The main points to come out of the Aged Care Royal Commission this week:
Monday marked day five of hearings for the Royal Commission into Aged Care, and the revelations, though far from new to many working in the industry, were nevertheless again confronting.
The hearings began with Glenys Beauchamp, Secretary of the Department of Health.
Senior counsel assisting Peter Gray QC pointed out to Ms Beauchamp that there were 3,773 assaults in nursing homes during the 2017-18 financial year.
Ms Beauchamp confirmed that at present there is no mandatory requirement to report assault in certain circumstances, for example, if the perpetrator is cognitively impaired.
Ms Beauchamp said a serious incident response scheme is being developed, but “it will require legislative changes,” she said.
“We’re looking at broadening as per the Law Reform Commission recommendation and, indeed, the Carnell Paterson, to include resident on resident assaults without exception,” she said.
Mr Gray asked Ms Beauchamp why there had been a “marked increase” in the number of “serious risk findings” between 2015-16 to 2017-18, with a rise from two to 61.
Ms Beauchamp said the increase was due to both an increase in scrutiny on the sector, as well as legislative changes.
“There has certainly been an increase in activity levels around both audits and reviews.”
The commission also heard that the Aged Care Funding Instrument, the tool used by the Department of Health to allocate funding to aged care providers, is being manipulated by some aged care providers.
Mr Gray asked Ms Beauchamp if suspending indexation on ACFI had had an impact on safety and quality after the 2016-17 budget?
Ms Beauchamp said, “There had been a number of providers maximising their revenue through ACFI instrument”, but she said the Department had not assessed whether this had compromised quality.
“There hasn’t been a direct assessment of the impact of the ACFI funding changes on quality and safety,” she said.
Ms Beauchamp also told the Commission that to fund 30,000 more high level home care packages and for waiting times to be cut to three months would cost the government “several billion dollars”.
On Monday afternoon, Janet Anderson, the new Aged Care Quality and Safety Commissioner, gave evidence.
She said the commission is looking at starting conducting unannounced visits after hours and on weekends within months.
“We have just embarked on a program of extending our out of hours visits… The quality agency which preceded the commission always did a proportion of out of hours visits and we are now working up a program to extend that,” she said.
She also confirmed that some quality auditors also work for aged care providers. But she said conflicts of interest are managed appropriately.
“We look very closely at the potential and manage the risks of conflict of interest very, very tightly,” she said.
She said auditors’ findings are assessed by a separate decision-maker.
“They come back from the visits with a set of findings. The decision is made separate from them. The decision is made by a decision-maker who is, in fact, a superior,” she said.
The final witness on Monday was Dr Harry Nespolon, President, RACGP. He told the Commission that fewer GPs are visiting aged care facilities.
“There is a progressive decrease in the number of GPs who are willing to work or go and see patients in nursing homes,” he said.
Dr Nespolon said increased funding, improved record keeping, and higher numbers of nurses would lead to better levels of care for residents.
On Tuesday, Maree McCabe, CEO, Dementia Australia, opened the hearings.
Ms McCabe said dementia is the “chronic condition of the 21st century”.
“Getting a diagnosis [of dementia] for someone over the age of 65 can take up to 3.1 years. For somebody under the age of 65 in their 50s, their 40s and their 30s, it can take seven years,” she said.
She said the incidence of young onset dementia is on the rise.
“One in 13 Australians living with dementia are in their 50s, their 40s and their 30s.”
Yet, Ms McCabe said most aged care workers have no dementia training.
“Of the 240,000 aged care workers in Australia, 70 per cent work as personal care workers, and their certificate III does not provide any education around dementia,” she said.
Pat Sparrow, CEO, Aged and Community Services Australia, said the aged care workforce needs to triple in the next three decades to cope with the expected rise to 1.1 million of the number of people living with dementia.
She said ACSA is working on programs to encourage young Australians, particularly millennials, to work in aged care.
“They generally don’t think about working in aged care but what we do know is the current generation – I think they’re referred to as the millennials – actually want to work in areas where they have relationships and meaningful connections and are making a social contribution,” she said.
Ms Sparrow also talked about some of the positive changes that have been occurring in the aged care industry, including the household model, Montessori, the Butterfly model of care, and the Eden Alternative, intergenerational living, and dementia villages.
Ms Sparrow said these models have “a good impact on the quality of care that people are receiving.”
Ms Sparrow also told the commission that ACSA did not support the implementation of resident-to-staff ratios.
“You actually need to understand more than just the flat number of staff on at any one time. So different models of care require different forms of staffing,” she said.
“We do think that they’re a blunt instrument. They don’t capture those variances and differences and that needs change over time, and providers need to be able to be flexible to do that,” she said.
However, she said she understood the desire for transparency around staffing levels.
“I think there’s scope for transparency so that people understand how a service is staffed, but I don’t think that a blunt instrument of a minimum number of staff actually is very informative or guarantees better quality of care,” she said.
Sean Rooney faced a grilling at the Royal Commission on Tuesday.
Sean Rooney, Chief Executive Leading Aged Services Australia, was asked why LASA attempted to water down the new quality standards, being introduced from 1 July 2018.
Senior counsel assisting the royal commission, Timothy McEvoy, asked Mr Rooney why he suggested the new standards amend the phrase “continuously monitored” to say “regularly monitored”.
Mr McEvoy questioned Mr Ronney about LASA’s apparent proposal to remove a requirement that airconditioning be installed in nursing homes.
LASA queried a line in the government’s draft quality standards which said aged care providers should ensure a “comfortable internal temperature” for residents. The requirement was removed from the final standards.
Mr McEvoy questioned Mr Rooney if LASA’s intent was to “reduce the burden for monitoring in relation to air-conditioning?”
“Does LASA ever advocate for changes that are in the best interests of residents at what might be thought to be the expense of providers?” Mr McEvoy asked.
Mr Rooney replied, “I cannot recall an occasion where we have advocated any change that I would see to have been – sorry, your words were, not in the best interests of residents or at the expense of a provider?
Mr McEvoy said, “My words were whether there’s advocacy for changes that are in the best interests of residents, but at the expense of providers.”
“I cannot recall a – any occasion where that has been the case,” Mr Rooney said.
LASA has since clarified with HelloCare that Mr Rooney could not recall any instance where LASA had not advocated for changes that are in the best interests of residents.
On Wednesday, Claerwen Little, National Director, Uniting Care Australia, said, “Some people suggested they would rather die than go into a residential aged care facility. They would rather poke their eye with a pencil than have to enter a home.”
Melissa Coad, National Coordinator for Aged Care, United Voice, said staff were underpaid, overworked, and often had a second job.
“There’s very little full-time employment among the direct care workforce… The wages, hourly wage rates are particularly low and so… there is a high number of workers that would like additional hours. There’s also a high number of workers that work more than one job,” she said.
“There are predictions that the workforce would need to reach a million people by 2050. I think if wages and other working conditions don’t change we’re going to have significant problems in attracting and retaining people to that workforce,” she said.
She said aged care workers often feel “stressed in their work, pressured in their work, that they don’t have enough time to do their job properly.”
“Our members tell us that a lack of staffing leads to quite high workloads for them and leads to them being rushed through things. One member described it to me as a conveyor belt of tasks that they have to undertake.”
She said staff often go above and beyond what is required of them, often purchasing items for residents out of their own pocket. Some will sit with a dying resident in their own time.
“They have finished their shift, gone home and had a shower and got changed and come back to the facility to sit with someone who’s dying in their own time,” she said.
Ms Coad said the times allotted for home care visits were often too short.
“We certainly think there should be some regulation around minimum [home care] visit times,” she said.
“They’ve been scheduled 15 minute [home care] visits sometimes to people’s homes and they say that is simply not adequate.”
Training in aged care was often inadequate, Ms Coad said.
She said a United Voice survey found 23% of members had carried out medical procedures or given medicines without training.
Ms Coad said aged care workers fear retribution if they speak out.
“Members have reported bullying and harassment in services where people are seen to rock the boat or make trouble,” she said.
Matthew Richter, CEO, Aged Care Guild, said the aged care industry in Australia is at a “tipping point”.
He said consumers require better information about aged care residences.
“We are in the process right now of building a prototype model that could online aggregate a whole range of consumer experience feedback,” with the help of CarePage, the sister company of this website.
“I would like people to be able to find out about how those services perform. So quality indicators would be important; quality indicators that mean something to consumers,” he said.
“We can have clinical quality indicators measuring falls and those kind of things but consumer outcome quality indicators as well; what has your experience been like, what has your family’s experience been like, would you recommend this facility to someone else that you care about are really important measures.
“And then to have benchmarks across the industry that are visible so the industry can see what’s good, what’s not so good, what’s great, what’s terrible. We don’t have that at the moment.”
Mr Richter said the aged care sector is under considerable financial pressure.
“The sector isn’t performing very well from a financial perspective and that has material implications,” he said.
“There is significant uncertainty about the future in aged care and from an investment point of view uncertainty always makes it harder to attract funds.”
“We would like a discussion… about what we want from an aged care system in Australia and how much we’re willing to pay for that and how we’re going to pay for that.”
Mr Richter said The Aged Care Guild (excluding Bupa) lost one-third of its nurses in 2017-18.
The final speaker on Wednesday was Anthony Bartone, GP, National President, AMA.
Dr Bartone said the lack of opportunity to handover to a properly qualified member of staff in aged care facilities was a major problem.
“The feedback that we’ve got from this survey in particular, but in many anecdotal instances as well, that lack of opportunity to hand over,” he said.
“If there is no one available to hand over.. it’s potentially putting that patient at a disadvantage.”
Dr Bartone said fewer doctors are visiting aged care facilities.
“If you’re… meeting barriers to exerting that care, to facilitating that care, that does really create anything from frustration to concern to worry. And ultimately for some of our members, that worry becomes an action item which leads to them to decide that no, I’m not going to continue.”
Dr Bartone said the AMA is in favour of staff ratios.
“When it comes to ratios… what we would like to see is a best practice… what are the minimum numbers of nurses and staff as well to a patient ratio.”
Dr Bartone said ambulances were called too often to nursing homes for matters that could be dealt with on site if the appropriate staff were available.
“There is… an inappropriately high level of transfer from community aged care facilities to emergency department of conditions that could be managed in the community by a good GP being available,” he said.
Dr Bartone said the Medicare rebate for GPs visiting aged care facilities was “exceedingly, exceedingly insufficient.”
He said geriatricians rarely visit nursing homes.
Commissioner Tracey said, “It would be a rare day you would ever see a geriatrician in a nursing home. Is that a correct impression?”, to which Dr Bartone replied, “Yes.”
On Thursday, Gerard Hayes, National President, Health Services Union, said the sector is being hampered by under-resourcing, under-staffing, cost cutting, and a lack of training.
“I think, to be quite honest, out of sight is out of mind. The morality of this country needs to be tested,” he said.
“Is it good enough to say that the people who went through the war years of the thirties and the forties and the consequent years of rebuilding this country are good enough to say, well, we don’t notice them every day so it must be okay?”
Mr Hayes said there needed to be better systems and protections for whistleblowers.
“What we advocate is that there should be protections for whistleblowers,” he said.
“Most people who work in aged care will tell you they go to work not for the money – and, clearly, they don’t go to work for the money – they go to the work for the love of what they do,” Mr Hayes said.
“We need to start to put our forebears on a pedestal that they deserve.”
Kaye Warrener, who cares for husband Leslie Warrener at home, spoke on Thursday.
She has been waiting more than 450 days for Les’s home care package to come through.
“I’ve watched Les get very depressed over things, about not being able to get the package,” she said.
“it’s hard to watch your loved one… to watch their health deteriorate. And I just feel with the extra support financially we would be able to help perhaps delay some of those onset things that are happening with age.”
She spoke of visiting an aged care facility when a family member went into care.
She said, “When I was visiting this aged care centre, the first thing that came to me was the smell in this place. I thought, ‘No aged care’.
Margot Harker, formerly a public servant and currently on a level four home care package, told the commission she suffered a stroke eight years ago and needs help to wash, cook and clean.
She said aged care needs more funding.
“You can’t get around the fact that aged care of all kinds is not funded adequately,” she said.
“There’s a sense in which we feel the Australian population doesn’t think that we deserve quite as much and it’s a bit sort of icing on the cake. There is no sense of us having served our community or our nation during your working life of 40 years,” she said.
The second round of hearings will begin on 18 March, and will focus on home care.
Please note: The picture used to illustrate this article does not reflect actual people or events. Image: iStock.