Chapter 3 - The aged care standards and accreditation agency
This chapter discusses the performance and
effectiveness of the Aged Care Standards and Accreditation Agency (the Agency)
in terms of:
- assessing and monitoring care, health and safety
of residents in aged care facilities;
- identifying best practice and providing
information, education and training to aged care facilities; and
- implementing and monitoring accreditation in a
manner which reduces the administrative and paperwork demands on staff.
The Agency plays an important role in the regulation of
the aged care industry. Evidence to the inquiry strongly emphasised that an
effective regulatory regime is important to protect elderly people placed in
aged care facilities – people who represent some of most vulnerable, frail, and
dependent members of the community. The regulator also has an important role in
ensuring accountability of the sector – a sector that receives very considerably
public monies to provide aged care services.
Role of the Aged Care Standards and Accreditation Agency
The Agency is an independent company established by the
Commonwealth Government under the Aged
Care Act 1997, is limited by guarantee incorporated under the Corporations Act 2001 and is subject to
the Commonwealth Authorities and
Companies Act 1997. The Agency was appointed as the 'accreditation body'
for residential care services and the Accreditation
Grant Principles 1999, made in accordance with the Aged Care Act, specify
the functions of the accreditation body and the procedures it is to follow in
carrying out those functions.
The core functions of the Agency include:
- managing the accreditation process using the
- promoting high quality care, and assisting the
industry to improve service quality, by identifying best practice and providing
information, education, and training to industry;
- assessing and strategically managing services
working towards accreditation; and
- liaising with the Department of Health and
Ageing (DoHA) about services that do not comply with the Residential Care
Standards or the Accreditation Standards.
Operationally these functions translate into activities
that can be described as:
- assessing homes for compliance with the
Accreditation Standards and determining the period of accreditation; and
- promoting high quality care and helping homes
improve service quality by providing education and information.
The Agency works within the broader regulatory
framework that governs the funding and provision of residential aged care. The
framework includes the Aged Care Act, the various Aged Care Principles, the
Complaints Resolution Scheme and State and local government legislation.
Assessing and monitoring care, health and safety
The Agency assesses compliance of residential aged care
services against the Accreditation
Standards made under the Quality of Care
Principles 1997 that consist of four parts involving:
- management systems, staffing and organisational
development – 9 expected outcomes;
- health and personal care – 17 expected outcomes;
- resident lifestyle – 10 expected outcomes; and
- physical environment and safe systems – 8
The Standards specify the outcomes that are to be
achieved for residents but they do not prescribe how the home must achieve the
outcome. This approach provides the opportunity for providers to tailor care
and services in a way that best meets the residents' needs and expectations.
The accreditation process involves a team of at least
two registered aged care quality assessors evaluating all aspects of a home's
performance through an assessment of the accreditation application and a two to
three day site audit. The site audit includes interviews with residents, their
families, staff and management. The assessment team will examine relevant documentation,
and observe the living environment and practices of the home. Information is
gathered to analyse the home's performance against the 44 outcomes.
There were 2949 accredited homes as at 30 June 2004 –
2640 homes (or 90 per cent) were accredited for three years, 78 (3 per
cent) for between two and three years, and 225 (8 per cent) for two years or
less. Some 6 homes have accreditation for four years.
The Agency also monitors the performance of all
accredited homes to ensure quality care is provided to residents in accordance
with the Accreditation Standards. Visits to homes to monitor their performance
may be 'support contacts' or 'review audits'. The Agency also conducts some of
its visits at short notice ('spot checks').
All accredited aged care homes are subject to a regular
series of support contacts conducted by the Agency, the purpose of which is to monitor
a home's ongoing compliance with the Accreditation Standards and the Aged Care
Act. A support contact involves either a visit to the home or a telephone
contact, conducted by quality assessors. A support contact (site) generally
lasts from half to one-day and may involve an overview of the home's
performance against all the Accreditation Standards, or may be focussed on
certain aspects of care or services. A support contact (desk) is a one or two
hour teleconference between a quality assessor and the management of the home. In
2003-04, 2904 support contacts were undertaken, of which 2815 were site visits
and 89 were phone contacts.
Review audits assess the quality of care provided by a
home against the expected outcomes of the Accreditation Standards. Review audits
may be conducted if the Agency has reason to believe a home is not complying
with the Accreditation Standards; there has been a change to the home such as a
change of ownership or key personnel; or the home has not complied with the
arrangements made for support contacts. In 2003-04, 86 review audits were
conducted, and 82 decisions were made following the review audits. Of these
decisions, 44 were to vary the period of accreditation, 36 were to not vary
accreditation and two were to revoke accreditation.
The Agency also conducts random and targeted spot
checks. They can either be support contacts or review audits. A spot check is a
visit where homes are given less than 30 minutes notice. Approximately 15 per
cent (553) of all Agency site visits in 2003-04 were conducted as spot checks.
Under the Deed of Funding with DoHA,
which commenced in July 2004, the Agency is required to visit each home at
least once a year and maintain an average visiting schedule of 1.25 visits per
home per annum. These visits may either be a site support contact or review
audit (and may also be conducted as spot checks). Additional visits are
arranged where the Agency assesses that there is a need for more visits such as
a reason for concern or serious risk has been identified.
Views on quality of care
Evidence to the inquiry expressed a range of views on
the impact of accreditation on the quality of care in aged care facilities. Aged
care providers, in particular, suggested that since the introduction of
accreditation the overall quality of care standards has improved across the
industry. The Australian Nursing Homes & Extended Care Association (ANHECA)
...the introduction of the accreditation system has had a
profound effect upon residential aged care and has driven a significant
improvement in the quality of services, but more particularly, led to the
adoption within residential care services of the systemisation of quality
improvement systems within organisations leading to services incorporating
these systems within their day to day service delivery framework.
Catholic Health Australia (CHA) also recognised a lift
in overall quality of care standards across the industry as a whole, while the
Review of Pricing Arrangements in Residential Aged Care (Hogan Review) noted
that 'submissions and evidence presented at consultations indicate broad
support for accreditation. There is general acknowledgment that standards of
care and accommodation across the industry have been improved substantially by
Other submissions have, however, raised concerns about
the standards of care across the industry. The Health Services Union (HSU) noted
argued that the Agency 'is failing in its duty to ensure that an adequate
standard of care and safety is provided to elderly residents in aged care
facilities'. The Australian
Nursing Federation (ANF) also noted that many of its members have raised issues
about inadequate standards of care and inadequate staffing levels in aged care
Seniors groups raised similar concerns. COTA National
Seniors expressed concerns as to the extent to which accreditation has
contributed to high quality care for residents and real options about lifestyle
for residents. The Combined
Pensioners & Superannuants Association of NSW (CPSA) stated that the performance
of the agency 'leaves much to be desired'. The Association argued that part of
the problem is that the Agency is not set up to directly control aged care
facilities. The accreditation system gives substantial power to proprietors – 'they
are allowed considerable leeway in terms of how services are carried out'. The Association argued that the
Agency should be abolished and aged care brought under the direct control of DoHA.
Evidence indicates that there is little systematic data
that demonstrates how accreditation has impacted on quality of care. One
submission noted that the Agency has 'not produced any material which would
provide the sector or the community with any level of assurance that the
overall intention of accreditation in improving service quality has been
The Audit Office also raised this as an issue in a
recent audit report. It recommended that the Agency and DoHA
plan an evaluation of the impact of accreditation on the quality of care in the
residential care industry. This
recommendation was accepted by both the Agency and the Department and the
project is expected to be completed in 2006.
While anecdotally it appears that quality of care has
improved in aged care facilities since the introduction of accreditation, a
number of concerns were raised in evidence and these are discussed below.
Ensuring adequate standards of care
Improved accreditation processes
Evidence indicates that there is a need for
improvements in accreditation processes.
A number of criticisms of the Agency by providers and
their peak bodies were raised especially relating to the first round of
accreditation. The criticisms centered on inconsistencies between assessors'
approaches, problems with duplication in the Accreditation Kit, inaccurate
comments appearing in final reports, lack of process to correct mistakes and
inconsistency where some decisions were overturned and other seemingly similar
decisions were not.
Comments from providers during the inquiry generally
indicated that many of these problems were addressed in the second round of
accreditation. CHA noted that due to the more rigorous requirement in round two
for assessors to have evidence of non-compliance, member services found that
the process was fairer and more balanced.
Aged and Community Services (ACS) SA & NT also reported that while their
members were initially critical of the Agency and its processes a more recent
survey of members indicated 'overwhelming support for the agency and the
A number of current issues of concern were, however,
raised during the inquiry and these are discussed below.
Lack of consistency in assessments
Aged care providers, provider peak bodies and others
complained of the lack of consistency in the assessments made by different
assessors. Blue Care noted that:
...[there are] inconsistencies in the understanding and
knowledge of different auditors when applying the standards to an aged care
facility. It is important that there is a consistent approach to assessing and
monitoring the health and safety among auditors.
The HSU stated that 'even the most casual analysis of
the publicly available reports produced by the agency shows huge
inconsistencies in the level of scrutiny applied by agency inspectors and in
the reports they produce'. The HSU reported that many of its members expressed
concerns regarding the way accreditation visits are carried out and the level
of scrutiny applied by inspectors.
Submissions noted that a facility may achieve 44
satisfactory outcomes during accreditation and be accredited for 3 years.
Within months a support visit may find that the facility is non-compliant with
one or more outcomes. A finding of this nature can be difficult to explain and
demonstrates an unacceptable level of subjectivity in the process.
CHA noted that the main reason for the lack of
consistency is the Agency's approach focuses primarily on examining the systems
and processes that facilities have in place to demonstrate that they meet each
of the expected outcomes – 'as these outcomes are expressed in generalised
terms, assessment of compliance must, as a requisite, involve subjective
elements of judgement'. The HSU
commented that the vague nature of the Accreditation Standards and the lack of
guidelines contributes to the problem as is the use of less qualified contract
staff by the Agency at times of peak demand.
Submissions also argued that training of assessors needs
to be improved. The CPSA argued that the training courses for assessors are
inadequate – 'QSA's training courses for aged care assessors run for 5 days and
appear to have no pre-requisites apart from a willingness to learn. The courses
are presumably of a high standard but 5 days does seem too short to guarantee
assessors will be trained to make appropriate assessments of added care
Regarding the qualification of assessors, the Agency
conceded that there is no formal qualification requirements prior to selection
however, they stated that only persons who are registered aged care assessors
are permitted to conduct assessments. There are 362 registered aged care
quality assessors registered by the Quality Society of Australasia. Some 65 of
those assessors are currently permanent employees of the Agency. Over half of
them are registered nurses (RNs) and about 80 per cent have post-secondary
qualifications other than registered aged care assessor qualifications.
Additional contractors are used to supplement the permanent assessors,
especially during peak times. Assessors are required to successfully complete a
training course on aged care quality assessment and complete an orientation
ANHECA submitted that the Agency also needs to provide
more data analysing the effectiveness of assessors in their auditing role. The
Association noted that the Agency needs to 'apply resources to the development
of a substantially improved data mining and reporting capacity, which would
have the capacity to report on assessors and audit outcomes at an individual,
regional, state and national level'.
suggested that more consistency may require the use of benchmarking or external
The Agency noted that it is reviewing and further
developing its quality assurance measures, including:
- reviewing arrangements for the registration of
quality assessors including improved competency specifications, and revised
training and assessment program;
- introduction of internal and independent reviews
of samples of accreditation decisions and audit reports to evaluate their
conformity with Agency standards; and
- organisational restructuring including the
creation of Principal Assessor and Assessment Manager positions in each State
The Committee believes that the Agency should ensure
that there is a consistent approach by assessors at all times in conducting
assessments. The Committee notes that the Agency is reviewing and further
developing its quality assurance measures and believes that these initiatives
The Committee also considers that the Agency should
establish benchmarks against which assessors' decisions can be evaluated and
that this information should be published annually. The Committee also believes
that a significant reason for the lack of consistency relates to interpretation
of the Accreditation Standards which are expressed in very generalised terms
and therefore open to markedly different interpretations. The Committee has made
recommendations later in this chapter addressing this issue.
3.37 That the Agency ensure
that the training of quality assessors delivers consistency in Agency
assessments of aged care facilities.
3.38 That the Agency publish
data on the accuracy of assessors' decisions in conducting assessments against
Agency benchmarks and that this data be provided in the Agency's annual report
and on its website.
'Enhancement' of facilities prior to accreditation
Some submissions argued that accreditation processes
encouraged some homes to employ additional staff and generally 'tidy up' the
facility prior to the arrival of assessors which created a false impression of
the true nature of the facility and the services provided.
The HSU noted that:
Scheduled accreditation gives management the opportunity to
roster extra staff on, adjust menus and activities, and generally have
everything looking ship shape for the accreditors. However, members argue that
the standards shown off at accreditation are rarely maintained outside of
The NSW Nurses' Association also noted that members
routinely reported that 'the accreditation process is a farce as everything is
set up for the day and then disappears'.
The Nurses Board of WA similarly commented that:
Arriving as anyone would arrive to an institution, you do get a
feel of what normally happens. With the provision of notice, there is
opportunity for preparation that may not normally be done.
The Agency countered these claims stating that it
receives information from time to time about homes attempting to mislead
assessors about their compliance with the Standards by increasing staff and
doing other things before a visit – 'however in these few cases, our follow up
has failed to find evidence that supports the claims made to us'.
The Agency advised that:
Accreditation is not a one-off event...Assessors triangulate
evidence of homes meeting the expected outcomes by interviewing residents and
staff, reviewing the systems, policy and processes documentation and other
records such as care plans, staff rosters and menus etc.
The Committee is concerned, however, that the evidence
received suggests that some homes may engage in the practices described above.
It notes that complaints of this nature come from staff 'on the ground' and
therefore people in a position to know the day-to-day management practices of
homes. The Committee believes that the Agency should continue to review the
nature and extent of these practices including carefully targeted spot checks.
Improved consumer focus
Evidence indicated the need for the Agency to involve
residents and their families to a greater extent than currently occurs in the
accreditation process and also in promoting informed consumer choice.
Prior to an accreditation visit, providers must inform
residents and relatives when the visit will occur, and that residents and
relatives will have an opportunity to speak with assessors in confidence. The
Agency stated that assessors are required to meet with a minimum of
10 percent of residents or their representatives as part of the
accreditation process. When assessors speak to residents they are required to
do so in a way that does not identify residents and does not cause residents to
be identified, although the Agency conceded that 'that does not mean that an
approved provider of care might not be aware that certain residents had spoken
to assessors'. The Agency asks
providers to ensure that there is a private room or space available to
interview residents who wish to speak to assessors. Residents are often
interviewed in the privacy of their own rooms.
Residents are often not aware of their rights to contribute to
the process of accreditation or understand the level of care required to be
provided by the facilities to meet each standard.
The advocacy group noted that residents are often not
aware that meeting many of the 44 outcomes requires a facility to demonstrate a
process of consultation with residents and family members.
The Aged Care Lobby Group argued that the proportion of
residents and their families required to be interviewed by assessors should be
increased. Advocacy Tasmania
also agued that the Agency should conduct a mid-cycle survey of all residents
to assist in monitoring standards of care between accreditation rounds. COTA National Seniors considered
Residents and their families must understand the accreditation
process and be directly involved in the process not just as complainants or
informants but assessing the quality of care particularly in relation to
Standard 3: Resident Lifestyle.
COTA suggested that even the term 'accreditation' is a
difficult concept for consumers to understand:
...it is a real challenge to get the information out to the
consumer. It does get out in some way, but, from the feedback we get from
people who are going through the process of looking for a place in an aged care
facility, just the word 'accreditation' is wrong. How does the normal consumer
know what the terms 'certification' and 'accreditation' mean? As a consumer
organisation...we provide information, but still people are at a loss when it
comes to knowing about accreditation.
Submissions argued that the Agency needs to improve its
information strategies to residents and families from culturally and
linguistically diverse (CALD) backgrounds.
The NSW Aged Care Alliance noted that accreditation reports do not provide
adequate information either about care strategies or outcomes for consumers
from CALD backgrounds. Submissions
also noted that the Agency's use of interpreting services during accreditation
visits is limited.
The Hogan Review suggested that the Agency needs to
significantly improve its focus on supporting informed consumer choice and
consumer input to monitoring standards by improving direct communication with
consumers, including those with special needs. The review argued that the
Agency's website should be improved to make it more 'user friendly' for older people
and their families. The review also suggested that the Agency explore, with
consumers and the industry, a star rating system to assist consumers to more
readily compare services and to provide incentives for providers to become more
competitive in providing quality services.
The HSU strongly supported the introduction of a star rating system to improve
informed consumer choice.
The Department advised that improvements to the
Agency's website are being developed and that a prototype version has been developed.
The Commonwealth has provided $2.1 million for the development of this website
and the establishment of a rating system for aged care facilities. A working
group is currently undertaking further development work on this prototype. The
improved website is expected to be operational in early 2006. The website aims
to provide older Australians, their families and carers, with a user friendly
and comprehensive online guide to aged care services and choices. The site will
include features that will enable consumers to search for standard information
about all aged care homes in Australia,
such as location, business address, contact details, type of care provided,
number of residents and current accreditation status.
Initial work has
been completed on the star rating system and this is being developed in
conjunction with the new website to enable consumers to search for relevant information
on aged care facilities. DoHA stated that decisions have yet to be made on the
form that a star rating system could take but work being undertaken on the
development of the website is providing useful information about what consumers
are seeking to assist them in making informed choices about meeting their, or
their families', aged care needs. Research to date indicates that consumers
require a system that will allow them to find and match aged care homes against
their own personal criteria. Relevant factors include issues such as location
of homes within a reasonable distance to family/friends; whether there are
vacancies; costs involved; services offered and individualised activities
provided; staff skills at homes; information on the 'environment' of the home
such as type of room, shared or private bathrooms, security, access to gardens
etc; safety and privacy policies and practices; languages spoken; and
information related to complaints and complaints feedback.
3.55 That the Agency further
develop and improve information provided to residents and their families about
the accreditation process, including those from CALD backgrounds and Indigenous
people, and more actively involve residents and their families in the
3.56 That the Agency develop
a rating system that allows residents and their families to make informed
comparisons between different aged care facilities. The Committee notes that
work is being done on a web-based prototype; however it considers that the
rating system should not be limited to a 'star rating' but should include
easily understood descriptions of a range of attributes, such as type and range
of services provided; physical features of homes; staffing arrangements; costs
of care; and current accreditation status.
JAS-ANZ and the accreditation
Many aged care providers and peak bodies representing
the industry argued that accreditation services would be better provided by
enabling providers to select from a range of agencies as is common in other
industries, rather than through a government monopoly of these services in the
form of the Aged Care Standards and Accreditation Agency, as is currently the
Groups such as ANHECA and ACSA argued that it would be
more appropriate to bring residential care accreditation services within the
Joint Accreditation Service-Australia and New
Zealand (JAS-ANZ) framework. JAS-ANZ would be responsible for
accrediting a number of quality improvement organisations to undertake
accreditation in the residential care sector. An open contestable quality
improvement environment would also provide a further benefit to the residential
care sector. Many providers of residential care are also providers of other
services to older people, including community aged care packages, Home and
Community Care programs, retirement villages and other community based and
residential programs for the elderly and others. Under current arrangements
they are required to participate in multiple accreditation systems to cover the
whole scope of their activities. This problem would be addressed if a market in
the provision of accreditation services were allowed to be developed to respond
to the industry's wider accreditation needs.
Other providers, including CHA, did not favour this
approach. CHA argued that providers would be dealing with another party in the
accreditation/compliance processes with possibly greater intrusion and
disruption to staff time. In addition, there could be an increase in costs when
two agencies have responsibility for two separate accrediting/compliance
monitoring tasks. CHA added that:
Allowing a number of accredited certifying organisations to
compete to provide accreditation of an approved service and have responsibility
to the Government for compliance would result in even less consistency of
assessments and decisions. CHA considers that neither consumers nor the
community would accept this approach.
The Committee does not support the suggestion proposed
by several providers of allowing a range of agencies to provide accreditation
services. It believes that such an approach has the potential to lead to
greater inconsistency in assessment outcomes by involving a greater number of
organisations in providing accreditation services. The Committee also considers
that it may encourage providers to 'shop around' for a 'soft' auditor and is
not convinced that the JAS-ANZ arrangements would militate against this
Improved compliance monitoring
The need for the Agency to improve compliance
monitoring of aged care facilities between accreditation periods was raised in
evidence. As noted above, aged care facilities are subject to a regular series
of support contacts to monitor their ongoing compliance with the Accreditation
Some providers criticised the way in which support
visits are conducted by the Agency arguing that they are intimidating
experiences and did not provide the 'support' expected – in fact some argued
that the term 'support visit' was a misnomer. CHA noted that many of its
members' experience of support visits 'had not been positive' reporting that
'there was a general view that support visits have not provided any 'support'
and in fact hindered processes'.
ACS SA & NT commented that some members feel intimidated by support visits
'believing that if they do not comply, or object to the timing of the visit
there will be retribution against them by the Agency'. The organisation noted, however,
that members report more positive experiences of more recent support visits.
The Agency's post-support visit questionnaires, however,
indicate a high level of support with the role of the Agency during these
visits – with a 2004 questionnaire indicating that 96 per cent of homes
reported that is was 'a satisfying and useful experience' overall.
The Committee notes that some concerns have been
expressed by providers in regard to the efficacy of support visits. The
Committee believes that the Agency should ensure that these visits, while
monitoring compliance, also assist in providing positive feedback to homes.
As referred to previously, the Agency is required to
visit each home at least once a year and maintain an average visiting schedule
of 1.25 visits per home per annum. These visits may either be site support
contacts or review audits – and they may be conducted as spot checks.
Additional visits are arranged where the Agency assesses that there is a need
for more visits such as a reason for concern or serious risk has been
Approximately 15 per cent (553) of all Agency visits in
2003-04 were conducted as spot checks. Of the 'repeat' spot checks in 2003-04,
thirty-eight homes had 2 spot checks; eight had 3 spot checks; four had 4 spot
checks; and six had 5 or more spot checks.
Spot checks may be targeted or random. Targeted spot
checks are conducted where the Agency has reasonable grounds to believe there
may be non-compliance, whereas random spot checks are conducted where there is
no indication of risk or non-compliance. The Agency does not keep separate
statistics on random and targeted spot checks. On average approximately 10 per
cent of homes per annum will have an unannounced spot check. Table 3.1 provides the number of
spot checks undertaken by the Agency since 1999-2000.
Table 3.1: Number of spot checks undertaken by the Accreditation Agency
Number of spot checks
1999 – 2000
2000 – 2001
2001 – 2002
2002 – 2003
2003 – 2004
Source: Aged Care Standards and Accreditation
Agency, Annual Reports, (various
A number of groups argued that the Agency should
undertake more spot checks. The HSU argued that:
...members consistently argue that spot checks or checks without
notice would be more effective than the current scheduled visits. Members tell
us that often management select the staff who are to speak with the accreditors
when they come. Members advise that additional staff are rostered on and that much
effort in the weeks leading up to accreditation goes on making sure that
paperwork and documentation are up to date.
Aged care provider peak bodies acknowledged the value
of spot checks in ensuring compliance with the Standards, with Aged Care Qld proposing
a more comprehensive system of spot checks instead of organised visits.
We have talked to the accreditation agency and we have talked to
many of our people, and we think that perhaps this whole system needs to be
looked at. Perhaps we need to do away with having organised visits and instead
have spot checks. The accreditation agency would drop in at any particular time
and take the home as it is, not superprepared for the event.
Aged and Community Services Australia (ACSA), while
noting that spot checks are a valuable form of accountability, argued that the
Agency needs to improve the way in which it conducts its spot checks:
We certainly have talked to them [the Agency] about developing
more refined approaches to spot checking, to targeting, to being clear about
which visits are about providing support and training and which are in response
to urgent issues that really cannot wait...Follow-up visits are a feature of all
forms of accreditation. Certainly our advocacy of a more universal system of
applying accreditation would not be at the expense of follow-up visits of all
sorts of classes.
Aged Care Qld argued that a system of spot checks could
potentially ameliorate the heavy demands of paperwork imposed on homes under
the current accreditation system.
Evidence also indicated that more spot checks would identify possible problems in
homes, such as poor medication management, much earlier than occurs at present.
The Committee believes that spot checks play an
important role in ensuring compliance with the Accreditation Standards. It is
vital that residents and their families, and the public generally, are confident
that the standards of care assessed when homes are accredited are maintained at
all times until the next accreditation round.
believes that the current system of spot checks is inadequate and needs to be
considerably strengthened to ensure that all homes receive at least one spot check for each year that they are
accredited. The Committee considers the fact that only one in 10 homes on
average receive a spot check per year is grossly inadequate.
3.74 That the Agency ensure
that all facilities be subject to a minimum of one annual random or targeted
spot check and at least one site visit with notification over its accredited
Improving quality of care
The need to improve specific aspects of care in aged
care facilities was highlighted during the
As noted earlier, a core Agency function is the
accreditation of aged care facilities against the Accreditation Standards. The
Quality of Care Principles state that:
The Accreditation Standards are intended to provide a structured
approach to the management of quality and represent clear statements of
performance. They do not provide an instrument or recipe for satisfying expectations
but, rather, opportunities to pursue quality in ways that best suits the
characteristics of each individual residential care facility and the needs of
residents. It is not expected that all residential care facilities should
respond to a standard in the same way.
It was claimed in evidence that the Standards are too
imprecise and far too generalised to effectively measure care outcomes. The HSU
stated that the Accreditation Standards 'need to be rewritten so that they are
measurable and enforceable'. The
Aged Care Lobby Group also noted that while the Accreditation Standards assess
standards of care to some extent – 'it needs some refinement. It is too
subjective. It relies on what is written by the provider and statements by
relatives and residents.
A study by Professor
Gray also noted that:
To the extent that the Agency does not assess actual care
delivered, but infers it from the information provided by residents, staff,
families and relevant documentation, its capacity to provide objective
information around care outcomes is limited.
Issues related to the quality of care in a
range of specific areas are discussed below.
Staffing levels and skills mix
Submissions pointed to inadequate staffing levels and
poor skills mix in aged care facilities as compromising the quality of care
available to residents. The Accreditation Standards do not prescribe minimum
staffing levels in aged care facilities. The Accreditation Standards only
require that there be 'appropriately skilled and qualified staff sufficient to
ensure that services are delivered in accordance with these standards'
(Standard 1.6) and that residents receive 'appropriate clinical care' (Standard
2.4) and that residents' 'specialised nursing care needs are identified and met
by appropriately qualified nursing staff' (Standard 2.5).
The ANF noted that staffing levels and the skills mix
of staff impact directly on the workloads of nurses and ultimately on the
quality of health outcomes for residents. The ANF expressed concern that there
are increasingly fewer registered nurses (RNs) and enrolled nurses (ENs) in
aged care facilities and some high care residents in low care facilities have
very limited or no access to a health care professionals such as RNs. The ANF
also expressed concern at the practice of replacing RNs and ENs with unlicensed
carers in order to provide a 'cheaper' alternative workforce where the work
requires the skills and knowledge of either a RN or an EN.
Submissions by unions with members working in the aged
care sector pointed to evidence from their members and union surveys that show
that nurses and other health care workers do not believe that they are able to
spend enough time with residents to deliver the care that residents require;
aged care workers regularly work unpaid overtime to complete tasks; and the
excessive paperwork required places increasing demands on staff and draws them
away from their primary caring role.
A recent survey of over 6000 care staff by the National Institute of Labour
Studies confirmed these observations.
The study found that:
- only 13 percent of nurses and 18 per cent of
staff overall believed that they had enough time to properly care for
- forty per cent of nurses and 25 per cent of
allied health workers spend less than one third of their time providing direct
- almost half of all personal carers spend less
than two-thirds of their time on direct care; and
- the major complaints of staff were that they did
not have enough time to spend with residents and the facility where they worked
did not employ sufficient staff.
The HSU argued that international research establishes
a clear link between staffing levels and quality of care. A major report to the US Congress on
the appropriateness of establishing minimum staffing ratios in nursing homes in
the United States
concluded that strong evidence supports the relationship between increases in
nurse staffing ratios and avoidance of critical quality of care problems. However,
above identified nurse staffing thresholds increased staffing did not result in
improved quality. Depending on the nursing home population, these thresholds
range between 2.4-2.8, 1.15-1.30, and 0.55-0.75 hours/resident day for nurse
aides, licensed staff (RNs and LPNs combined) and RNs, respectively. Although
no significant quality improvements were observed for staffing levels above
these thresholds, quality was improved with incremental increases in staffing
up to and including these thresholds.
Some submissions, however, did not support the
introduction of minimum staffing levels arguing that appropriate care depends
on a range of variables that change frequently. The Nurses Board of WA stated
The Board gets many requests by employers to come down and make
a statement about minimum numbers. However, the Board is very much of the view
that it is the appropriate skill mix in the context of where the care is being
delivered that determines what you require at any given time. That is not
helpful to employers and it is not helpful to the staff on the floor. But the
context in which aged care is delivered is varied and it depends on a whole
range of variables.
Many submissions argued that a benchmark of care linked
to minimum staffing levels should be established. The ANF argued that a
benchmark of care which links resident outcomes, staffing levels and skills mix
to funding should be developed for inclusion in regulatory instruments. The ANF
further argued that guidelines should be developed providing for minimum
staffing levels and skills mix in aged care settings and that there be a clear
requirement for 24 hour RN cover for all high care residents in aged care
The National Aged Care Alliance also called for the
establishment of benchmarks for staffing levels and skills mix, which meet duty
of care requirements; achieve optimal health and quality of life outcomes for
residents; and provide flexibility at the local level to be able to respond in
a timely manner to changes in the care needs or the way in which care is
The Liquor Hospitality and Miscellaneous Union (LHMU)
also argued for a national benchmark of care. This would encompass all aspects
of care, including establishing minimum staffing levels and skills mix in
delivering care. The benchmark of care, which would be fully costed, could be
used as the tool to determine the funding that the government provided for
The HSU also argued for the introduction of minimum
staffing levels that should only be introduced after a process of industry
consultation that involved providers, staff and residents – 'they would not be
a one size fits all but a regulated minimum number determined by resident needs
and acuity' involving a mix of nurses and personal care assistants in caring
for residents. The HSU added that:
Those minimum staffing levels need to be flexible so that they
can be adjusted for the particular care plans and circumstances of each
facility. But underlying that there has to be a stage when government says:
'One person looking after 73 residents at night when 43 of them are high care
is not something that as taxpayers we are going to fund'.
The HSU argued that the regulatory requirements for staffing,
stripped away by the current government, need to be re-introduced and
significantly extended – 'minimum staffing levels covering all care and
ancillary staff are the only way to provide a basic guarantee of care and
safety for residents and their families'.
CHA also proposed a quality of care compact based on an
agreed level of care which commits government, providers and staff to achieve
specific care results for the frail and sick. A key component would be the
establishment of an aged care benefit schedule to modernise government care
subsidies and to deliver appropriate support to the frail elderly. CHA stated
...a compact would include a commitment to introducing a benchmark
of care which is fully funded by government and provides clearly defined levels
of service. It is linked to the benchmark. There needs to be a commitment of
funding to ensure appropriate staffing levels are in place for facilities,
depending on their size, and the resident profile. The benchmark of care needs
to take into account all aspects of a person's needs: physical, emotional,
social and spiritual.
CHA further explained how the benchmark of care would
Under the benchmark of care approach, what we would be saying is
that there are certain dependency levels and clinical groupings of care need
for residents. When you have a group of residents that are in a similar care
cohort or casemix, then you really need a mix of staff to meet that care need
for that particular casemix of residents.
Evidence to the inquiry indicated that quality of care
for residents in aged care facilities could be improved by the introduction of
greater regulation in relation to staffing levels and skills mix in aged care
facilities. Many submissions argued for the introduction of a benchmark of care
or a quality of care compact that links resident outcomes, staffing levels and
Evidence indicates that the introduction of such a system
would ensure that realistic staffing levels are in place in aged care
facilities. The Committee believes, however, that such a system would need to
be sufficiently flexible to take into account the changing needs of residents.
3.93 That the Agency, in
consultation with the aged care sector and consumers, develop a benchmark of
care which ensures that the level and skills mix of staffing at each
residential aged care facility is sufficient to deliver the care required
considering the needs of the residents. The benchmark of care that is developed
needs to be flexible so as to accommodate the changing needs of residents.
Access to medical and allied health
Submissions referred to the difficulty in attracting
doctors and other health professionals to attend to the medical needs of
residents in aged care facilities. The Australian Society for Geriatric
Medicine (ASGM) noted 'older people in residential care facilities are
significantly disadvantaged and have poor access to both basic medical care and
specialist medical care'. The
Australian Medical Association (AMA) noted that only 16 per cent of GPs are
visiting nursing homes on more than 50 occasions a year – that is once a week.
The AMA noted that disincentives for health
professionals in providing care in nursing homes included lack of remuneration,
a deficient rebate structure for doctors, the absence of appropriate MBS items
for geriatricians, the large amount of paperwork required by aged care
facilities and the absence in many facilities of consultation rooms with
adequate treatment facilities and computer facilities to facilitate access to
patient records. Witnesses
commented that the Aged Care GP Panels Initiative announced in November
2003, which aims to improve access to primary medical care for residents of
aged care homes, has only been successful in some areas in attracting GPs to
aged care facilities either because of the shortage of GPs in general and a
reluctance by some GPs to provide services in nursing homes.
The ASGM noted that few geriatricians or other
specialists are prepared to work in aged care facilities and pointed to the
fact that a GP assessment in a facility is now remunerated at a higher level
than a complex, comprehensive specialist geriatric assessment. In addition,
there are few geriatricians who consider residential care their area of
particular interest in geriatric practice. The ASGM noted that 'the best models
of care focus on a multidisciplinary approach to care, with allied health,
nursing and medical practitioners working together. That does not happen in
this country in residential care'.
Residents in aged care facilities are required to have
access to a range of specialist care including speech therapy, podiatry,
occupational care and physiotherapy. The Accreditation Standards state that
residents be referred 'to appropriate health specialists in accordance with the
resident's needs and preferences' (Standard 2.6), although evidence indicated
that there are huge variations in the quality and provision of these services. The
Australian Physiotherapy Association (APA) expressed concerns that the Agency
places insufficient emphasis on ensuring the presence of preventive programs and
that therapy is properly provided in facilities. The APA noted that some aged
care facilities that advertise a comprehensive physiotherapy service do not
employ sufficient physiotherapists to provide this service. The Australian Psychological Society
called for the increased use of psychologists in aged care facilities
especially in the areas of mood and anxiety problems and physical disorders.
The Society argued that psychologists have little current role in aged care despite
the effectiveness of psychological interventions in these situations.
The provision of adequate dental care was also cited as
a problem in aged care facilities. The Accreditation Standards require that
residents' 'oral and dental health is maintained' (Standard 2.15). The Aged
Care Lobby Group noted that 'oral care is often lacking and as a
follow-on...there are dental problems' for residents in homes. The CPSA also noted that studies
have reported poor dental care in nursing homes and commented that this
situation was 'not exactly a glowing testimony to the way accreditation is
A number of issues in relation to medication management
were raised in evidence including significant problems regarding medication use
in aged care facilities. These include selection of management options,
prescribing decisions, administration and use of pharmaceuticals and the lack
of ongoing review and follow-up of residents.
The Accreditation Standards provide that residents' medication 'is managed
safely and correctly' (Standard 2.7). The Australian Pharmaceutical Advisory
Council's Guidelines for Medication
Management in Residential Aged Care Facilities (2002) provide guidelines
about improving the quality use of medicines in aged care facilities. It was suggested
that, while the facilities pick up on those guidelines as part of the
accreditation process, 'there are very major gaps...between what is recommended
in guidelines and what actually happens in practice'.
There was evidence to suggest that medication is used
in some aged care facilities to deal with a range of behavioural and other problems
that could best be dealt with by other approaches. The Australian Society for
Geriatric Medicine noted that:
The problem of polypharmacy and drug use is a very serious and
significant one in residential care facilities, and in part it comes from the
ignorance and skill mix of those who provide care. The answer to behavioural
problems in patients with dementia, for example, is not to give them
antipsychotic medications but to put in pace appropriate behavioural and
One submission also pointed to studies that show CALD
residents with dementia in generic aged care facilities are often over
medicated with sedatives, although this is a less serious problem for CALD
residents in ethno-specific facilities.
The ASGM suggested that medication use in aged care
facilities could be improved if a multidisciplinary approach was adopted
involving doctors, nursing staff, geriatricians, with pharmacy input 'in order
to help work out what is the best evidence in terms of treatment approaches...we
have really fallen short of having a proper multidisciplinary approach to
The issue of the relative effectiveness of different
medication systems was raised in evidence, especially possible means of
streamlining the process. The Centre for Research into Aged Care Services
conducted a study into a comparison of two types of medication administration
systems, particularly in terms of the time and resources involved in the two
systems. One was the traditional dosette box and the other was the computerised
sachet. The study found that with the computerised delivery system 'there were
fewer errors, there was more confidence with the people dispensing the
medications and they were able to move away from the big trolley and all that
stuff that takes up time'.
Advocacy groups and others commented on the poor
standard of food in some aged care facilities, although these groups could not
provide substantive evidence of the extent of the problem throughout the
industry. The Dietitians
Association of Australia stated that the Agency in recent years has given
increasing attention to nutrition standards in aged care facilities and more
dieticians are now employed directly by facilities than in the past.
Complaints to the inquiry included poor quality of the
food, lack of variety, and lack of fresh food in some facilities. Poor
nutrition can lead to a range of health problems. The Accreditation Standards
merely require that residents receive 'adequate nourishment and hydration'
of good quality food for residents was emphasised by the Aged Care Lobby Group:
Most people never see fresh fruit in a nursing home unless it is
brought by relatives. For elderly people, and for us all, food is a celebration
and we hang our day on what we are going to have...That is one of the real
pleasures that most aged care facilities do not provide.
Groups argued that that Standards in relation to food
and nutritional care need to be further defined or enhanced. The Aged Care Lobby Group suggested
that a committee should be established to assess the nutritional needs and types
of food that should be available in homes.
The Dieticians Association also argued that the Agency should consult with the
profession on continuous improvement in assessment and review processes of the
Submissions noted the lack of accessible and affordable
transport options available to people in residential aged care.
NCOSS, in a report on the transport needs of people in
aged care facilities in NSW, found that:
- most residents relied on family and friends as
their primary source of transport support;
- a third of residents reported having no
significant access to family and friends and thus great difficulty in accessing
- many residents would prefer to use transport
services more often to travel to appointments and outings;
- a major barrier to travel for many older
residents was the lack of an accompanying escort;
- people from CALD backgrounds were unlikely to
use transport services other than family;
- there were significant inequities in access and
eligibility to subsidised taxi transport; and
- many facilities had great difficulty in
providing available, affordable and accompanied transport services for
The NCOSS study recommended that more information needs
to be provided to residents on their rights in relation to transport and the
options available upon entry to nursing homes and that this information be provided
on an regular ongoing basis; that additional funding be available for the taxi
subsidy scheme and that the eligibility criteria for the scheme be expanded;
and that a more coordinated approach be adopted for the effective use of
existing transport resources.
The NSW Aged Care Alliance noted that, while aged care
providers carry some responsibility for providing transport services to
residents, current funding levels do not adequately cover the costs of
providing residents with appropriate transport options. NCOSS proposed the introduction of a
residential aged care transport supplement. This supplement to be funded by the
Commonwealth – and be similar to other supplements under the Aged Care Act –
would provide a dedicated funding allocation towards transport support for
people living in aged care facilities.
Needs of people from culturally and
linguistically diverse backgrounds
Submissions and other evidence from groups representing
people from culturally and linguistically diverse (CALD) backgrounds argued
that the Accreditation Standards do not adequately address the needs of
residents from these backgrounds. Fronditha Care noted that:
The current regulatory framework...is deafening in its silence on
the importance of language and cultural identity, to service delivery and the
experience of CALD elders.
The projected demographic profile of Australia's
CALD population indicate significant increases in demand for aged and community
services over the next 20 years. Currently the number of elderly from CALD
backgrounds is 20 per cent of the population aged 65 years and over. This is
projected to increase to 23 percent, or almost a quarter of the aged population
65 years and over, by 2016.
Submissions noted that only one of the 44 expected
outcomes makes reference to cultural identity (Resident Lifestyle Standard 3.8)
and there is no mention at all in relation to language and the importance of
communication in the residents' own language. One witness cited the example of
elderly Greek-speaking women in their mid-80s who speak very little English:
They are in a mainstream nursing home for 24 hours a day, 365
days of the year...how does this elderly person connect with their carers and
with the social system that forms that nursing home or hostel? If you do not
have the language and if you do not share a common sense of history, values,
music or food...then it is an extraordinarily isolating experience.
Submissions also noted that often the Agency assessors
do not utilise interpreting services during their assessment visits to
facilitate effective communication with residents who do not speak English and
therefore argued that they would be unable to obtain adequate feedback from
residents as to whether their needs are being met.
The Agency stated that when visiting services that
cater for specific, or large numbers of CALD residents, 'it may be appropriate'
to engage the services of a translator to assist assessors to communicate
effectively with residents. The decision to engage a translator rests with the
local State manager and will be based on information collected regarding the
dominant cultures and languages used in the service. It may also be appropriate
to discuss the need for a translator with the provider at the service. The
Agency noted that 'it is not practical' for it to provide a translator for
every cultural group or language group in a particular service.
Submissions and other evidence argued that the
Accreditation Standards need to address the needs of CALD residents in the
- Cultural diversity needs to be effectively
addressed across all the Standards, as all are relevant in meeting the full
range of individual care and health needs of CALD residents.
- Specific expected outcomes need to be introduced
relating to the language and communication needs of CALD residents.
- Agency auditors should be trained in cultural
competency in aged care service provision. 'Cultural competence' refers to the
ability of an individual to function effectively in cross-cultural situations
taking into account the culture, lifestyles and experiences of the particular
individuals with whom they are interacting.
- The Agency should develop and utilise standard
cultural competence assessment tools.
- A designated position to represent CALD
residents should be created on the Board of the Agency.
Regarding the qualifications of assessors, the Agency
stated that some registered assessors do have specific knowledge or language
skills for certain CALD groups – 'whenever possible these assessors should be
used as part of a team'. Cultural factors, language and ethnicity is included
in the attributes identified for quality assessor registers. The Agency also
maintains its own list of staff who speak a language other than English.
Needs of Indigenous aged people
Evidence indicates that the needs of aged Indigenous
Australians are currently not being met in many aged care facilities. Some
witnesses called for the construction of more Indigenous-specific aged care
facilities in areas of large Aboriginal populations or the construction of
specific wings in local nursing homes in other areas. There are only two
Indigenous-specific residential care facilities in NSW.
Evidence pointed to the need for culturally appropriate
residential aged care that is conveniently located. One witness noted that:
We have a lot of people out west [of NSW] who want – who need –
to go into residential care and just cannot access to it, because it means
leaving their homes, their regions and their families. Aboriginal communities
and Aboriginal people do not particularly want residential care anyway, but
when we get to the point where we need it, we would like to be able to have
something that is culturally appropriate, that is close by and that has
Aboriginal workers providing that care.
Evidence also emphasised the importance of Indigenous
staffing of aged care facilities:
Aboriginal staff actually address a lot more issues than just
carrying out their required duties – it entails the emotional care of our
elders, which no non-Aboriginal person with any amount of cultural awareness
can address. There are also our historical conversations, if you like – some of
our elders with dementia go back to things that happened in the past.
Aboriginal people are much more empathetic...and we deal with it much better.
Witnesses also commented that where non-Aboriginal
staff are employed they should be trained in cultural competency and be aware
of cultural issues relevant to Indigenous aged people.
Conclusion – how effective are the
Evidence indicates that in a range of areas from
medication management to access to medical services there are significant
problems in the provision of services to residents in aged care facilities.
It was suggested in evidence that the Accreditation
Standards are failing to measure areas where care is clearly deficient. The
Committee believes that the Accreditation Standards are too generalised to
effectively measure care outcomes. The wording of the Standards necessarily
lead to varying levels of service being provided in homes because the Standards
are open to widely different interpretations by proprietors and assessors. The
Committee believes that the Accreditation Standards need to be defined more
precisely so that standards of care in aged facilities can be delivered – and
measured – in a consistent manner across all aged care facilities.
3.125 That the
Commonwealth, in consultation with industry stakeholders and consumers, review
the Accreditation Standards to define in more precise terms each of the
Expected Outcomes and that this review:
- address the health and personal care needs of
residents, especially nutrition and oral and dental care; and
- include specific
consideration of the cultural aspects of care provision, including the specific
needs of CALD and Indigenous residents.
3.126 That the Agency make
greater use of interpreters during accreditation visits to aged care
facilities, especially those facilities that cater for specific or predominant
numbers of CALD or Indigenous residents; and that assessors be trained in
cultural competency as part of their formal training courses.
A number of complaints mechanisms operate for people
concerned about possible breaches of a provider's responsibilities under the
Aged Care Act. All aged care services are required to establish an internal
complaints system. The Aged Care Complaints Resolution Scheme (CRS) also
operates to enable people to formally raise concerns about aged care services. DoHA
also funds aged care advocacy services in each State. These services provide
independent advocacy and information to residents of aged care services and
Complaints Resolution Scheme
The Complaints Resolution Scheme enables people to
raise concerns about aged care services funded by the Commonwealth Government,
including Community Aged Care Packages (CACPs), residential care and flexible
services. The Scheme is based on alternative dispute resolution principles and
provides an opportunity to both parties to address a grievance in a way that
enhances or rebuilds the relationship between the provider, the care recipient
and their family. The Scheme, which is free, offers a means of making a
complaint, independent from a residential facility. Complaints can be made
verbally or in writing and can be dealt with in an open, confidential or
anonymous basis. A national toll free number is available to ensure people have
access to the scheme.
Resolution processes under the Scheme include
preliminary assessment which is handled by complaints resolution officers prior
to the acceptance or non-acceptance of a complaint; negotiation is managed by complaints
resolution officers; mediation is conducted by qualified, external officers;
determination of complaints is conducted by committees, which are constituted
of independent members with skills in aged care and complaints resolution,
where complaints cannot be resolved through negotiation or mediation; and
determination review and oversight of the Scheme is conducted by the
Commissioner for Complaints.
The Scheme is administered by DoHA.
The Commissioner for Complaints has a statutory requirement to oversight the
effectiveness of the Scheme. The Commissioner also deals with complaints about
the operation of the Scheme; manages the determination process; and promotes an
understanding of the Scheme.
As noted above, all aged care services are required to
establish an internal complaints system and advise care recipients of any other
mechanisms available to address complaints as well as providing such assistance
as the care recipient requires to use those mechanisms.
suggested that the internal complaints system is less than satisfactory while
other evidence suggested it operates effectively. The Aged Care Lobby Group
noted that 'some homes have very good internal complaints mechanisms which make
it unnecessary to go to the complaints resolution unit'. The Group noted, however, that in
some instances family members have found the internal complaints system
In 2003-04, the CRS received 967 complaints. This
represents a 21 per cent reduction in the number of complaints over 2002-03. The
Commissioner for Complaints argued that the principal reasons for the decline were
the increased use of internal complaint mechanisms and ongoing refinement in
the practices adopted by the Scheme.
The Committee notes, however, that statistics are not kept on the number of
The majority of complaints (97 per cent) related to
residential aged care services and 3 per cent related to CACPs. Relatives
lodged the majority of complaints (67 per cent). Nine per cent of complaints
were lodged by staff, while care recipients lodged eight per cent of
complaints. Some 126 complaints (13 percent) of all complaints were not
accepted by the Scheme. A complaint may be refused if it is frivolous or
vexatious; the matter is subject to legal proceedings; or there is an
alternative way of dealing with the subject matter of the complaint and the
complainant agrees to have the matter dealt with in that way. The majority of
complaints are resolved by negotiation and/or referral, 2 per cent through
mediation by an independent mediator, and 3 per cent are finalised by a
determination by a committee.
The nature of complaints are becoming more complex and
multifaceted. Complaints have changed from concerns about single issues such as
laundry, cleaning and catering to more intricate issues such as security of
tenure, clinical care, medication, resident safety and communication and
management. The main complaint issues raised in 2003-04 were health and personal
care (300 complaints), consultation and communication (240), physical environment
(180), choice and dignity (170), personnel (150) and medication management (100).
Concerns with the Complaints
A number of concerns were raised in relation to the
operation of the Scheme. Submissions argued that the complaints mechanisms
often do not work in the interests of consumers, and the mechanisms are
unclear, unnecessarily complex and in some cases complaints are actively
Evidence indicates that the CRS needs to become more
accessible and responsive to consumers.
The Committee received an example of a concerned
citizen who tried to make a complaint about an incident at a nursing home and
found the whole process extremely harrowing.
...[I] wrote to the Department of Health and Ageing. I got a
standard reply, saying, 'Please go to the Aged Care Complaint Resolutions Scheme'.
The standard letter – everything was standard. I rang the number. It was one of
those 'you want this, buzz number 1 or 2', and I thought, 'If I were an NESB
person I would probably not have a clue how to do that.' I finally got onto that,
and again they were saying, 'You have to get onto the mediation action.' I
said: 'No, I am not a relative of the nursing home resident or anything. I am
just a concerned member of the public.
NCOSS noted that instances such as the above are not
The very strong message that NCOSS gets from the Aged Care
Alliance consumer groups is that the complaints mechanism is not accessible to
people and not responsive. There are some disjoints between making a complaint,
how that goes through the scheme, whether or not it gets to the agency...and then
how that is enacted.
The Aged Care Lobby Group argued that family members
have given up complaining to the CRS because the overall impression is that
'their complaints are trivialised or are made by an over-fussy, neurotic or
guilt-ridden family member'. The Group also complained that anonymous complaints
are not treated as seriously as other complaints. DoHA
conceded that due to the nature of these complaints there can be no ongoing
two-way communication with the complainant to provide feedback about their
complaint, although they may be used to illustrate in a general sense
Evidence suggests that complainants have difficulty
getting complaints accepted by the CRS. Submissions noted that complaints made
to the CRS have not been accepted because documentation and staff reports have
not been available to substantiate a breach of standards. The CRS can accept complaints about
any aspect of aged care which may be a breach of an approved providers responsibilities
under the Aged Care Act. The Commissioner of Complaints noted that a
preliminary assessment of a complaint is made to determine whether or not the
complaint is to be accepted. This assessment is made on the information
available and a complaint is accepted only if 'sufficient information' is
provided in relation to the complaint. Moreover, the CRS must be satisfied that
accepting the issue as a formal complaint is the best way to handle the
explained this process and the frustration that it causes complainants:
The process is that they will then take the complaint to the
home and there will be an investigation. Because there is an allegation, there
is not automatically a complaint in a technical sense. That whole thing does
not make any sense to consumers – if you have a complaint, it is a complaint –
and it is very difficult to explain that technicality to people. So they go
along and investigate what has been said. Of course they go to the home and ask
about the incident and they look in the documentation....It boils down to one
person's word against another, and because nothing in the documentation seems
to suggest that this [incident] happened then there is no complaint. The
complainer is told, 'Sorry, your complaint is not accepted'.
Evidence suggests that the number of complaints would
be considerably higher if the CRS did not use such strict criteria for
accepting complaints – in effect the CRS 'culls' the number of potential complaints.
This also has the effect of discouraging many potential complainants from
As noted above, some 13 per cent of all complaints
lodged in 2003-04 were not accepted by the Scheme. The rate of non-acceptance
of complaints was 33 per cent in the Northern Territory,
31 per cent in Tasmania, 26 per
cent in Victoria,
8.5 per cent in Western Australia,
5.2 per cent in the ACT, 3 per cent in NSW and 1.9 per cent in South
Australia. In Queensland
all complaints lodged were accepted.
Witnesses also expressed dissatisfaction with the
mediation process arguing that in many instances it is difficult to mediate,
especially when serious incidents are involved, and often complainants are not
given sufficient support.
...you cannot mediate about some things. It depends on the actual
incident that has happened...Mediation is fine if there has been some behaviour –
[for example] someone being nasty. Ideally it should be recognised that that
did happen and there should be some acknowledgment of the fact that it
happened...mediation is not always satisfactory, and unless people are supported
it can be extremely intimidating.
It is rather difficult to mediate with your jailors. If the
climate in a particular home is more concerned with matters other than the care
of the elderly then it is very hard to bring about change.
Submissions also argued that complaints about care are
not necessarily passed on to the Agency by the Scheme unless they are serious
or relate to a facility about which persistent complaints have been received. DoHA
noted, however, that all complaints are passed on to the Agency some
individually, in the case of serious complaints, and others collectively in the
sense that they may indicate broader trends or problems within facilities.
pointed to the need for whistleblower protection so that staff can report
inadequate standards of care without rear of reprisal. The ACT Disability, Aged & Carer
Advocacy Service (ADACAS) noted that many complaints schemes and similar bodies
charged with the investigation of community concerns include protection for
people who reveal information which identifies deficiencies in systems, or
alleged criminal activity by individuals.
Concern was also expressed about the apparent overlap
of complaints schemes and the feeling that complainants are 'shunted' from one
agency to another. As one witness noted:
In our case we have exercised all available complaints processes
at state and Commonwealth levels about the serious situation of poor care and
abuse. Two years after the completion of those processes our situation is
actually worse than when we began. So we think our case is valuable in the
sense that we are a rare test case of just how well the current system works.
Independent complaints agency
A number of submissions argued that due to the
inadequacies of the CRS an independent complaints agency should be established.
NCOSS argued that such an agency should:
- provide an accessible avenue for complaints and
identify sector trends;
- report publicly and use transparent and
- respond to the specific needs of people from
culturally and linguistically diverse backgrounds and Indigenous Australians;
- involve independent advocacy at individual and
systemic levels; and
- establish a transparent relationship with the
The LHMU argued that an aged care ombudsman should be
established to provide transparency and accountability in the management of complaints.
The ombudsman would also have a role in educating residents, families and the
broader community about the rights of older Australians receiving aged care
Evidence to the inquiry suggests that there are
deficiencies with the operation of the Complaints Resolution Scheme. Concerns
were expressed that the Scheme is not accessible nor sufficiently responsive to
the needs of consumers, and the complaints mechanisms are unclear,
unnecessarily complex and in some cases complaints are actively discouraged. The
relatively high non-acceptance of complaints by the Scheme would indicate that
there are grounds for concern.
While some evidence argued that an independent
complaints agency should be established to improve the transparency and
accountability of the complaints mechanism the Committee is not convinced that such
an agency would necessarily address the concerns raised during the inquiry. The
Committee therefore favours a reform of the current arrangements.
The Committee also considers that whistleblower
legislation is required for those people wishing to disclose inadequate
standards of care in aged care facilities.
3.154 That the
Commonwealth review the operations of the Aged Care Complaints Resolution
Scheme to ensure that the Scheme:
- is accessible and
responsive to complainants;
- provides for a
relaxation of the strict eligibility criteria for accepting complaints;
- registers all
complaints as a complaint, with the complaints being categorised by their
degree of severity, such as moderate level of complaint, complaints where
mediation is required or where more significant levels of intervention are
- provides that the
mediation process is responsive and open and that sufficient support for
complainants is provided in this process.
3.155 That the Commonwealth
examine the feasibility of introducing whistleblower legislation to provide
protection for people, especially staff of aged care facilities, disclosing
allegations of inadequate standards of care or other deficiencies in aged care
presented during the inquiry detailing the fear of, or instances of, actual
retribution and intimidation of residents and/or their families if residents or
their families complained about conditions in homes or the quality of care. One
submission noted that 'the scope of the issue is difficult to determine. Its
very existence means people are afraid to report it, disclosing it only when they
feel safe to do so. They may remain silent, even though significant efforts are
made...to inform people of their right to complain'. Information indicated that
retribution or threats could occur in a number of situations, for example,
staff against residents, management against residents or management against
The types of retribution of residents are varied and include:
- being embarrassed or humiliated in front of
- being forced to conform to routines;
- being called a 'dobber' if they complain;
- not encouraged to participate in activities;
- not being allowed to sit with friends at the
- having personal items removed from their rooms;
- staff becoming less friendly, more formal with
- being shouted at and abused by staff; and
- any form of bullying or harassment.
Some indication of the extent of retribution was
provided during the inquiry. In the ACT, the Disability, Aged & Carer
Advocacy Service (ADACAS) reported 55 instances of actual retribution in aged
care facilities from 2001-2004. Of the 23 homes in the ACT retribution was
reported in 13 homes – almost half of all homes in the ACT. In nine homes
the retribution reportedly came from management; in six it came from staff and
in two it came from both management and staff. In five homes the number of
reported cases of actual retribution was high, ranging from four to 10 cases.
In the other nine homes, the number of cases ranged from one to three instances. In relation to the ACT, in 2003-04,
the CRS dealt with four cases which raised the issue of real or potential
retribution. All four of these complaints have been finalised.
The Committee questioned the Service as to whether
retribution was part of an entrenched management culture in the aged care
industry. The Service stated that this was not the case adding that where
management is involved in cases of retribution – 'I would see that as a
systemic issue within those particular homes. The others may be isolated'.
The Committee pursued this issue during the hearings in
other States. In South Australia,
the Aged Rights Advocacy Service stated that it provides advocacy services to
an average of 800 people per year through its residential care program with
another 300 people seeking information about their rights as consumers.
Retribution or fear of retribution is raised in approximately 15-20 percent of
these contacts. The Aged Care Lobby
Group in South Australia also
noted that 'fear of reprisal and victimisation is a very real fear in nursing
homes, particularly in smaller ones owned by some of the private providers'.
noted that it only receives 'a handful of actual instances of retribution' a
year, but added that this 'is not the same as the number of people who fear
retribution'. The group also noted
that residents and family members often fear retribution if they speak to
assessors with concerns during accreditation visits.
ADACAS stated that all State and
Territory advocacy groups have reported to the Service instances of actual
retribution in their respective jurisdictions.
The CPSA stated that the low proportion of complaints to
the CRS by residents compared with relatives 'does indicate that intimidation
could be a factor' – 'nursing home residents have to put up with any possible
retribution. Relatives do not'.
The issue of retribution in aged care facilities was
highlighted by the Commissioner for Complaints in a recent annual report.
Many discussions with relatives and friends of care recipients
reveal an obvious and pervasive attitude – one where there is an expressed
anxiety not to make a fuss, not to complain, not to inquire too often and not
to be noticed for fear that it would reflect badly on their relative and lead
to some kind of retribution.
While advocacy and other groups argued that retribution
is a problem in nursing homes, providers and unions representing workers in the
aged care sector suggested that it is not a significant issue, although the
fear of retribution may be an issue.
The ANF stated that the issue 'is not something that we
would ever condone at all and it has come up from time to time. Sometimes it is
more a fear than something that actually happens' but the union stated that it
was not a significant problem in aged care facilities. The ANF submitted that it was not
raised in recent phone-in surveys in relation to issues in aged care nor in surveys
conducted in the union's journal. The AMA also indicated that it was not aware
of any reports of intimidation of residents or their families made to its
Providers indicated that they were not aware of
retribution being a significant problem in homes. A representative of ACSA
...I have heard no instance of bullying or intimidation by providers
of residents or their families...I meet quite regularly with the residents'
rights association. We sit on the same committees and so on. No-one has raised
that issue with me.
noted that residents 'may have a fear of retribution and it would never be
actualised, but the fear is enough if you are on your own and do not have a
choice. The biggest challenge is really creating an environment for people to
feel safe to raise the point'.
Another provider noted that 'we would love to think that we could eliminate
that perceived fear. Certainly, I am not aware that anybody would actively
pursue that sort of retribution. We are very aware, and want to act immediately,
if there is any suggestion that any of our staff may be acting inappropriately
in how they care for and respond to the care needs of a resident'.
Advocacy groups stated, nevertheless, that there needs
to be an investigation to identify the actual level of retribution in aged care
homes. The groups also proposed that a national strategy for the elimination of
retribution, and fear of retribution in aged care facilities, should be
implemented involving all stakeholders. ADACAS noted that a national strategy
should identify and trial ways of eliminating the fear of retribution and
identify and implement ways to eliminate actual retribution.
advised the Committee that the Department and the Commissioner for Complaints
have met with ADACAS to seek their views on options for addressing the issues
of actual and perceived fear of retribution. Since then the Department has
sought and received feedback from ACT-based homes. The Commissioner for
Complaints has also undertaken a project to review available literature and
evidence and identify strategies that could be considered; and in May 2005 the
Aged Care Advisory Committee, the major forum for consultation with the aged
care sector, considered these issues – industry groups have agreed to consider
specific initiatives to address both any incidence and perceptions around this
issue in aged care homes.
Evidence to the Committee pointed to instances of retribution
and intimidation of residents in aged care facilities and their families across
many States. The Committee found this evidence particularly disturbing and
reprehensible as these practices prey on particularly vulnerable people and cause
obvious concern to the families of residents some of whom may themselves be
victims of intimidation.
was unable to form a view as to the possible extent of the problem. The Committee
believes, however, that there needs to be a comprehensive investigation of this
issue to determine how widespread it is and the extent to which it represents
an entrenched culture in aged care facilities or sectors of the industry. The
Committee believes that the review should also examine the feasibility of
introducing a national plan of action to address this issue should the problem
be found to be extensive across the industry.
3.173 That the Commissioner
for Complaints conduct an investigation into the nature and extent of
retribution and intimidation of residents in aged care facilities and their
families, including the need for a national strategy to address this issue.
Promoting education and training
One of the functions of the Agency is to promote high
quality care, and assist the industry to improve service quality, by identifying
best practice and providing information, education and training to the industry.
The Agency's underlying philosophy for education is that high quality care will
be promoted through a combination of education and accreditation activities –
'neither strategy alone will bring about sustained improvement in the sector'.
Promoting best practice
The Agency seeks to promote best practice through a
number of means, including:
- internal identification of best practice –
Agency assessors report examples of better practice and where the Agency
considers the practice warrants wider distribution, the provider is contacted.
- articles in the Agency's quarterly newsletter, The Standard, on better practice – the
Agency's publication regularly showcases facilities willing to share their
better practice systems and processes.
- Better Practice events – programs on better
practice have been held in several capital cities and other centres.
- Better Practice compendium – the compendium
showcases some of the homes that achieve an Agency higher award.
- Higher awards – homes achieving a higher award are
showcased on the Agency website.
The Agency's efforts to promote best practice have been
generally viewed favourably. One witness commented that the Better Practice
events have been seen 'in a very positive light' by participants. One industry peak body noted,
however, that the seminars did not involve formal consultation with the
industry, but relied on the practices demonstrated by those facilities which
had been awarded meritorious or commendable ratings by the Agency.
Some areas for improvement were, however, suggested. CHA
argued that the Agency should develop a standard evidence-based approach to
defining what is actually 'best practice' in aged care. Blue Care argued that the showcasing
of best practice initiatives should be an ongoing process rather than at the
end of an extensive round of accreditation.
argued that the Agency should provide aggregated information about the best approaches
to improving the quality of service provision in facilities. While facilities
seek to continuously improve standards, improved access to annual comparative
information on successful ways of operating would be helpful. Benetas noted that the identification
of best practice by the Agency remains 'elusive' but inroads are being made
through evidence based practice and other key initiatives.
Education and training
The Agency provides a number of education and training initiatives.
- Seminar series – the Agency conducted a seminar
series for the industry Turning Data into
Action in 2003. Some 68 seminars were conducted in capital cities and rural
and regional areas, with 1507 participants attending.
- Self-directed learning packages – these packages,
on the Agency web-site, cover self assessment, continuous improvement and data and
- Assessor and provider resource material – the Audit Handbook for Quality Assessors and Results and processes in relation to the
expected outcomes of the Accreditation Standard handbook are available on
the Agency web-site. These provide information about the Accreditation Standards
and how the assessments are undertaken.
- Agency newsletter – the Agency's newsletter, The Standard, is distributed nationally
to industry and other stakeholders.
- Education during support visits – education
sessions are available – delivered by trained Agency staff – as part of support
- Satellite television – the Agency is conducting
a pilot to evaluate the use of satellite television as a medium for delivering
training particularly to remote sites.
- Consumer education – the Agency conducted 40
information sessions directed at residents and relatives across Australia in
2004. Some 1169 people attended these sessions.
- Presentations at industry conferences.
The Committee received a variety of views on the
appropriateness of the Agency's education and training role. Some provider peak
bodies noted that there was a potential conflict of interest in the Agency's
dual roles of monitoring compliance in addition to promoting quality
ANHECA noted that:
...[we] see no difficulty with an agency that purely has quality
improvement as its objective, undertaking this role. However, an organisation
that also has a large compliance role is not able to effectively do this as the
industry will not seek advice and support from an organisation, that the next
day can be 'inspecting' its services and ensuring compliance.
ACS of NSW & ACT also noted that education is not
the Agency's core business and there are other better qualified organisations which
could fulfil this role for the industry.
The Hogan Review also argued that the role of the
Agency should be directed primarily to accreditation services and the
dissemination of accreditation results. The review questioned the expansion of
the Agency's education role to compete in areas of staff training where there
are other competent providers. The review also questioned the appropriateness
of an agency tasked with evaluating performance also being a major source of
training relating to performance.
Other provider peak bodies, however, supported the
Agency's education role. CHA argued that if the Agency took on a purely
'policeman' role it would create a 'them and us' situation between the Agency
which would be counter-productive. CHA added that:
The Agency gains a significant amount of information from the
auditing and compliance processes. Sharing this information is a valuable way
for the industry to learn about 'best practice' in quality management and to
gain from their peers.
CHA in a survey of its members found that they rated
the education and training role of the Agency as generally favourable. Some
respondents, however, expressed the view that that the Agency needs to be more
proactive with an education process that reflects industry issues. They felt
that education and training is irregular and not readily accessible. Others
considered that the education packages produced by the Agency are comprehensive
but an ongoing program of training in their use would be beneficial. While the
packages are available on the website, not everyone has access to the internet
and in some cases facilities were unaware of the packages' existence.
While ACSA in its submission to the inquiry noted that,
while the Agency operates as a monopoly, it would be better to confine its
education and training role to ensuring that the industry is fully informed about
the accreditation system, in oral evidence the organisation indicated that it
was not opposed to the Agency providing training courses. ACSA stated that:
...[we] have got no objection to it being a participant in that
marketplace for the provision of quality training but I think it needs to be
careful not to overuse its strong position in that regard...They are a legitimate
player but by no means the only one.
The Committee believes that the Agency has a legitimate
role in promoting 'best practice' throughout the industry. The Committee considers
that the Agency's involvement in these activities can assist in the promotion
of high quality care in aged care facilities. The Committee believes, however, that
the Agency should not have a direct role in staff training due to the potential
conflict of interest that that involves.
3.187 That the Agency's
role in promoting 'best practice' continue and that it:
- develop a
standard evidence-based approach to defining 'best practice' in aged care; and
- provide regular
aggregated information to the industry on methods for achieving 'best practice'
in the provision of aged care services.
The Committee further recommends
that the Agency consider ceasing its direct role in providing direct staff
training given the potential conflict of interest that this entails.
Reducing excessive documentation
Evidence to the inquiry, especially from providers and
unions with staff employed in the aged care sector, complained of the excessive
administrative and paperwork demands placed on staff as a result of
accreditation and the requirements of the RCS.
ANHECA noted that:
...the current accreditation system does [not] in any way assist
the sector to reduce administrative and paperwork demands on staff, in fact,
the reverse. Because the Agency is so focused on the minutia of day to day
activities and not on systems improvement, it is forcing residential aged care
providers to focus on forms and ticking of boxes, rather than ensuring that the
quality systems work effectively for overall service improvement.
The Royal College of Nursing, Australia (RCNA) noted
that its members:
...have expressed their frustration at the huge amount of
documentation required by the accreditation process and the increasing amount
of time they have to spend on paperwork to meet accreditation requirements
instead of providing hands-on nursing care.
The HSU noted that members consistently express concern
about the amount of documentation required of them. The LHMU also noted that 'paperwork
is one of the largest barriers to the direct delivery of care. It is also one
of the largest frustrations of those that work in aged care'. The Nurses Board of WA noted that
the administrative and paperwork demands 'have a real cost in dollar terms and
a cost on the emotional and morale demands on staff'.
The Agency, responding to these concerns, stated that
that it does not expect homes to create paperwork or documentation other than
the accreditation application. For most homes this requirement falls only once
every three years. The Agency stated that the application form has recently
been simplified following consultation with the industry.
The assessment process seeks evidence of compliance with the
Accreditation Standards. Agency assessors have no expectation to see any more
documentation than that which would exist within a quality management
The documentation required for accreditation, Application for Accreditation, consists
of a 49 page document. The main part of the document consists of a
'self-assessment' section which consists of blank pages where the provider is
required to provide information that demonstrates that the provider has achieved
the Expected Outcomes of the various Accreditation Standards.
The Agency noted that the accreditation application
information and forms are available on-line on its website. The Agency
encourages all homes to apply for their accreditation on-line. A version is
also available on CD. A printed version is also available for those unable to
access a computer or have difficulty down-loading a printed version, or who
would prefer to fill in a printed application rather than on-line.
Some groups were of the view that the documentation
requirements are not excessive. Geriaction noted that aged care services with
well established quality management systems 'do not find the administrative
requirements of the three year accreditation application onerous'. Geriaction
noted, however, that there may be opportunities for refining processes related
to the accreditation of newly established or restructured services to minimise
paperwork demands on staff. The
Victorian Branch of the ANF also commented that the accreditation paperwork was
not 'overly burdensome compared to other such systems'.
Throughout its hearings the Committee pressed groups
concerned about excessive documentation to be specific as to what documentation
they considered was not required. Some suggestions to reduce the amount of
paperwork required were made during the inquiry. Some witnesses suggested the
interRAI (Resident Assessment Instrument) as a useful model. The interRAI
series of assessment protocols consist of a series of data items that
constitute a clinical assessment. One witness stated that the Instrument:
...will effectively reduce paperwork....Currently, in order to substantiate
our funding, we are required to generate very text-driven documentation...what is
being proposed...it is almost like a tick system, I guess. It is a very prescriptive
set of assessment documents.
The Australian Society for Geriatric Medicine suggested
that systems such as the internationally benchmarked interRAI Instrument 'may
appear complex when first examined, but in the long run are the most efficient
since they achieve the desired outcomes'.
CHA noted that some of its members argued that provision
of an annual summary of activities to the Agency would reduce the three year
'panic' when the audit time comes around again. The RCNA suggested that the Agency should
further refine the Accreditation Kit to reduce unnecessary repetition between
visits; and not require already accredited facilities to complete the full version
of the Kit – this should only be required of new
services or those requiring improvements. The College also suggested that the
dual system of accreditation should be abandoned for facilities that are part
of a larger organisation and undergo Australian Council on Healthcare Standards
The Committee examined the issues of reporting by
exception and the increased use of IT as possible means of reducing the burden
of excessive paperwork arising out of the accreditation process.
Reporting by exception
Reporting by exception was supported by a number of
organisations. Aged Care Qld noted that:
We would certainly say that it would be helpful if more of the
reporting could be done on an exception basis rather than having to tick the
box every time you did something or write a comment every time, with every
detail needing to be recorded.
The Nurses Board of WA also indicated its support noting
that 'most documentation across all areas of health is by exception. Clearly if
you have the care planning processes in place and the understanding of what is
normal then exception reporting is by far the better approach'.
Witnesses noted, however, that the requirements of the
accreditation process are a barrier to its introduction. Bennetas stated that
it would take substantive change to the accreditation process for the system to
At the moment we have a system where, if you cannot prove that
you have provided care to a resident...you would not actually pass accreditation
because you have no evidence to back up what you have done.
Another problem identified was that with a the high
turnover of staff in many aged care facilities, especially agency staff or
staff that work on a temporary or casual basis, there would need to be an
effective system in place that records what tasks have and have not been
performed. The Victorian Association of Health & Extended Care (VAHEC)
noted that while reporting by exception could be introduced in a facility with
regular staff – 'certainly staff turnover and the skills set of staff would be
very important' in moving to this system.
The increased use of IT, including palm pilots and
other systems, to reduce paperwork was also raised in evidence. Witnesses
commented that such systems have the potential to free-up staff to devote more
time to patient care.
If the format of the software was very much a click-and-flick
type process...it would free up time for someone to be able to provide care to
residents instead of sitting down with paper based systems and writing out in
longhand what they had done that day.
Witnesses noted, however, that the underlying reporting
systems would need to be compatible with any new IT system.
...even if you have a system that is electronic rather than paper
based, unless the systems underlining that are streamlined it is not going to
make it any easier...So, while there may be some gains...there has to be some
underlying work to the reporting systems.
Aged Care Qld noted that there has been some resistance
to utilising IT systems in the aged care sector – 'there is a fear that you
might end up with a standard care plan produced by the system, not personalised
enough for the person. So the system is producing a standard rather than the
staff directing specific things for each resident'.
Witnesses argued that the level of investment in IT
would need to be substantial. ACSA noted that there has not been any explicit
investment in IT by 'any of the funding levels of government', in contrast with
the acute health sector where there has been substantial government investment
in such systems. One provider
submitted that at present the return on investment in IT 'would not be there in
either efficiency or productivity, so we are reliant on a document system'.
currently working with the aged care sector to develop an information
management and communications technology framework that will support a planned
and coordinated approach to the use of IT in the sector. The framework will
incorporate outcomes from the Clinical IT in Aged Care project. This project is
investigating how clinical IT applications or tools can support and improve
care standards for residents in aged care homes. A series of projects are being
funded to trial clinical IT tools or applications that are not currently in use
in the sector to evaluate their ability to assist in the delivery of care for
residents. The tools focus on point of care assistance and the increasing interrelationship
between aged care and the broader health sector, such as GPs and pharmacists. The
projects include the use of computerised medication management in aged care
facilities and electronic prescribing between homes and local GP practices.
The Department is also sponsoring a series of seminars
to assist providers to better understand how IT and electronic commerce, if
implemented appropriately, can improve the efficiency of aged care services. DoHA
is also working on a project to develop electronic channels for submission of
various aged care forms from facilities to the Department. 
Resident Classification Scale
The second area of concern relating to excessive
documentation was with the paperwork required by the Resident Classification
Scale (RCS). The RCS is a
validation system which monitors and determines the care level classification –
and thus the funding level – of residents in aged care facilities. Some
submissions suggested that the documentation required of the RCS imposes
greater paperwork demands on staff than accreditation paperwork requirements.
The RCS is to be replaced in 2006 with a new funding
Instrument – the Aged Care Funding Instrument (ACFI). DoHA
stated that the new funding assessment tool will improve the funding system so
services will spend less time on paperwork and more time in providing care. The
Department acknowledged that:
The existing RCS framework has become an administrative concern
for aged care providers. RCS ratings that were originally intended to be drawn
from existing care documentation developed by aged care homes to provide care
for each resident have increasingly become a driver of care documentation
rather than being a by-product of it.
that in contrast to the RCS, the ACFI:
- focuses on those areas of care that are the best
predictors of differences in the relative cost of care, so it has fewer care
domains than the RCS.
- is designed to measure the need for care, not the care provided (as supported by
documentation) when determining funding.
- supports a different model of accountability for
funding. The focus of the ACFI will be on the resident and on assessments of
care need required by the ACFI rather than being based on the care plan and the
on-going record of care delivery.
The ACFI will be
tested in a national trial during 2005. The data collection of the national
trial will be conducted during July and October 2005, followed by an assessment
of the results. Data collected during the trial will allow a detailed analysis
of the documentation burden of ACFI on assessors and aged care home staff.
welcomes the development of the ACFI, especially in its aim to reduce the
paperwork burden on staff in aged care facilities, and looks forward to a
successful outcome of the trial into the Instrument.
The Committee received evidence indicating that the
administrative and paperwork demands in connection with accreditation and the RCS
pose a considerable burden on providers and staff. Time spent complying with
excessive paperwork was significantly affecting the time spent by staff in
providing care. The Committee believes that the Agency should review its
documentation requirements in relation to accreditation with a view to
streamlining the paperwork requirements where possible without compromising the
accountability requirements of providers. The Committee notes that the RCS is to
be replaced in 2006 with a new funding Instrument with one of the aims of the
new system being a reduction in paperwork for aged care services. The Committee
supports this initiative.
The Committee also considers that the Agency should examine
other possible options of reducing paperwork including reporting by exception.
The Committee notes the current initiatives that the Department is undertaking
in relation to the promotion of IT in the aged care sector and believes that
such initiatives should be implemented as a matter of priority as another means
of streamlining operations and reducing the paperwork burden on services and
3.217 That the Agency, in
consultation with industry stakeholders and consumers, review the information
required to be provided in the document Application
for Accreditation and consider the feasibility of other options such as
reporting by exception, with a view to reducing superfluous and time consuming
3.218 The Committee welcomes
the Commonwealth's initiatives in promoting IT in the aged care sector and
recommends that the implementation of these initiatives, as well as increasing
the take-up rate, should be a matter of priority.
Navigation: Previous Page | Contents | Next Page