A national concern
[T]here is evidence to suggest that accreditation may not be
adequate in delivering quality care outcomes for consumers.[1]
4.1
As outlined in Chapter 3, many of the submitters and witnesses to this
inquiry have raised concerns that the oversight and regulation failures, which
allowed the poor conditions at Oakden to continue for so long, are not isolated
to the specialised type of service delivery at Oakden, and that the same
regulatory failures can be seen more widely across the aged care sector.
4.2
Conversely, aged care sector providers and representative organisations have
submitted that Oakden was a special case, and should not be seen as
representative of the broader aged care sector or the quality oversight
frameworks.[2]
4.3
Notwithstanding the views of aged care providers themselves, a
significant body of evidence has been presented to this inquiry which
highlights a broad range of problems with the quality oversight and regulation
framework. Given the extensive evidence received of this nature and the terms
of reference for this inquiry, this chapter will not seek to analyse or make
recommendations on those sector-wide regulatory and oversight concerns. Instead,
this chapter will highlight the key concerns raised within the scope of this
inquiry, which go beyond the regulatory and oversight failures specific to
Oakden and impact the aged care sector as a whole.
Concerns raised in evidence
Broad concerns with the accreditation
system
4.4
Submitters and witnesses raised a number of broad criticisms of the
current accreditation system.
4.5
Monash University Health Law and Ageing Research Unit submitted that the
existing regulatory mechanisms are almost 20 years old, and there has been
'profound changes in the past 20 years about measuring, regulating and
investigating quality of care'. The submission from Monash University further stated
that the aged care regulatory mechanisms and legal systems are 'complex,
fragmented and risk averse with divergent, discordant or contradictory
approaches. This contributes to significant gaps in care, especially in
[Residential Aged Care Facilities] (RACFs)'.[3]
4.6
The Victorian Government submitted that while the accreditation process
has supported improvements in RACFs over the past two decades, the focus on
compliance to minimum accreditation standards by individual providers does not
support sector-wide capacity building or encourage improvements beyond the
minimum benchmarks.[4]
4.7
The Victorian Government submitted it supports amending the
Accreditation Standards to ensure they are clear, measurable and specifically
applicable to residential aged care.[5]
The Victorian Government further submitted that the monitoring approach should
not focus only on individual providers, but should also monitor the performance
of the aged care sector as a whole.[6]
Specialised dementia and mental
health care
4.8
The committee heard that there is an increase in the prevalence of
dementia and the increased demand for specialist beds is growing faster than
supply.[7]
Responding to this need, in the 2016–17 Mid-Year Economic and Fiscal Outlook
the Australian Government announced the introduction of Specialist Dementia
Care Units in residential aged care settings.[8]
4.9
However, there does not appear to be an Australian Aged Care Quality
Agency (Quality Agency) accreditation process specific to aged care services
with specialist elements of mental health or Behavioural or Psychological
Symptoms of Dementia (BPSD) services. The South Australian (SA) Chief
Psychiatrist argued the current aged care assessment and accreditation
framework is not suitable for care settings for consumers with severe mental
illness and dementia care needs.[9]
4.10
The Australian Commission on Safety and Quality in Health Care advised
the Review of National Aged Care Quality Regulatory Processes (Carnell Paterson
review) that all health services where patients have a severe form of dementia
should be assessed against the National Safety and Quality Health Service
(NSQHS) Standards. The Makk and McLeay wards were not assessed against the
NSQHS Standards as they were rated as aged care facilities, despite the fact
that the specialised aged care being delivered incorporated dementia and mental
health services. Conversely the Clements ward, which was not receiving Commonwealth
aged care funding, was assessed against these higher health care standards.[10]
4.11
The Carnell Patterson review found that despite some stakeholders
arguing Oakden does not represent the mainstream aged care sector, the issue of
specialist dementia and mental health care in an aged care context is relevant
to the broader aged care sector:
We know from the Aged Care Funding Instrument, for example,
that around half of residential care consumers have symptoms of mental illness.
This group overlaps with the approximately half who have dementia. We know that
frailty is increasing, and that the number of people in care with dementia (and
therefore with severe dementia) is increasing. Oakden is not unique, because
the characteristics and needs of its residents were not unique.[11]
4.12
The Carnell Paterson review found that regulation must include the
capacity to review the full complexity of care being provided to aged care
residents and wrote:
The regulatory system must be designed to respond to the
profile of consumers in a service. Had that been the case ten years ago,
Oakden—and other facilities with more vulnerable consumers—could have been
supported and monitored more closely.[12]
Consumer involvement
4.13
Multiple submitters and witnesses argued that the accreditation and
audit processes do not adequately involve consumers and their families.[13]
This view was also put forward by the Chief Executive Officer (CEO) of the Northern
Adelaide Local Health Network (NALHN) in relation to accreditation audits
conducted at Oakden:
Take Oakden as an example: the residents of Oakden had little
or no capacity themselves to speak to people who came for assessments. I don't
believe that the carers or the families of the people who lived at Oakden were
given an opportunity to share their perceptions with the accreditors. Certainly
the past residents' families that I met with subsequent to the report being
released, they all, without exception, reported observing the same issues, the
same behaviours, the same treatment over many, many years. If they had been
involved in the accreditation process, because the residents had no capacity,
we would have seen a different outcome.[14]
4.14
The Quality Agency submitted the current audit process has been recently
amended to ensure a minimum of 10 per cent of care recipients and their
representatives are interviewed using a new structured interview process with
standardised questions and that consumers' feedback is published in Consumer
Experience Reports as part of a move to greater transparency.[15]
4.15
However Alzheimer's Australia submitted there needs to be greater
involvement of consumers at the organisational level of the Quality Agency
itself, to drive improvement in the quality assessment processes.[16]
4.16
Submitters also argued the Accreditation Standards only let consumers
know which RACFs are failing, but do not let consumers know which facilities
are providing high quality care.[17]
Older Persons Advocacy Network also submitted that the accreditation process
does not require consumers be informed when there are concerns in relation to a
facility.[18]
4.17
The Federation of Ethnic Communities' Councils of Australia submitted
that processes to accredit and monitor RACFs do not adequately cater for the
needs of ageing Australians from a culturally and linguistically diverse background,
particularly in the lack of independent translation services provided during
accreditation and audit visits.[19]
Personal care vs medical care and
clinical governance
4.18
Evidence to this committee shows there is a clear schism in how the aged
care sector defines different levels of aged care services as personal care as
opposed to health or medical care, and therefore the level of clinical
governance required for that care.
4.19
HammondCare, which operates more than 1000 residential aged care places,
submitted:
[I]t is not appropriate for the accreditation framework for
residential aged care services to monitor the appropriateness of medical care
provided to residents, as aged care homes are not medical facilities. While
approved providers of residential aged care under the Aged Care Act 1997 are
required to provide residents with nursing services and to assist them with
daily living activities, their responsibility when it comes to medical care is
simply to assist in accessing the services of appropriate medical practitioners
as required (Quality of Care Principles 2014, p.6)...
As aged care homes are not responsible for the direct
provision of medical care, they should not be held accountable for the manner
in which it is provided. Instead, the adequacy and appropriateness of the
medical care provided to aged care residents should be overseen by the
appropriate medical colleges.[20]
4.20
Despite arguing that aged care providers are not responsible for medical
care, HammondCare also submitted evidence on the specialised health care
services it provides, which includes services for people with severe
behavioural and psychological symptoms of dementia and palliative care.[21]
4.21
However, the Productivity Commission 2001 report Caring for Older
Australians defines the 'care' component of aged care as a 'mix of health
(or medical care) and personal care services'.[22]
Importantly, the Productivity Commission does not make a distinction between
medical care and other forms of health care, such as mental health or nursing
care.
4.22
Leading Age Services Australia, a national peak body representing aged
care service providers, submitted that many providers have recommended that in
order to properly assess the quality of clinical care being provided in
individual RACFs, all Quality Agency auditors should have a background in
clinical care.[23]
BUPA similarly submitted that allied health service provision should be
considered in the Quality Agency assessment process.[24]
4.23
However, Aged and Community Services Australia, another provider
representative body, argued that individual clinical care was not an area that
the Quality Agency should be assessing at all, and submitted that:
Concerns about the standard of care provided by doctors and
other health practitioners should be considered by the appropriate health
practitioner body and is not something that an assessor from the Australian
Aged Care Quality Agency would or should be able to make a decision about.[25]
4.24
The Quality Agency submitted that clinical issues, such as governance
and practices, are currently incorporated into the Quality Agency's Accreditation
Standards.[26]
4.25
However, Professor Craig Whitehead of Flinders University noted that
clinical care oversight in the aged care sector was significantly less
developed than in health care, and told the committee:
One of the things that struck us is that the idea of quality
or clinical governance in an aged care institution is very much in its infancy.
Some aged care organisations are starting to look at risk and quality and
managing adverse events, but, by and large, it is not mandated.[27]
4.26
The Victorian Government submitted it supported the development of a
clinical governance framework for aged care providers, arguing 'the clinical
needs of people living in residential aged care are increasing' and that
clearly defining clinical care standards will facilitate workforce development.[28]
The Victorian Government further submitted that this framework should include a
definition of clinical risk as 'where action or inaction on the part of the
organisation results in potential or actual adverse health impact' and goes on
to list a number of personal care services such as hydration and nutrition,
skin integrity and oral hygiene which, if done poorly or neglected, can result
in adverse health outcomes for elderly people.[29]
4.27
The Law Council of Australia submitted that any changes to the oversight
of clinical governance should include oversight of prescription medications, in
particular the use of antipsychotic medications, which is linked to the
practice of chemical restraint.[30]
Committee
view
4.28
The lack of a defined model of care, coupled with appropriate clinical
governance to deliver that model of care, was raised in Chapter 2 as a
significant contributor to the substandard service delivery at Oakden.
4.29
The committee notes the evidence shows this issue is not isolated to
Oakden. The evidence presented to this inquiry shows there is significant
conflict within the aged care sector as to the definition of the care being
provided, who is responsible for providing appropriate clinical care in RACFs,
and which agencies should have quality oversight responsibility of that care.
4.30
The current impasse cannot continue and needs to be resolved.
Abuse and Restrictive practices
4.31
Investigations of care and practices at Oakden revealed an over-reliance
on restrictive practice. The chair of the Oakden Oversight Committee stated it
was one of the worst aspects of the abusive treatment found at Oakden.[31]
The SA Chief Psychiatrist report found that:
There has been ongoing, repeated use of restrictive practices
at Oakden that has contravened legislation, national standards, state policy
and local procedures and likely implemented for staff convenience and or used
as punishment.[32]
4.32
Beyond Oakden, the unregulated use of restrictive practice across the
broader aged care sector was raised by a number of submitters and witnesses as
being a key concern. Alzheimer's Australia noted the use of chemical restraint,
in the form of over-prescribing antipsychotic medication, was a continuing
problem in the aged care sector.[33]
4.33
The Law Council of Australia also raised concerns with restrictive
practice, and pointed to the Australian Law Reform Commission (ALRC) June 2017
report, Elder Abuse – A National Legal response (Elder abuse report), discussed
in greater detail later in this chapter, which recommended regulating the use
of restrictive practice in the aged care sector.[34]
Aged care workforce
4.34
A number of different workforce related issues were raised as matters of
concern by submitters and witnesses, including training, staffing levels and
regulation.[35]
4.35
Monash University submitted that the lack of gerontology-specific
nursing training directly impacted the ability of nurses to monitor standards
of care in aged care:
[T]here is not a single tertiary nursing course on
gerontology, let alone specific training for care of persons in [RACFs]. With
such a large gap in the nursing workforce knowledge and training it is
unreasonable to expect nurses to be able to monitor standards of care, advocate
and challenge the status quo. This is very unlike the situation of health care
in public hospitals.[36]
4.36
Staffing levels were raised in a number of submissions, with the
majority being in favour of minimum nurse to patient ratios 'to ensure that
skilled care can be provided to residents in a timely way'.[37]
The Victorian Government pointed to the ALRC Elder abuse report, which
expressed concern that low staffing levels could lead to restrictive practises
being used to manage patients, as well as lead to abuse or neglect.[38]
4.37
The heavy reliance of personal care attendants in the aged care
workforce was also raised as a significant concern for quality care, given it
is an unregulated workforce.[39]
Submitters pointed to the recommendations of the ALRC Elder abuse report to
increase the regulation of this section of the aged care workforce.[40]
This recommendation was also made by the recent Senate inquiry into the Future
of Australia's Aged Care Workforce.[41]
Data
4.38
The lack of data on quality of care was raised by multiple submitters as
being a significant barrier to ensuring an appropriate quality framework for
aged care services. Monash University discussed this at great length, and
pointed to a recent study of coronial data which indicates there are a
disturbing number of preventable deaths occurring in RACFs.[42]
4.39
Following on from the above study, Monash University have produced a
report Recommendations for prevention of injury-related deaths in
residential aged care services, which makes 104 recommendations on
strategies to prevent similar deaths from choking, medication events, physical
restraint, an unexplained absence 'while in respite care', suicide and,
resident–resident aggression.[43]
4.40
Monash University further submitted there is a lack of empirical
research into RACFs, regulatory mechanisms and quality of care, largely due to
the lack of dedicated funding to support research, and that research is made
all the more difficult by the lack of readily available, standardised national
measures for quality of care.[44]
4.41
In relation to medication management data, the Department of Health have
indicated that the government does not currently collect specific data on
prescription rates or patterns of usage in aged care as many people who live
within RACFs may not receive all of their medications through that facility.
However national residential medication charts, where they are in use, offer an
opportunity for data collection about medications prescribed in particular
facilities, and data under the PBS can be narrowed to the population aged over
65 years, so these could be areas for improvement in data research in the
future.[45]
Critical, serious or reportable
incidents
4.42
The Quality Agency told the committee 'no accreditation or compliance
monitoring system can fully safeguard against individual instances of abuse or
neglect'.[46]
The Law Council of Australia similarly submitted that the accreditation looks
at systemic issues, not individual serious incidents[47]
and recommended a serious incidents response scheme.[48]
4.43
Monash University discussed the need for a 'national register which is
comprehensive, coordinated and requires mandatory reporting of a suite of
significant adverse events that include but are not limited to: physical
restraint, elder abuse, resident–resident aggression, suicide, choking,
unexplained absences that are occurring in [RACFs]'.[49]
4.44
The Victorian Government similarly raised the need for a reportable
incident register and pointed to the ALRC Elder Abuse report recommendation for
an independent body to oversee the investigating and monitoring of serious
incidents.[50]
Complaints handling
4.45
In addition to the need for a serious incident reporting framework,
submitters and witnesses discussed the need to improve the complaints handling
systems, both within individual RACFs and systemically.[51]
4.46
Mr Stewart Johnston, a family member of a resident at Oakden, told the
committee there is a range of serious problems with the complaints handling
systems, both internal and external:
Overwhelmingly, the consistent theme for all people who have
come forward to me in the conversations I've had is the confusion experienced
about where to lodge a complaint, how to lodge a complaint and whether it's
safe to lodge a complaint. And after lodging a complaint via the many channels,
there are no clear avenues of independence and responsibility to follow up
communication.[52]
4.47
The SA Principal Community Visitor told the committee of his concerns
that complaints raised within facilities are investigated by a member of staff,
raising conflict of interest issues as well as concerns regarding the
complaints investigation skills of the person reviewing the complaint:
The way that complaints are raised at facilities—say at NALHN
at the moment—are investigated is by a consumer liaison officer, which is a
member of staff who sits among staff that they're investigating. So it puts
them in a very difficult situation. Again, I think it's really important to
have a level of independence of anyone investigating any of these complaints
and it's important that they have the skill sets—the investigative interviewing
skills—and a background in enquiry and in making objective independent
assessments.[53]
4.48
The CEO of NALHN told the committee that many complaints to relevant
external agencies are never made, due to fears of repercussions or other
intimidation:
I asked them why they [family members of Oakden residents] didn't
complain. They complained internally, to the management team. I'm not
speculating when I say they were intimidated, in relation to using any of the
external agencies to make further complaints...It is my view that people who
could have complained were intimidated.[54]
4.49
The Aged Care Complaints Commissioner (Complaints Commissioner) agreed that
there was work to be done around encouraging consumers to engage with complaints
processes, particularly where they are conducted by a Commonwealth entity:
...I do think there is some evidence that more people know
about us and more people are coming to us, but I would be the first to admit
that there's a lot more we have to do and particularly to help those people who
are frightened to come to us or who are worried that there'll be repercussions....
If you're sitting in an aged-care facility and you're worried about involving
the Commonwealth Aged Care Complaints Commissioner because that might lead to
repercussions, a local advocate can be equally as effective with some
complaints and seem a lot less scary. The provider's certainly likely to be perhaps
a little less intimidated than if it's escalated to us. There's that
opportunity.[55]
4.50
The Complaints Commissioner echoed the evidence provided by other
witnesses and submitters that consumers have problems with engaging with the
complaints process as it stands for a number of reasons and described the work
being done to change this, including:
-
actively encouraging industry to be more open about complaints,
with increased transparency in complaints processes;
-
working with providers to improve complaints handling 'at the
front door', as many complaints are made to the provider first;
-
working with advocacy networks to help families and consumers
through complaint processes either with a provider, a state or territory
entity, or with the Complaints Commissioner; and
-
raising the public profile of the Complaints Commissioner to
ensure that consumers know this is an avenue for complaints.[56]
4.51
The Complaints Commissioner also provided evidence that the complaints
resolution process in aged care does not have the same strength as similar
processes for health care, submitting that all Australian hospitals are
required to openly disclose adverse events to patients and their families and respond
appropriately, but no such requirement exists in aged care. The Complaints
Commissioner further submitted that '[r]equiring proactive and appropriate open
disclosure of adverse events is one of the key steps to ensuring failures of
care are acknowledged and appropriately and promptly remediated'.[57]
Broader actions
4.52
In addition to the Oakden-specific responses outlined in Chapter 3, the
Australian Government is undertaking two key reforms of the aged care sector.
These are discussed below.
Independent Aged Care Legislated
Review
4.53
A critical input to future reform is the Independent Aged Care
Legislated Review, undertaken by Mr David Tune AO PSM. This review assessed the
impact of aged care reforms announced in 2012, how the system has changed and
adapted, and where the Government could make further changes. The final report
was provided to the Minister for Aged Care on 31 July 2017 and a response by
the Australian Government has not yet been released.[58]
Single Aged Care Quality Framework
4.54
The Australian Government announced in the 2015–16 Budget it would work
with the aged care sector to make changes to the Aged Care Accreditation
Standards used by the Quality Agency, and proposed to establish a Single Aged
Care Quality Framework (single quality framework) for all aged care services.[59]
4.55
The single quality framework has undergone a public consultation process
on the two proposed components: a single set of quality standards and options
for a streamlined approach for assessing provider performance against those
quality standards.[60]
It is important to note that while the single quality framework was announced
in May 2015, the public consultation process was opened in March 2017, at a
time when the Oakden complaints were public knowledge and the SA Chief
Psychiatrist's investigation was underway.[61]
Single standards
4.56
The single set of standards, which is
proposed to apply to all aged care services including residential care,
home care and flexible care, were
released in draft form on 30 January 2018 with a view to start the transition
to these standards by mid-year.[62]
These standards:
...focus on quality outcomes for consumers rather than provider
processes. This will make it easier for consumers, their families, carers and
representatives to understand what they can expect from a service. It will also
make regulation simpler for providers working across multiple aged care
services, and encourage innovation, excellence and continuous improvement.[63]
4.57
The draft standards also include a draft explanatory document detailing
the application of the standards, noting that they 'have been structured so
that aged care providers will only have to meet those standards that are
relevant to the type of care and services they provide and the environment in
which services are delivered'.[64]
4.58
The consultation report on the single quality framework noted '[p]rior
to implementation, the draft standards will be tested and piloted. This will
provide valuable insight into the application and assessment of the standards
and guidelines to support their refinement'.[65]
The Department of Health also described publishing the draft standards at this
point as 'an important step in strengthening the standards and ensuring we're
setting contemporary best practice benchmarks for providers to meet'.[66]
The pilot phase will be undertaken from late January to April 2018 by the Quality
Agency and will involve a number of service providers and consumers from around
Australia.[67]
4.59
The Department of Health further noted the development of the single
quality framework as part of an overall shift to 'a more market-based system
where the consumer drives quality'.[68]
4.60
The Carnell Paterson review also made comments on the need for overhaul
of the current regulatory system, writing that the system 'gives the impression
of being the result of multiple incremental changes, rather than system-based
design to achieve the most efficient and effective regulation of
quality in aged care'.[69]
Streamlined provider assessment
4.61
The 2015–16 Budget also proposed privatising aged care accreditation
services:
The Government will also work with the sector to deliver private
market provision of accreditation services as part of a single aged care
quality regime across both community and residential care. Currently, the
Government's Aged Care Quality Agency is the sole provider of aged care
accreditation services.[70]
4.62
However, the March 2017 public consultation process on the single
quality framework did not include privatisation of accreditation services in
the three options for assessing performance it presented for comment. The
consultation report found the majority of stakeholders supported the adoption
of a single, risk-based assessment process for all aged care settings, combined
with the use of a safety and quality declaration by organisations providing
low-risk services.[71]
4.63
The Carnell Paterson review also made comment on external regulation,
and wrote:
In our view, the rationale for regulation of residential aged
care quality is that the market is an inadequate mechanism to ensure the safety
and well-being of highly vulnerable residents. Elderly citizens living in care
facilities, many of whom suffer from disabilities and dementia associated with
ageing, are especially in need of protection.[72]
Committee
view
4.64
The committee notes the fundamental change to the aged care quality
assessment framework and processes being brought about under the draft single
quality framework. As this new framework has only just been published in a
draft form, but is directly relevant to the terms of reference for this
inquiry, it will be difficult for the committee to form a final view and set of
recommendations for this inquiry.
4.65
Furthermore, the committee notes the Department of Health comments that
the provision of aged care is moving to a more 'market-based system', which is
similar to the change to disability services which resulted in the National
Disability Insurance Scheme. While this move in disability services has been
positive overall, there have also been significant unintended negative
consequences for some service users as well as implementation difficulties,
which should be studied and used to inform any such market-based reform of aged
care services.
Recent inquiries
4.66
Perhaps the most compelling argument pointing to a regulatory system
that is failing to provide adequate oversight of the aged care sector is the
number of recent reviews and inquiries into various aspects of aged care
service delivery. Many of the recommendations made in these inquiries remain
unimplemented.
Productivity Commission
4.67
The Productivity Commission recommended an overhaul of the aged care
regulatory system in its 2011 report Caring for Older Australians,
finding 'the current regulatory framework is unsatisfactory and there is scope
to improve its efficiency and effectiveness while ensuring an acceptable
approved standard of care'.[73]
Relevant to concerns raised in this inquiry, the Productivity Commission
recommended the establishment of an Australian Aged Care Commission, with
Commissioners for Care Quality and for Complaints and Reviews and to implement
a national independent statutory Community Visitors Program and improvements to
data collecting and sharing.[74]
Australian Law Reform Commission
4.68
The ALRC June 2017 Elder abuse report looked at, among other things, the
issue of abuse and neglect in residential aged care facilities. The Elder abuse
report recommended the development of a National Plan to combat elder abuse,
and specifically in the aged care context recommended establishing a serious
incident response scheme, reforms relating to the regulation of care workers,
regulating restrictive practices and developing national guidelines for
community visitor schemes.[75]
To date these recommendations have not been implemented, or agreed to by the
Australian Government.[76]
Senate inquiry into Aged Care
workforce
4.69
The Senate inquiry report Future of Australia's aged care sector
workforce, released on 28 April 2017, made a series of recommendations
regarding the regulation of residential aged care workforce, including a
national employment screening or worker registration scheme.[77]
The Minister for Aged Care, the Hon. Ken Wyatt AM, MP, responded to the report
on 21 June 2017, announcing the Australian Government's intention to establish
a taskforce to support an industry led workforce strategy.[78]
The Minister for Aged Care subsequently announced the establishment of the
taskforce on 1 November 2017, to be led by Professor John Pollaers to 'explore
short, medium and longer term options to boost supply, address demand and
improve productivity for the aged care workforce'.[79]
Concluding committee view
Aged care is the only institution where the person who goes
in dies—that is almost guaranteed—so there are no repercussions for society
about how they've been treated. If you have a bad education system, a bad
prison system or a bad hospital system, there are repercussions for society
when those people leave those institutions. That's not the case in aged care.[80]
4.70
The evidence presented to this inquiry, which includes the reports of two
in‑depth inquiries into the services provided at Oakden, shows that
Oakden had a toxic culture of wilful negligence, cover-up and avoiding
management and regulatory responsibilities, which resulted in a 'care' service
which shocked the two external reviews tasked with making an in-depth
investigation into Oakden.
4.71
Services at Oakden included appallingly sub-standard clinical and
personal care, as well as abusive practices, some of which have been reported
as criminal acts. Evidence of this sub-standard care was noticeable to anyone
who cared to pay attention, but it seems that no-one in a position to effect
change wanted to pay the required attention.
4.72
The committee commends the SA Government for the extensive actions taken
to remediate the services at Oakden. However, the committee must also strongly
condemn the length of time it took for the relevant SA authorities to take
action after receiving serious complaints and clear warnings relating to Oakden.
Some of the instances of abuse or neglect occurred well after the date of the
Spriggs family complaint, and most likely would not have been possible had
appropriate action been taken at the time of the complaint.
4.73
The committee is deeply concerned that the Quality Agency visited Oakden
and had no concerns with the service as late as November 2016. This a mere
month before the CEO of NALHN formed a serious view about the quality of
service at Oakden, a view that was based on complaints made five months
earlier. The Committee is not convinced by the Agency's explanation as to how
this came about.
4.74
The committee believes that if a situation like that at Oakden can occur
for many years under the eyes of the regulators, then there are serious
concerns about the quality of oversight for the broader aged care sector, and
the quality of care being provided to vulnerable aged Australians.
4.75
The committee cannot be confident that there are not other aged care
facilities where abuse and neglect are occurring elsewhere in Australia.
4.76
The committee notes that while the two key inquiries into the standards
of care at Oakden have concluded, investigations into individual instances at
Oakden are ongoing. These investigations are by the Australian Health
Practitioner Regulation Agency into the standards of professional care being
given by individual registered health practitioners, by SA Police into assaults
on residents under the guise of restrictive practice, and by SA Independent
Commission Against Corruption into the appropriate actions of individual local,
state and federal management personnel. This last investigation, when
concluded, will be crucial in providing an assessment of any oversight
failures, and whether those are systemic failures or the actions of individuals
acting outside their mandated area of responsibility.
4.77
The committee strongly agrees with the views expressed by the majority
of submitters that while Oakden is at the extreme end of sub-standard aged care
services, it exemplifies broader concerns with the quality and oversight
frameworks for the overall aged care sector.
4.78
Of particular concern to the committee is the body of evidence relating
to model of care issues, definitions of personal versus medical care, and
clinical governance within aged care facilities. The aged care sector appears
divided in how it defines the provision of allied health or medical services,
and who takes ultimate responsibility for the quality of service provision or
the oversight and regulation of that health service.
4.79
The committee is concerned about the ongoing use of restrictive
practice. We are aware that there are residential aged care facilities that
have virtually eliminated use of chemical and physical restraints. The reform
process needs to address this issue.
4.80
Additionally, aged care is experiencing an explosion of demand for
dementia and mental health specialist services. Providers of those services are
themselves divided as to whether these are health (or medical) services, and
whether there needs to be specialist internal governance and external oversight
mechanisms. It is clear the aged care sector needs better links to broader
mental health and cognitive impairment service providers, to implement best
practice of those specialisations within an aged care context.
4.81
The committee notes the views expressed above by aged care sector expert
Professor Ibrahim. The committee firmly states that vulnerable aged Australians
deserve the same level of personal and clinical care, the same level of
oversight, regulation and protection from abuse that any other Australian
deserves, regardless of their time of life.
Recommendations
4.82
The evidence presented to this inquiry clearly showed that many of the
circumstances that led to the substandard level of care given to residents of
Oakden were not unique to that facility. Not only are there similar models of
care in other facilities, many of the failures in the quality oversight
frameworks are universal, in that they could occur again in relation to any
aged care facility, in any location, providing any kind of general or
specialised aged care service.
4.83
The committee intends to extend this inquiry to further investigate aged
care quality frameworks, with amended terms of reference to remove reference to
Oakden, to ensure the inquiry can review the same issues without any
restriction on location.
4.84
The committee anticipates that the Australian Government response to the
recommendations of the Carnell Paterson review, due to be announced in the
context of the Budget in May 2018, and the new Single Aged Care Quality
Framework, due to be introduced in July 2018, will play major roles in the
ongoing examination of the Aged Care Quality Assessment and accreditation
framework. Continued inquiry by the committee will be directed by the outcomes
of those external bodies of work.
Recommendation 1
4.85
The committee recommends the extension of this inquiry into the effectiveness
of the Aged Care Quality Assessment and accreditation framework for protecting
residents from abuse and poor practices, and ensuring proper clinical and
medical care standards are maintained and practised.
4.86
A primary cause of the failures at Oakden was due to the specialist
mental health services being delivered in the context of being classified as an
aged care service as opposed to a health service. This incorrect classification
directly led to lower levels of service planning, workforce specialisation,
oversight and regulation.
4.87
The committee strongly agrees with the views put forward to the Carnell
Paterson review by the expert organisation in health safety, the Australian
Commission on Safety and Quality in Health Care, which recommended that all
services for severe dementia should be accredited under the Australian Health
Service Safety and Quality Accreditation Scheme and must meet the National Safety
and Quality Health Service Standards.
Recommendation 2
4.88
The committee recommends that in the current aged care oversight reforms
being undertaken, all dementia-related and other mental health services being
delivered in an aged care context must be correctly classified as health services
not aged care services, and must therefore be regulated by the appropriate
health quality standards and accreditation processes.
Senator Rachel Siewert
Chair
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