Why increasing audits won’t improve the quality of aged care

The Aged Care Minister, Ken Wyatt AM MP, recently announced that unannounced re-accreditation audits will triple in 2019, and unannounced inspections will increase to more than 3,000, as the government ramps up its crackdown on aged care quality.

Public concern is high about the quality of care we provide to the oldest members of our society in the wake of the Oakden scandal and widespread media coverage of other care failures, and following a number of damning investigations into the industry.

But Social Gerontologist and researcher, Dr Sam Davis, who has visited “thousands” of nursing homes all over the world, has told HelloCare that increasing the number of audits at nursing homes won’t improve the quality of care in Australia.

Audits about punishment, not guidance

Audits are more about punishing operators who don’t comply than showing homes how to provide the best care, Dr Davis said.

“I think the providers tend to see them [audits] as punitive rather than something that’s going to guide their care,” she said.

“It takes them away from what the accreditation system is trying to mandate, which is person-centered care and how to put that into practise.”

“More visits isn’t going to help those who are struggling with the idea of providing good quality care,” said Dr Davis.

Doing more visits and putting more pressure on the organisation and the people who work for them is not appropriate way to improve the quality of care, she said.

“You can’t just keep putting more legislation and more rigorous checks on people.”

Paperwork takes staff away from providing care

Dr Davis said she believes, “The majority of the providers tend to treat it [an audit] as a checklist: these are the things we have to do and document.”

But the focus on paperwork and processes can get in the way of providing care.

“I think the kinds of things that residents will benefit from the most are being set aside to make time for the paperwork and the task-orientated approach the providers take,” she said.

Staff “terrified” of unannounced visits

Dr Davis said some staff are “terrified” of unannounced visits, which she has seen first hand when visiting nursing homes and is sometimes mistaken for an assessor.

“My colleagues and I have walked into places and where we’re doing training for example, and because we’re fairly well dressed, we look fairly important because we’re not dressed like visitors, they’re [staff are] like deers caught in the headlights.

“That’s how terrified they are of unannounced visits,” she said.

Audits are subjective

Audits findings aren’t consistent, Dr Davis said. Findings can also vary from one inspector to another.

“A surveyor will go in and, with all the goodwill in the world, they have a subjective opinion – and they are the ones interpreting the guidelines,” she said.

Dr Davis gave the example of one assessor going into a home and saying, ‘you can’t have an animal in here because it’s dribbling on the floor and that’s a risk’. But the next assessor might say, ‘isn’t it lovely you’ve got an animal in here. All the residents are really enjoying it’.

Audits put most pressure on carers who are furthest from decision making

Dr Davis said the audit process puts the most pressure on the people who are supposed to be providing care.

“The accreditation approach requires the organisation to meet the requirements which then puts pressure on the people who are supposed to be providing the hands-on care,” she said.

And audits put the most pressure on the very people who are furthest away from the organisation’s decision making, she said.

New person-centered standards a band-aid solution

The new person-centered standards won’t help improve the quality of aged care, Dr Davis said.

“You can have all the standards in the world, but you can’t keep treating something that’s not working.

“For all the money they throw at aged care – billions of dollars – and for all the money they’ve spent on trying to improve aged care, they’re really just putting band aids on an issue.

Ratios just “another big hammer”

Ratios aren’t the answer, according to Dr Davis, although she does believe that greater transparency around staffing numbers would be helpful.

Ratios are “just another big hammer” and “another numbers game”, she said.

Carers don’t have time for person-centered care

Dr Davis said she hears over and over again that staff don’t have enough time to provide proper person-centered care.

“I don’t know how many times my colleagues and I have been been told ‘we do person-centered care when we have time’,” she said.

Care staff need better recognition

The first thing that has to be done in aged care is to give staff greater recognition, Dr Davis said.

“The first thing we have to do is recognise that aged care staff, particularly the personal care workers, do a tremendous job and don’t get any credit for it. They’re poorly paid, they’re not recognised,” she said.

“It’s not sexy, it’s not respected, and yet they’re doing one of the most important jobs there is in the community,” Dr Davis said.

Australia’s aged care model needs revising

Our society need to reconsider our whole model of aged care, Dr Davis said.

“I think they need to start from scratch,” she said. The current model is very expensive and “it’s not doing the job it’s supposed to do” – proving person-centered care for older Australians.

Dr Davis, who is now retired but still works in research, says many others in working in her field share her concerns, but are not game to be open about it.

Now she’s retired, Dr Davis said she’s prepared to be “slapped over the knuckles” for speaking out.

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  1. Dr Davis is correct on many points but I have to take exception at the term of “terrified” when used to describe the feeling when an agency visit either announced or not occurs. The feeling is close but its not about being caught out doing something wrong its the fear of assessors personal interpretation of a standard. Thats what operators are concerned about and with good reason. Lately we have been hearing about Homes meeting all the standards and a couple of months later they “fail” twenty! That is ludicrous in the extreme!

    Another thing Dr Davis has gotten spot on is the terminology oxymoron being bandied about, Person Centred care is by the very phrase designed to provide individualised care with the very best possible outcome, this comes through flexibility and compassion; but; at the same time we need to fit snuggly in amongst the Standards in a very rigid system that is open to massive interpretation differences in a very flawed product.

    While everyone needs rules and standards lets at least have standards that get a better result for the clients, the Government has our nurses (and others) so tied up in paper work and red tape that they dont have time to do what they know best and this frustrates them greatly and this and payrates need attention.

  2. I am afraid that I do not agree with many of the statements made by Dr. Davis other than with the comments that “Australia’s Aged Care Model Needs Revising” and “I think that they need to start from scratch”. In fact, a total dismantling and restructure of the current model is urgently needed.

    One of the first and greatest challenges is to change the culture and mindset of the Government.
    in relation to –

    a) how they view the elderly;
    b) the purpose of nursing homes;
    c) its responsibility in ensuring that an independent audit requiring transparency and accountability for
    funding received by the service provider is undertaken annually;
    d) increasing the entry level and educational standards for staff employed in nursing facilities;
    e) requiring competency in the English language by all care staff;
    f) legislating the rights of families/friends by statute so that they are protected from the
    bullying, intimidation and threatening tactics of service providers when complaints are
    made regarding the poor standard of care their loved one is receiving
    g) implement safeguards such as requiring cameras in all rooms and in common areas.

    The above is only the tip of the iceberg.

    I am astounded that Dr. Davis states that “ratios are just another big hammer and a numbers game” and yet in the same breath states that she repeatedly has been told by staff “we do person-centred care when we have time”. If one staff member is looking after 10 people as opposed to one staff member looking after 4, then common sense alone would indicate that staff ratios are a crucial step in providing optimum care.

    Also, it is well known that visits made by the assessors are nothing other than window dressing and that the government assessor has failed miserably in ensuring adequate standards are met by the service providers. Almost all visits were not “unannounced visits” thus allowing the service providers to temporarily cover up the shortcomings on the appointed visit day. Unannounced visits were a rarity and the complainant had to beg the organisation to conduct an unannounced visit before it took place. This has only recently changed.

    I am really quite dismayed at the enormous amount of commentary made by academics and other
    persons who have NEVER spent more than half an hour in a nursing facility yet feel that they have more insights into the problems associated with nursing facilities than families/friends who are at the coalface and experience these problems first hand and on a daily basis. How many of these academics, medical personnel etc. have spent a minimum of 6 hrs. per day in a nursing facilitiy over a five year period? I certainly have and so have many other families – ask them to be included in the formulation of a new model of care – not the academics most of whom need a reality check!

    It is also worth noting that during her tenure, Dr. Davis and her colleagues had concerns regarding the operations of nursing facilities yet did nothing and said nothing to expose them. Only now that she is retired is she is prepared to speak out. To say that she is now prepared “to be slapped over the knuckles” speaks volumes about the canker and rot that is rife throughout the industry including past and present governments which were well aware of what was going on but chose wilful blindness instead of positive action.

    When there is fear of reprisal for speaking out about what is intrinsically wrong, it is clear that aged care, on so many levels, is big business where the almighty dollar and the corridors of power will do all that is necessary to protect their pots of gold and their political careers. The elderly for too long has been treated as “stock in trade” and “cash cows” for both opportunists and governments alike.

    The Guardianship Tribunal, Public Guardian and Public Trustee is a perfect example of being not fit for purpose and uses the elderly as the necessary head counts to keep them in employment and fill the govt. coffers through involuntarily placements in nursing facilities and confiscation of the elderly person’s estate.
    That is human trafficking!

    It is timely that a Royal Commission is taking place but if service providers and other organisations
    with a vested (financial) interest are protagonists in the hearings and the voices of families and victims of nursing home abuses are relegated to tokenism, then this country needs to hang its head in shame.

    1. I agree with your statements wholeheartedly. I work in Aged Care and am starting to feel that the sector is failing badly across all facilities. The new standards will help (I think) but they are only a tiny and insufficient part of what needs to be done to help improve the lives of our elderly.

      Her comment about ‘ratios not being the answer’ held up next to ‘staff don’t have enough time to do person centred care’ ruined this whole article for me, made it laughable that they are holding her up as an expert in how to fix aged care.

  3. I agree with all of these assertions. It’s broken. Bandaiding won’t fix it. More mandated requirements mean more documentation and more people NOT doing the caring. We must do it differently and enculturate differently.

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