out that a resident has the right to complain, to take action to resolve disputes and ‘to be free from reprisal, or a well-founded fear of reprisal, in any form for taking action to enforce his or her rights’. If a consumer believes that their rights are not being upheld by a provider, they may make a complaint to the Complaints Commissioner.
During the accreditation process, the Quality Agency assesses whether consumers understand their rights and responsibilities under the Charter, and whether the provider has systems in place to comply with the Charter. The Complaints Commissioner and Quality Agency may refer matters to the Department of Health, which may take compliance action if the requirements of the Charter are not met.
The Charter was described by the Australian Nursing and Midwifery Federation as ‘an essential document’, but which ‘needs to be more rigorously enforced’.
The utility of the Charter was questioned by inquiry participants. Mrs Rosaleen Appelhans called the Charter ‘well meaning but in some ways impossible to deliver on’. The Charter was also described as: having a ‘low/minimal profile within facilities’, ‘ineffective’, ‘not adequate’ and in need of review. The language used in the Charter was described as vague or ‘generalised’. The Office of the Public Advocate (Victoria) (OPA Victoria) questioned ‘whether the charter has genuine vitality’.
The Older Person’s Advocacy Network (OPAN) uses the Charter when discussing issues with residents, particularly if the resident has expressed a fear of reporting mistreatment. The OPAN also stated that the practical application of the Charter had been questioned, with residents asking who would protect them when the advocate is not there. The OPAN stated that ‘This is a very real concern and a question that can be difficult to answer’. The need for clear supporting guidelines was also highlighted.
The OPAN also considered that the interpretation of care recipients’ rights ‘is often a challenge and it can be difficult to ensure that interpretations remain focused on the consumer perspective rather than that of providers’.
A low level of understanding and awareness of the Charter by residents and staff was highlighted by inquiry participants. The Law Council of Australia recommended ‘an obligation for facilities to regularly provide education or information on rights, support for making complaints and the complaint process’.
The Charter’s emphasis on full and effective use of rights was questioned, with one inquiry participant suggesting that consumers may not be aware of their consumer rights. The inquiry participant stated that information relating to consumer guarantees for services ‘should be explained in a way that can be easily understood’. Elderlaw described this aspect of the Charter as a ‘generalised statement which is meaningless unless understood to mean that steps will be taken by the provider’.
The Australian Association of Social Workers (AASW) made the point that the Charter may not be accessible or understandable to consumers, and that even though the Charter is available in aged care facilities, it is ‘usually in small print’ which made it difficult to read. The AASW also observed that language barriers may present a challenge, as the Charter is:
… only available in certain languages other than English and [is] therefore not an accessible resource to older people and their families from culturally and linguistically diverse (CALD) backgrounds … the Charter should be made more easily accessible to families, those with functional impairments and those from a non-English speaking background.
The Australian College of Nursing agreed that there is a need for the Charter to be available in more community languages, and for the Charter to be discussed more frequently. The Royal Australian College of General Practitioners also recommended that the Charter be available in more languages, and further, that an Easy English version be created.
In contrast, the Aged Care Industry Association expressed the view that the Charter provides ‘a reasonable framework for specifying consumers’ rights and identifying avenues to express dissatisfaction’.
Carers NSW recommended ‘mandatory training for all care staff on the practical applications’ of the Charter. Carers NSW also recommended a Charter of Family and Carers’ Rights and Responsibilities, with reference to the Commonwealth Carer Recognition Act 2010. Carers NSW envisioned this family and carers’ charter ‘informing carers of their rights as a supporter and guiding staff engagement with residents’ carers, friends and families’.
Community Visitors Scheme
The Australian Government Community Visitors Scheme (CVS) ‘uses volunteers to make regular visits to people who are socially isolated or are at risk of social isolation or loneliness’ in residential aged care. The CVS was expanded to include consumers of home care services, and group visits to residential aged care facilities.
Consumers can be referred to the CVS by their provider, a family member or friend, or can self-identify. Volunteer visitors are matched with aged care recipients in order to improve quality of life, and provide friendship and companionship.
The CVS services are provided through state and territory organisations, referred to as Auspices, to support the relationships, recruit, train and support volunteer visitors, and also match visitors with volunteers. The Auspices are funded by the Australian Government to recruit and train volunteer visitors, and receive funding for each ‘Active Visitor’, which equals one volunteer attending at least 20 visits per year or equivalent.
Volunteers who may be concerned about ‘an aspect of a recipient’s care’ are ‘encouraged to seek the advice of their CVS provider’s coordinator’.
In its report Elder Abuse—A National Legal Response (ALRC Report), the Australian Law Reform Commission (ALRC) drew attention to the CVS’s ‘important role in reducing social isolation, which may itself be protective against abuse’.
The ALRC set out that the CVS does not have detailed national guidelines, with ‘limited guidance about how to respond to concerns about abuse or neglect’. The ALRC Report recommended the development of national CVS guidelines which would include policies for volunteer visitors to follow where they become aware of abuse or neglect.
The ALRC had canvassed the idea of an Official Visitors Scheme, which would focus on safeguarding aged care consumers by providing independent monitoring of care and to identify abuse or neglect. In its report, the ALRC did not to pursue this as a recommendation, instead recommending that focus be put on the development of a serious incident response scheme.
The Combined Pensioners and Superannuants Association of NSW (CPSA) supported an Official Visitors Scheme, rather than the expansion of the CVS, suggesting that an Official Visitors Scheme provide opportunities for staff and residents to raise concerns to an independent observer. Health Care Consumers Australia (HCCA) also supported the introduction of an Official Visitors Scheme, and recommended the model employed in the Australian Capital Territory.
Dementia Australia stated that the ‘scope and reach’ of the CVS should be increased to include a role for volunteers in quality monitoring, possibly as part of the accreditation process. Similarly, the Council of the Ageing Australia (COTA Australia) supported the ALRC Report’s recommendation to expand the CVS, and suggested that the expansion could include ‘the identification of any issues to the Complaints Commissioner as a third party complaint, or as ‘tip-offs’ about problems with compliance or with accreditation’. COTA Australia also stated that it would support an exploration of an Official Visitors Scheme.
State Community Visitor Schemes
Victoria’s Community Visitors Program (CVP) is coordinated by the OPA Victoria, which is a statutory office answerable to the Victorian Parliament. The CVP differs from the Australian Government-funded CVS, in that Victorian community visitors are empowered by law to visit certain facilities, unannounced, to ‘monitor and report on the adequacy of services provided in the interests of residents and patients’.
Although the CVP does not visit residential aged care facilities, it monitors the ‘quality of care provided to older people in disability accommodation and mental health in-patient settings’. The expansion of the Australian Government CVS to empower visitors to monitor abuse, neglect and social inclusion was proposed by the OPA Victoria.
The OPA Victoria contended that the CVP is able to provide ongoing monitoring of facilities, and the identification of issues:
OPA [Victoria] Community Visitors are considered to be the eyes and ears of the community; they represent an important safeguard for all residents, but most importantly for those who do not have family, friends, other representatives or advocates.
Box 2.1: Case study: Community Visitors Program, Victoria
The OPA Victoria described a situation in which an aged persons’ mental health residential facility had recently passed all 44 accreditation standards.
Members of the CVP and staff at the facility, however, had observed potential failings and prepared complaints on their observations, which included:
Allegations of patient abuse;
Overall low-quality care.
Consequently, the Quality Agency completed a follow-up review and ‘concluded that, contrary to its initial report, eight of the standards were not being met’.
Members of the CVP were subsequently involved in two further investigations into the facility, led by the Chief Psychiatrist and Health Network, which resulted in ‘a significant improvement’.
Queensland also has a CVP in operation for adults with ‘impaired decision-making capacity’, which employs community visitors to make announced and unannounced visits to facilities in order to monitor the quality of service. Community visitors are appointed by the Office of the Public Guardian (Queensland) (OPG Queensland).
Community visitors under this program may lodge and resolve complaints on behalf of residents, talk with staff and residents, review documentation and programs, and lodge reports with the OPG Queensland.
The OPG Queensland commented that members of the CVP had raised a number of significant issues which were observed in aged care facilities:
To give you an idea: in any year, my visitors will regularly visit about 1200 sites. Last year, 2016-2017, we made 5224 visits across Queensland and raised 1931 issues. A very large proportion of those related to the personal safety, security, abuse and assault of people in those institutions.
The expansion of the Australian Government CVS was supported by the Office of the Public Advocate (Queensland).
Residential Aged Care for Aboriginal and Torres Strait Islander People
Aged care services (residential and home care services) were delivered to 35 083 Aboriginal and Torres Strait Islander people in 2014–2015, at an estimated cost of $216 million. The Aged Care Act designates Aboriginal and Torres Strait Islander people as a ‘special needs group’, which requires aged care service providers to have regard ‘to the particular physical, physiological, social, spiritual, environmental and other health related care needs of individual recipients’.
Aboriginal and Torres Strait Islander people make up less than one per cent of people in permanent residential aged care, but access home care and home support in higher numbers.
Aboriginal and Torres Strait Islander people who are over the age of 50 years are eligible for residential aged care services. Aboriginal and Torres Strait Islander people in aged care are more likely to develop serious medical conditions earlier in life, and Aboriginal and Torres Strait Islander people in residential aged care tend to be younger than non-Indigenous people.
The Australian Government administers the National Aboriginal and Torres Strait Islander Flexible Aged Care Program (Flexible Aged Care Program), which ‘funds organisations to provide culturally appropriate aged care for Aboriginal and Torres Strait Islander people close to their communities’. Services delivered under the Flexible Aged Care Program may be residential or home care, and are mainly located in remote and very remote locations.
The Flexible Aged Care Program has a set of Quality Standards for service providers, assessed by the Quality Agency. These Quality Standards include ‘two overarching principles’: Continuous Quality Improvement and cultural safety.
The Department of Health advised that the Remote and Aboriginal and Torres Strait Islander Aged Care Service Development Assistance Panel provides ‘culturally appropriate local solutions to address the challenges of maintaining and delivering quality aged care services to Aboriginal and Torres Strait Islander communities and people living in remote areas’. The Department of Health engages qualified organisations to provide specialist advice and assistance to aged care providers.
Accreditation and Monitoring
The Accreditation Standards are set out in Schedule 2 of the Quality of Care Principles. Approved providers have a responsibility to comply with the Accreditation Standards.
The ongoing assessment of a provider against the Accreditation Standards is conducted by the Quality Agency. Assessment is undertaken on a case management model ‘to ensure targeted contact based on relevant information and compliance history’.
Accreditation of a provider includes a self-assessment by the provider, assessment by the Quality Agency, an audit report, a decision on accreditation and the issuing of the certificate as well as publication of the decision.
The Quality Agency assesses a provider against the 44 expected outcomes from four categories which make up the Accreditation Standards:
Management systems, staffing and organisational development;
Health and personal care;
Care recipient lifestyle; and
Physical environment and safe systems.
Single Aged Care Quality Framework
A Single Aged Care Quality Framework (Single Quality Framework) was introduced in the 2015-2016 Budget, and was developed by the Department of Health and the aged care sector. The Single Quality Framework is expected to take effect from 1 July 2019, with a transition period to enable the sector time to make arrangements already begun.
Primarily, the Single Quality Framework will replace four separate sets of Accreditation Standards with one set of aged care standards for aged care services. The Department of Health advised that this will simplify processes for aged care providers who deliver more than one type of care service.
The Department of Health advised that the aged care standards will replace the current Accreditation Standards, rather than be a revision, will be ‘far more consumer-outcome focussed’, will be centred on individuals and will begin with ‘I’ statements, such as: ‘I am treated with dignity and respect, and can maintain my identity. I can make informed choices about my care and services, and live the life I choose’. This will be followed by an organisational statement, on which the aged care provider is tested.
Site Audits and Accreditation Decisions
Site audits are conducted by registered quality assessors with the Quality Agency. During a site audit, an assessment team evaluates the quality of care and services against the 44 total Accreditation Standards. The Accreditation Standards are set out in the Quality of Care Principles.
Interviews with staff, care recipients, relatives and others are conducted, and observation of the practices of staff and reviews of documents are undertaken. The Quality Agency stated that around 55 000 interviews are conducted each year in residential aged care facilities, which is around ten to 15 per cent of care recipients and family members in assessed facilities.
The audit report is compiled by the assessment team, which makes a series of recommendations to a decision-maker. The assessment team does not make the decision on accreditation, and the site visit may be augmented by further documentation provided by the aged care provider, which has:
… an opportunity to provide additional information not available on the day, or perhaps they can inform the decision-maker of additional resources or efforts they might make, and they're entitled to do that under the principles … A decision-maker must take that on board.
The accreditation audit report is then published to the Quality Agency website, along with accreditation decisions and serious risk decisions.
The Quality Agency had passed the Makk and McLeay wards of the Oakden aged care facility in South Australia on all 44 Accreditation Standards in March 2016, accrediting it for three years. A second accreditation audit was conducted one year later, which found that the facility passed only 29 of the total 44 Accreditation Standards. The wards were closed in July 2017.
On 25 October 2017, the Hon Ken Wyatt AM MP, Minister for Senior Australians and Aged Care, stated that announced reaccreditation visits will be replaced with unannounced audits. The move to solely unannounced visits follows a recommendation made by the Carnell-Paterson Review.
Identification of Issues by Agencies
In the event that an issue is identified during a quality assessment of a residential aged care facility, the Quality Agency sets out ‘specific areas for improvement that are required to ensure that the Standards are complied with, and a timetable for making these improvements’. The Quality Agency then informs the Department of Health, which will undertake ‘a risk-based assessment to determine whether it is appropriate and proportionate to take compliance action in relation to the non-compliance’. The Department of Health advised that:
Where the Quality Agency identifies a failure that has (or may) place the safety, health or well-being of a care recipient of the service at serious risk, the Department is notified as soon as practicable. The Quality Agency liaises closely with the Department when there are concerns about a provider’s performance, including those providers on a Timetable for Improvement.
The Department of Health receives information on non-compliance from the Quality Agency, Complaints Commissioner, prudential compliance statements and members of the public. This information is examined to establish non‑compliance and a response, based on the risk to consumers.
The Department of Health can respond with an ‘administrative approach which involves educating the provider’ on responsibilities, and monitoring the provider’s return to compliance, or it may issue a Notice of Non‑Compliance, which requires the provider to improve within a set timeframe.
The main objectives of the accreditation system are to ensure the safety of residents, and to ‘help providers get back into compliance’ rather than coming ‘from a position of shutting them down or revoking accreditation’. The Department of Health advised that revoking accreditation is a last step action as it is a ‘bad outcome for the residents involved’.
Sanctions may be imposed on a provider that does not return to compliance within the timeframe, such as:
Ceasing subsidies for new care recipients;
The appointment of an advisor or administrator to assist the provider to return to compliance; and
Training of staff and management.
Non-compliance with a Notice of Non-Compliance or sanction is recorded on the My Aged Care website and is accessible to the public.
Inquiry Participant Views on Accreditation and Monitoring
Inquiry participants stated that the current accreditation process is focussed on process, rather than on consumer outcome. The CPSA stated that the Accreditation Standards ‘do not currently consider the care outcomes residents experience. Rather, they consider the organisation’s processes and systems as a proxy for quality care’.
Similar sentiments were expressed by the Australian College of Nursing, who agreed that compliance with the Quality Agency’s requirements ‘does not equate to improved resident outcomes’. The Australian College of Nursing further stated that ‘compliance requires key staff to be dedicated to documentation and audits to provide evidence of care rather than actually delivering the care’. The Health Services Union asserted that the ‘accreditation framework is disadvantageous to the provision of optimal resident care outcomes’, and has an ‘emphasis on self-regulation and reducing regulatory burden’ instead of the promotion of quality care.
Dementia Australia outlined the view that the accreditation process does not deliver useful information or insight to consumers, stating that:
From a consumer perspective, the accreditation process has served to reassure consumers that, over time, there will be consequences for aged care providers offering unacceptable levels of care. However, the [Accreditation] Standards only establish the minimum acceptable level of service for accreditation, rather than providing any insight or guidance into whether a provider is delivering high quality care.
The Community and Public Sector Union (CPSU) stated that recent changes at the Quality Agency were ‘impacting on the ability of front line staff to assess compliance in a manner that is strongly focused on resident protection and well-being’. The CPSU identified the following areas of concern:
The failure to monitor the effectiveness of the Computer Assisted Assessment Tool (CAAT) and the Consumer Experience Report (CER);
Concerns of frontline staff not being addressed or remedied;
Poor scheduling and planning of assessment visits, increased workloads and stretched capacity to undertake the assessment to the standard needed; and
A failure to engage with the right staff across the Quality Agency.
A stronger focus on the role of the consumer, and hearing consumer voices, in the accreditation process was recommended by the Victorian Council of Social Service (VCOSS), which recommended that the number of audit-related interviews be increased and more widely publicised for residents and their families. The VCOSS also recommended that the Quality Agency undertake audit-related interviews out of business hours, or remotely, and provide alternative interview models for those facing communication barriers, stating that ‘residents and families are often not made aware that accreditation processes are taking place, or provided opportunity to participate’.
The accessibility of the information contained in accreditation reports was questioned by Dementia Australia, which asserted that the assessment against the 44 Accreditation Standards:
… does not provide more nuanced information on meaningful, consumer relevant outcomes and this makes it difficult for consumers to ascertain whether the provider is delivering high quality care or just passing the minimum standards for accreditation.
The OPAN stated that there is an opportunity for its network of advocacy services to be involved in the accreditation process, and stated that there is no formal mechanism for the Quality Agency to speak with advocates or advocacy services about their experiences with a facility.
The Queensland Nurses and Midwives’ Union (QNMU) compared the aged care quality standards with the standards used in the acute health sector, stating that ‘there seems little comparison between accreditation processes accepted as the norm in other health care sectors and those undertaken by the Quality Agency for the aged care sector’.
Ms Fiona Duff put forward the view that the Quality Agency does not have the right approach, and stated that the Quality Agency focuses on a ‘facility’s successes rather than a facility’s deficiencies. But the deficiencies are what are putting our aged at risk’.
In contrast, Estia Health expressed the view that the Quality Agency focuses too much on identifying non-compliance:
The focus by the [Quality] Agency on non-conformance tends to move their thinking away from the balance of quality improvement looking at the inherent robustness or weaknesses of the systems that support care and service delivery into a focus on that which has failed.
The Aged Care Industry Association also suggested a focus on ‘positive outcomes for residents rather than regulatory responses’.
Until recently, residential aged care facilities received one unannounced contact visit per year, with other visits announced in advance. Unannounced visits also occurred on receipt of a high risk referral.
Under recent changes, resulting from recommendations from the Carnell-Paterson Review, announced visits have begun to be replaced with unannounced audits. Initial accreditation audits will continue to be conducted in consultation with the aged care provider, with subsequent re‑accreditation reviews to be replaced by unannounced audits.
The Quality Agency set out that unannounced re-accreditation audits will apply ‘to all applications for re-accreditation from 1 July 2018 and to residential aged care services with an accreditation expiry date on or after 1 January 2019’.
A number of inquiry participants asserted that announced visits had been inadequate, with a number stating that providers had prepared facilities in order to pass the accreditation and re-accreditation process.
Support for a change to unannounced visits to aged care facilities was expressed by Mrs Rosaleen Appelhans, who stated that it might ‘sharpen up providers’. Mrs Yvonne Buters stated that the move to unannounced visits is ‘essential’.
Catholic Health Australia supported the introduction of solely unannounced visits, as did the COTA Australia and the Australian Nursing and Midwifery Federation. The COTA Australia also requested further information on how this would be implemented.
On the other hand, the Aged Care Industry Association stated that it had not seen ‘definitive evidence supporting the effectiveness of unannounced visits as a quality assurance tool’. Aged Care Crisis similarly stated that unannounced visits ‘resulted in only minor benefit’, citing Quality Agency data that only ten per cent of Findings of Failure and Serious Risk Decisions over a three year period to 2018 had come from unannounced visits.
Aged Care Matters called for the publication of reports from unannounced visits, stating that the reports ‘would enable consumers to make informed choices when selecting an aged care home’.
Staffing of Residential Aged Care Facilities
The Department of Health advised that the legislative requirements for staffing of residential aged care facilities are left to the determination of aged care providers:
Approved providers are required to maintain an adequate number of appropriately skilled staff to ensure that the care needs of care recipients are met. They also have an obligation to ensure that police certificates, not more than three years old, are held by all staff members who are reasonably likely to have access to care recipients, whether supervised or unsupervised, and volunteers who have unsupervised access to care recipients.
The Department of Health commissioned the National Aged Care Workforce Census and Survey (the Workforce Survey) in 2016, which received responses from more than 15 000 aged care workers from 4500 facilities. The Workforce Survey found that the ‘overall staffing ratios and the proportion of RNs in the residential sector [has] remained constant since 2012’.
The number of Registered Nurses (RNs) and Nurse Practitioners (NPs) had increased between 2012 and 2016, but the number of Enrolled Nurses (ENs) had decreased:
Table 2.1: Direct Care Employees in the Residential Aged Care Workforce
Nurse Practitioner (NP)
Registered Nurse (RN)
Enrolled Nurse (EN)
Personal Care Attendant (PCA)
Allied Health Professional (AH)
Allied Health Assistant (AHA)
Source: Department of Health, The Aged Care Workforce 2016, p. 13.
The Workforce Survey also reported, however, that there had been a decrease in the number of RNs, from 24 019 in 2003 to 22 455 in 2016 (6.5 per cent). Inquiry participants drew attention to the longer-term decline in numbers of RNs.
The average size of residential aged care facilities has remained constant between 2012 and 2016, with an average ratio of direct care workers to residential aged care places at 0.77 in 2012 and 0.78 in 2016. The Workforce Survey also stated that negative perceptions of aged care work as having low pay and status remain, and that ‘given the need for the expansion of the aged care workforce, this issue must be addressed’.
Productivity Commission reports in 2013 and 2018 outlined that the number of people receiving residential aged care services increased from 269 269 people in 2011-2012 to 298 607 in 2016-2017.
The care needs of people in residential aged care have also shifted over time. Table 2.2. outlines data on care needs from the Australian Institute of Health and Welfare.
Table 2.2: Care need ratings of people in residential aged care, across all care domains (per cent)
Inquiry Participant Views on Staffing
The important role of trained staff in the delivery of high quality care was raised by G W Hitchen, who highlighted the vulnerability of some people receiving care:
Any resident who actually requires high care is in a very risky situation. His or her care depends entirely on who is on a particular shift – as always, it is all about the people. You cannot have good aged care with bad people, just as you cannot have good hospital care without good staff.
Dementia Australia observed a ‘trend towards employing less skilled (and [to a] lower cost [to the employer]) staff in residential settings in the delivery of direct care services’, stating that this trend was occurring while the acuity of care required is increasing. The Australian College of Nursing also stated that ‘increasingly business models are being deployed where nurses are being utilised only for 'legislative requirements', with Assistants in Nursing (AINs) … fulfilling most of the traditional care elements’.
The challenging role of RNs in aged care was raised by the Australian Nursing and Midwifery Federation (ANMF), which stated that RNs possess the training and skills to deliver quality care, and that this role is undermined by current staffing conditions and skill levels. The ANMF stated that RNs are:
… educationally prepared to assess and instigate or delegate appropriate care, and to monitor for, and identify, where mistreatment might be occurring. However, current staffing conditions, in terms of staffing numbers and levels of qualified staff, are undermining their role as clinical leaders within aged care.
The New South Wales Nurses and Midwives’ Association (NSW NMA) highlighted that professional duties to report issues which apply to RNs do not apply to ‘unlicensed Assistants in Nursing/Care workers’ who ‘provide the most direct care to residents’.
A decrease in the employment of RNs, facilities with no nursing staff after hours, and a high turnover of staff were identified as major workforce issues by the Australian Medical Association (AMA).
Palliative Care SA stated that staffing shortages lead to higher workloads for remaining staff, who may not have the experience or skills to carry out the work:
Inadequate worker-resident ratios and the inadequate level of registered nurses employed across all shifts in residential and community aged care means that too many times evidence and best practice are submerged under the sheer volume of work expected of staff who are paid the least and without the skills and ongoing training provided and required.
The QNMU stated its belief that unintentional neglect ‘stems primarily from the continuing and systemic deskilling of the aged care workforce and decreasing levels of care (both in terms of the skill of those providing the care and the hours of care provided)’. The QNMU identified the consequences of inadequate quality and quantity of care:
Increased resident-on-resident harm;
Higher rates of pressure injuries;
Resident weight loss and nutritional deficits; and
Medication errors at higher rates.
Mrs Betty Tuohy described the effect of gaps in available staffing, stating that, in her husband’s facility, staff who are unavailable for work are not replaced. Mrs Tuohy stated that her husband, who has dementia, has left the facility three times: ‘The first two times, they didn't know he was missing. I put all this down to lack of staff, not enough staff to really know what is happening with them.
An inquiry participant described the effect that low staffing levels can have on the workforce:
Over decades of visiting family and friends in aged care facilities, it is my observation that poor practices/ inadequate staffing levels contribute to workplace stress and this feeds directly into frustration, fatigue, impatience, rough physical handling, sometimes to physical mistreatment and abuse that may be mental or physical or both.
Another inquiry participant described their experience as an aged care consumer, stating that although many carers ‘do the best they can … the help mostly does not eventuate. This means that you have to continually keep asking, especially if you need the toilet, and your needs can get desperate at times’.
Minimum Staffing Levels and Staffing Ratios
The ANMF stated that ‘the current level of staffing is inadequate to provide for the needs of Australians living in residential aged care facilities’, with missed care a common result of lower staffing numbers. A survey conducted by the NSW NMA and the ANMF in 2016 found that a higher proportion of low skilled staff ‘was a common factor in situations where resident to resident abuse occurred, and, that inadequate staff numbers overall [were] a precursor to elder abuse’. A ratio of one RN for 60 to 100 residents, with the potential for the RN to be on call rather than on site, was described as ‘inappropriate’.
Minimum staffing levels and/or a mix of staffing skills were recommended by members of the medical profession. The NSW NMA stated that ‘the provision of safe staffing ratios and skills mix in aged care [is] intrinsically linked to safety and protection against abusive practices’. The Australian College of Nursing recommended a minimum requirement for an RN to be on site and available at all times, and the AMA recommended that the Accreditation Standards ‘should demonstrate a ratio of suitably trained nurses to patients at any one time’.
The ANMF stated that on average, residents receive 2.84 hours of care per day, and recommended that this be increased to an average 4 hours and 18 minutes per day, with a skills mix of:
Enrolled Nurses (ENs) – 20 per cent; and
Personal Care Workers – 50 per cent.
The HCCA recommended an improved ratio of skilled staff to residents, and stated that a reduced staff to resident ratio ‘contributes to a systemic environment conducive to mistreatment of residents’.
On the other hand, aged care providers did not agree that mandated minimum staffing levels, or a mandated skills mix, would be appropriate. UnitingCare Queensland stated that although the concept of mandated staff ratios ‘has been discussed for many years, there seems to be no substantive evidence that they achieve better quality outcomes for residents’.
UnitingCare Queensland suggested that it is ‘incumbent upon providers … to apply flexible staffing models’ that will be appropriate for each individual facility, given the ‘regularly changing occupancy levels and changing needs of residents’.
Leading Age Services Australia (LASA) described staffing ratios as a ‘blunt instrument’ that does not allow the provider staffing flexibility. Similarly, Aged and Community Services Australia (ACSA) stated that mandated ratios do not take into account different models of care, and may limit the ability of providers to be innovative in their care model.
Estia Health stated that the layout of an aged care facility can make a difference to staffing requirements, and that an aged care facility built in wings would require more staff than a facility where all of the residents are on the same floor.
Resthaven suggested that the level of staffing in facilities is reflective of available ACFI funding, and stated that an increase in staffing availability would require an increase in funding:
The proposal to lift staff ratios to an average of 4.3 hours/day per resident is of enormous significance in the context of the current and historical resourcing of residential aged care services. A move to 4.3 hours per resident per day as a minimum would suggest increasing government funding through the ACFI in the order of 50 per cent if we move current average ratios levels to this requirement.
Efficacy of the Current System
Inquiry participants expressed strong concerns at the overall efficacy of the current system, stating frustration at the complexity and utility of the current delivery of aged care.
Relationship Between Agencies
The QNMU characterised the shared regulatory environment for the delivery of aged care as ‘complex, and apparently fragmented’. Similarly, the Vintage Reds of the Canberra Region stated that the way in which agencies refer complaints to one another has a ‘circular nature’.
Aged care providers Estia Health and HammondCare raised concerns over duplication of services between the Quality Agency and the Complaints Commissioner.
The Law Council of Australia recommended a ‘comprehensive review of the aged care sector’, and stated that there ‘are often a lack of structures to support coordination and information sharing between these agencies’.
Mrs Kate Mannix expressed the view that ‘from the perspective of the family, our interest is rather less in ‘improving the system’ for some time in the future, but in getting real care for our frail aged parent now’.
Family members of residents raised concerns over the roles of the agencies involved in the accreditation and complaints process, and confusion at the separation of responsibilities. Ms Fiona Duff expressed frustration at the separate nature of the agencies:
I initially called the [Quality] Agency to be told they don’t deal with the public and the only recommendations they would accept are ones that are deemed by the [Complaints Commissioner]. They did not want to know about our issue even though it related to a standard they initially failed the home on in the last accreditation.
Similar sentiments were expressed by Ms Denise Newton, who described her experience during the interview process which occurs during accreditation audits undertaken by the Quality Agency. Ms Newton stated that documents she had prepared relating to her concerns were not accepted by the assessors. In Ms Newton’s view, her concerns were representative of wider issues within the facility. Other inquiry participants indicated that they had compiled information to provide during the accreditation process but which was not accepted, being told that the Quality Agency is ‘not a complaints department’.
In contrast, the Quality Agency advised that it can receive information from members of the public at any time, independent of the Complaints Commissioner, although this information is used to inform a view of the system. The Quality Agency clarified its role in the complaints process, stating that it is a ‘systems regulator and a systems assessor’, which looks for ‘clear evidence of that system working’, while the Complaints Commissioner assesses individual complaints.
Complexity of the Current System
Estia Health expressed the view that the language used by the Complaints Commissioner ‘tends to be legalistic’, and stated that:
… the current complaints processes tend to be cumbersome, built on the exchange of correspondence and sometimes continue over a long period. We accept the Commissioner’s report that 74 per cent of complaints are resolved in 30 days. It is the other quarter that are problematic.
The Law Council of Australia suggested that the Complaints Commissioner ‘is not considered accessible or user-friendly by many residents and their representatives, but rather as protracted and bureaucratic’, and further suggested that existing consumer protections under the aged care legislative framework are ‘confusing and inadequate’.
The complexity of the aged care system was also highlighted by Dementia Australia, the QNMU and the Federation of Ethnic Communities' Councils of Australia.
The Department of Health acknowledged that the aged care system is complex, but stated that ‘while complex, Australia’s current regulatory system aligns well with some accepted best-practice regulatory principles’. The Department of Health stated that ‘there are areas that can be improved to ensure that the system consistently provides the assurance of quality that the community needs and expects’.
Aged Care Funding Instrument
Funding for aged care resources is assessed for individual consumers and delivered, via the ACFI, to the residential aged care facility as the financial entity providing care. The ACFI subsidises three ‘domains’ of residential care: activities of daily living, behaviour and complex health care.
General Practitioners (GPs) working for New Aged Care described feeling pressured by provider staff into signing ACFI forms which provided no clinical information on how bruises or skin tears were sustained, and which may have had inappropriate diagnoses of dementia. New Aged Care stated that GPs were told that if they did not sign the form, a replacement GP would be found who would.
Inquiry participants stated that the funding provided through the ACFI, and the model itself, was insufficient for the requirements of a modern aged care consumer. The Australian Physiotherapy Association stated that the ACFI model is not ‘fit for purpose’ and is not able to deliver the best quality care model:
At present, the ACFI funding model is prescriptive and has incentives to practise in ways that are contrary to the best available evidence and quality care. It channels funding to passive treatments to manage pain, rather than to models that include the prevention or slowing of functional decline, and importantly early detection of mistreatment.
Similarly, LASA highlighted issues with the ACFI model, stating that the current operation of the ACFI means that consumers with dementia are ‘not being considered for admission to residential care’:
The ACFI prioritises funding towards complex care needs and assistance with activities of daily living (ADL), rather than responding to behaviours. Yet interventions in relation to dementia and its associated behaviours are the most time consuming. This means that funding is inadequate given the resources actually required to care for people with dementia who need minimal assistance with ADLs or complex care.
The QNMU agreed, stating that the ACFI ‘has significantly outlived its usefulness and urgently needs to be replaced by a sustainable alternative’, and instead recommended an ‘activity based funding model’.
The VCOSS stated that there was no incentive to help consumers’ conditions improve, and asserted that consumers requiring a higher level of care would attract more funding for the provider.
Aged care providers stated that the ACFI amount allocated per consumer is too low. Catholic Health Australia stated that this limited the capacity of providers to ‘deliver the staffing levels and skills mix often expected by relatives’. The Aged Care Industry Association stated that the ACFI amount allocated to each resident had been ‘revised several times in recent years to reduce growth in funding per resident’.
A potential link between decreased funding and a lowering of service quality was raised by United Voice, which stated that a ‘decrease in funding to aged care providers can … not be discounted in considerations of quality’. Estia Health also stated that the:
… inadequacy of subsidy levels must never be acceptable as an excuse for quality failure. However, we cannot fail to note that the failure to increase subsidies in line with cost growth and increasing resident acuity has created financial tensions for some providers.
Resthaven agreed that ACFI funding was too low, stating that ‘in the current financial year there was zero indexation of ACFI and there is proposed continued reduced indexation’ in 2018-2019.
The Australian College of Nursing described the ‘laborious’ amount of work required to be undertaken for care plans, which it characterised as ‘not read other than by the [Quality] Agency’:
The staff hours required to generate such detailed assessments are not recouped in the funding, nor does it improve the quality of care provided to the resident. Such care plans and audit documents have little tangible advantage to the staff who are providing direct care to the residents.
The Department of Health stated that work on the funding model for aged care services is currently underway, and that ‘moving away from ACFI, given that the business models are all built around ACFI, is a key consideration’.
A Resource Utilisation and Classification Study (RUCS) is being undertaken by the Department of Health to examine the ‘clinical and need characteristics’ of aged care consumers which may influence the cost of care and how those costs are spread. The RUCS is ‘a recognition that we need to examine more contemporary ways of looking at the needs of care recipients and how they are funded by government’.
Compensation and Civil Accountability
Elderlaw stated that the Aged Care Act ‘expressly disallows any legal consequences arising from a breach of the [Aged Care] Act, whether civil or otherwise’, except for the consequences for breach set out in the Aged Care Act.
A breach of the Aged Care Act may result in sanctions on the aged care provider. Elderlaw asserted that ‘an individual case of harm is unlikely to warrant the Secretary [of the Department of Health] to impose sanctions’, and questioned the utility of the complaints format in the event of mistreatment. Elderlaw stated that:
… the aged care system offers only advice about complaints. There is no redress for the individual, no improvement of the level of attention to their health needs, no overt recognition of harm and causation.
Elderlaw put forward the view that ‘at the moment, under this system, there are no consequences’ for serious harm, and suggested the introduction of legislation on elder justice which would allow a civil or criminal route to be taken.
The National Association of Community Legal Centres (NACLC) stated that the rights of residents who do not own their dwelling, such as tenants, are protected through legislation. The NACLC suggested that similar rights should apply to residents of aged care facilities, which would provide a ‘forum for individual civil enforcement’ of the principles in the Aged Care Act.
GW Hitchen observed that, in the United States of America, multimillion dollar damages have been awarded for pain and suffering caused by aged care facilities.
New Aged Care Quality and Safety Commission
A new Aged Care Quality and Safety Commission (Commission) will start on 1 January 2019 and bring together the functions of the Quality Agency and Complaints Commissioner, with the aged care functions of the Department of Health to join the Commission from 2020.
The Commission has been proposed to respond to the Carnell-Paterson Review into failures at South Australia’s Oakden facility. That report found that the current aged care regulatory framework is fragmented, and not able to provide a level of assurance in line with community expectation.
The Commission will establish a Chief Clinical Advisor, who will provide advice to the Commission on complex clinical matters.
Additional quality reforms that have been announced include:
Developing options for a serious incident response scheme;
A performance rating against quality standards; and
A provider comparison tool on the My Aged Care website.
The Department of Health stated that the Commission will differ from the model put forward by the Carnell-Paterson Review by appointing ‘a single commissioner with a clinical care advisory structure to support that commissioner’ instead of appointing several commissioners, as recommended.
Community Visitors Scheme
The Australian Government-funded Community Visitors Scheme (CVS) has provided significant comfort to isolated older Australians in residential aged care. The Committee considers that this is an under-used resource, and could be harnessed to provide a voice for residents who are unsure about raising issues of quality of care.
There is currently limited guidance for CVS volunteers on how to respond to allegations or suspicions of mistreatment, with volunteer visitors advised to seek the advice of the provider’s coordinator. A consistent, national approach could strengthen the role of the CVS in residential aged care.
Accreditation and Monitoring
A number of inquiry participants described the current accreditation process for residential aged care facilities as being inaccessible, having the wrong approach and being too focussed on the provider.
The Committee agrees that the current Accreditation Standards, published on the Quality Agency’s website for each aged care facility, do not allow a consumer to know if a provider is delivering high quality care, or passing minimum standards.
Recent changes to the accreditation and monitoring process, including a move to unannounced visits and a reframing of the Accreditation Standards, may assist the Australian Aged Care Quality Agency (Quality Agency) to determine a more accurate view of the quality of care delivered in a residential aged care facility.
Efficacy of the Current System
This Committee, along with the many inquiries before it, has heard evidence which points to significant failings in the effectiveness of the federal government regulatory agencies in preventing the mistreatment or provision of poor care of individuals in residential aged care. This was most dramatically exposed at Oakden, where a facility (now closed because of its failings) passed the accreditation process.
The Committee is concerned that consumers are facing complex bureaucracy and an onerous administrative system during periods of stress and transition as they care for loved ones in aged care facilities. Many consumers indicated to the Committee their frustration navigating the existing mechanisms for interacting with the bureaucracy, including concerns about the complexity of the My Aged Care website and the responsiveness of information services.
A number of inquiry participants described frustration and confusion at the separation of the Australian Government agencies responsible for the delivery of aged care.
There are significant reforms to the aged care system underway, including the new Aged Care Quality and Safety Commission (Commission), consumer-oriented Accreditation Standards for residential aged care facilities, a move to solely unannounced visits to residential aged care facilities and the development of a new Charter of care recipients’ rights and responsibilities – residential care.
The Committee supports the creation of the Commission as an important reform to reduce the existing complexity and lack of clarity in relation to responsibilities inherent in the current system. The Committee considers that the establishment of the new Commission may ameliorate many of the concerns put forward by those inquiry participants who raised concerns about the separation of the agencies, and the lack of communication between them.
Staffing levels and mixes in residential aged care facilities are not set out in Australian Government legislation, which leaves it to the provider to determine the most effective staffing system. The issue of staffing levels is complex, and will require a balance between provider flexibility and ensuring minimum safety standards.
The Committee notes that workforce data indicates an increase in the number of Registered Nurses (RNs) employed in the aged care sector over the last five years. However the Committee also notes that the number of residents in aged care has increased, as has their acuity. The trend has over the past 15 years shown a reduction in the number of RNs.
The Committee also received evidence that there are barriers to patients receiving timely access to general practitioners and allied health professionals in aged care facilities, and that this may have led to an increased rate of hospitalisation and a delay in the provision of quality care. The Australian Medical Association stated that it had surveyed its members who visit aged-care facilities, and that one in three respondents intended not to take on new patients, not increase the number of visits, or stop aged care visits entirely in the next two years.
Many inquiry participants expressed a desire for minimum staffing levels in aged care facilities, or a mix of skills, to ensure that a consistent standard of care can be delivered at all times.
A trend towards RNs being expected to provide care for increasingly large numbers of residents as they are replaced with less qualified carers has emerged in recent years. The potential consequences of such changes are missed care, unintentional neglect and a declining quality of care. Appropriate staffing levels and skills mixes need to take into account the significant experience and training of RNs, and ensure that high quality care can be delivered on a continuous basis, in a consistent manner.
The Committee considers that the continuous presence of a RN in a residential aged care facility is needed in order to meet the complex care needs of residents. As a minimum, a RN should be present at an aged care facility at all times unless it can be demonstrated that the resident mix or size of a facility does not warrant compliance with this minimum standard.
The Committee notes calls for the publication of staff ratio numbers to allow consumers to make more informed decisions. This specific matter is currently before the Committee as part of the Inquiry into the Aged Care Amendment (Staffing Ratio Disclosure) Bill 2018 and so discussion of this matter will be included in a future report.
The Committee recommends that the Department of Health develop national guidelines for the Community Visitors Scheme, including policies for volunteer visitors to follow in the event of observed or suspected abuse or neglect.
The Committee recommends the Australian Government review:
the Aged Care Funding Instrument (ACFI) to ensure that it is providing for adequate levels of care for the individual needs of aged care recipients;
the adequacy of funding levels to ensure ACFI funding is indexed annually; and
the range of penalties relating to breaches of ACFI funding standards by aged care providers.
The Committee recommends that the Australian Government review the Medicare Benefits Schedule relating to medical practitioner visits to residential aged care facilities.
The Committee recommends that the Australian Government:
legislate to ensure that residential aged care facilities provide for a minimum of one Registered Nurse to be on site at all times; and
specifically monitor and report on the correlation between standards of care (including complaints and findings of elder abuse) and staffing mixes to guide further decisions in relation to staffing requirements.
The Committee recommends that the Department of Health ensure consumer information, including the Charter of Rights, for aged care residents and their families is available in a wider range of languages to ensure better access for those from culturally and linguistically diverse backgrounds.
The Committee recommends that an independent review and a parliamentary inquiry (by the appropriate Committee) be undertaken into the Aged Care Quality and Safety Commission after two years to determine its effectiveness in ensuring high standards of care, best clinical practice and reducing mistreatment.
The Committee reiterates and supports the recommendation from the Carnell-Paterson Review for the current to move to unannounced audits in residential aged care facilities and that any unannounced visits to residential aged care facilities should not be confined to business hours.