Review of the residential aged care accreditation process

Submission to the Department of Health and Ageing Office of Quality and Compliance

Download: CPSA's submission to the Review of the Residential Aged Care Accreditation Process [Word Document - 431.5 KB]

Quicklinks

  1. Recommendations 
  2. Introduction
  3. Monitoring of homes
  4. Case Study: Karingal Nursing Home mouse infestation
  5. Efficacy of site audits
  6. The Aged Care Standards and Accreditation Agency's Board of Directors
  7. Public information about aged care facilities
  8. Resident, relative and staff input into the monitoring of homes 
  9. Complaints avenues
  10. Involvement of independent stakeholders and clinicians in the monitoring process 
  11. Clinical care and quality of life indicators
  12. Unnanounced visits
  13. Nomination of assessors
  14. Culturally and linguistically diverse and Aboriginal and Torres Strait Islander residents and the assessment process
  15. Staff to resident ratios and skill mix 
  16. References

Recommendations

1. Monitoring of nursing homes focus on residents’ wellness and wellbeing rather than a home’s systems designed to support compliance with the Aged Care Act (1997).

2. Appointees to the Aged Care Standards and Accreditation Agency Ltd’s board do not hold conflicts of interests.

3. Information about individual home’s fees and charges be made publicly available.

4. The audited accounts of homes be acquitted against actual expenditure and made publicly available.  

5. All reports compiled by the Agency on homes be made publicly available.

6. Monitoring recognise the vulnerability of nursing home residents and the possible inability and/or reluctance of residents to complain about quality of care or lifestyle in a nursing home.

7. The ability to disclose the identity of staff who make comment or complaint to the Agency be abolished. Staff must be able to make comment in confidence to the assessors.

8. An inquiry be undertaken to assess the efficacy of the Complaints Investigation Scheme by the Commonwealth Ombudsman.

9. The Office of the Aged Care Commissioner be independent of the Department of Health and Ageing. 

10. As a matter of course, monitoring expand its scope to interview individuals who are in regular contact with the home, but are not part of management or employed by the home. For example, a greater involvement of general practitioners, podiatrists, pharmacists, and others independent of a facility would improve the robustness of monitoring processes.

11. Clinicians be part of the assessment process, to examine the health of residents in aged care facilities.

12. Standards of clinical care and quality of life not be treated in isolation, rather viewed as inherently linked, by both providers and assessors.

13. Unannounced visits that concern the wellness and wellbeing of residents be increased to ensure that homes are meeting their obligations under the Aged Care Act (1997).

14. Support contacts by phone be abolished. All support contacts must involve a visit to the home.

15. Unannounced visits and audits not be restricted to business hours. Night and weekend unannounced visits should be a standard part of the monitoring process.

16. The ability for homes to nominate an assessor for an accreditation audit be abolished.

17. Monitoring of a home’s ability to meet all the cultural and communication needs of residents (including CALD and ATSI residents) be made part of the standards for accreditation and compliance.

18. All staff must be able to communicate effectively with all residents, and receive appropriate language training as required.

19. Mandatory staff to resident ratios be employed in aged care facilities to ensure quality of care and lifestyles of residents are achieved and maintained.

Introduction

CPSA welcomes the opportunity to provide comment to the Department of Health and Ageing (the Department)’s Review of the residential aged care accreditation process. Monitoring and assessment of standards of care and quality of life in nursing homes (residential aged care facilities) is essential to ensure residents, their families, staff and the broader community can have confidence in the aged care system. Residential aged care facilities are peoples’ homes rather than transitory accommodation (although a very small number of residents access aged care facilities for respite services). For this reason, quality of lifestyle and the ability to be part of care delivery is as essential as quality clinical care. Currently, the aged care outcomes centre on a nursing home’s systems regarding operations and as such, there remain considerable gaps in the monitoring and assessment process. These gaps become stark when lapses in care arise, generally to the detriment of residents’ wellbeing (and at times, that of staff too). The current accreditation process is based on minimum standards rather than a standard scale. For people needing care, and their families, this effectively means that if a home is accredited, it provides a minimum standard of care and living environment. It results in an accreditation process whereby minimum standards equal accreditation (and government subsidies), and the community is left without any indication of the quality of care and services in homes. 

Monitoring of homes

The primary overseer of nursing home standards is the Aged Care Standards and Accreditation Agency (the Agency). The Department also monitors nursing homes, usually in response to a complaint or when a home’s non-compliance is serious and sanctions are required.

While the monitoring and accreditation process generally results in action being taken where non-compliance is found, gaps in this process remain. There is concern that non-compliance fails to be detected in audits. There have been several examples of homes passing accreditation site audits (the most extensive of compliance with standards assessments), yet, not long after, a home is found to be failing its duties under the Aged Care Act 1997 (the Act). Often it is only when a complaint is made to the Department or following exposition of a nursing home’s failure by the media that action is taken to address a home’s non-compliance.

Case study: Karingal Nursing Home mouse infestation

A prime example of this is the mouse infestation in a Queensland nursing home in April 2009. The problem came to the fore when two residents were bitten by mice, one of whom was gnawed in his sleep. The incident attracted media attention, and promptly afterward the Department ordered an investigation by the Agency into the matter. The Department also facilitated the home’s management of the mouse plague.

Alarmingly, the Agency’s report on the infestation revealed that the problem had been present for at least ten months before eradication of the mice was successful. [1] Of even more concern, the Agency had conducted its accreditation review in September 2009, which was during that ten month period, but failed to pick up on the problem. The accreditation report makes no mention of residents, relatives or staff discussing the presence of mice in the home, despite concerns being raised by residents only five days after the Agency had completed their site audit. [2] Reasons behind the escalation of the mouse infestation were attributed to poor reporting systems within the home, as well as poor implementation of pest control measures. [3] However, in the Agency’s accreditation report only several months earlier, these systems were found to be satisfactory. [4] The report also noted that incidents regarding mice had been recorded, mostly in the maintenance log. The Agency, although having reviewed the maintenance log at the site visit in September, did not take any action about the presence of mice in the home.      

Efficacy of site audits

This case highlights weaknesses in the accreditation system. The accreditation process takes account of a home’s systems, which are in place to “provide quality service time and time again”.[5] However, as shown in the example above, systems do not necessarily produce quality care, nor does an assessment of systems result in the detection of problems. The Agency must notify homes of their upcoming site audit three months in advance, giving homes time to prepare for the audit, which generally lasts for three days. There are concerns about this process (which is arguably the Agency’s most extensive review of a nursing home), as it gives homes a considerable period of time to prepare. There is sentiment within the industry itself that providing a home’s paperwork is satisfactory, problems within a facility are not necessarily detected. [6] These views, and the example of Karingal Nursing Home, highlight that the accreditation process’s assessment of the quality of ‘systems’ does not necessarily result in a promotion of quality care and quality lifestyles for residents. 

Recommendation 1: Monitoring of nursing homes focus on residents’ wellness and wellbeing rather than a home’s systems designed to support compliance with the Aged Care Act.

The Aged Care Standards and Accreditation Agency’s Board of Directors

CPSA considers the appointment of directors to the Aged Care Standards and Accreditation Agency’s board who are currently employed by, or board members of, an aged care provider, inappropriate. Appointment of members who are directly involved with the provision of aged care creates, in CPSA’s view, a clear conflict of interest.

Currently, five of the 12 members of the Agency’s board are employed by an aged care provider, or sit on the board of an aged care provider. In the interests of independence of the Agency, it is prudent to ensure that its board of directors are independent of aged care service provision. 

The Agency is the principal monitor of standards in nursing homes, and therefore, its board members should not have direct involvement in the provision of aged care. The board of directors of the Agency should comprise experts in the field of aged care who do not hold a conflict of interest.

Recommendation 2: Appointees to the Aged Care Standards and Accreditation Agency’s board do not hold conflicts of interests.

Public information about residential aged care facilities

There is a dearth of public information about individual aged care facilities. There is no requirement for facilities to make public information about service fees charged, including accommodation bonds, nor is there a requirement for facilities to make public their audited accounts. Legislation provides for the Department to make public this information. However, to CPSA’s knowledge, the occurrence of this is rare. In 1997, the Australian Government removed the requirement that aged care facilities’ subsidies be acquitted against actual expenditure, [7] thus removing accountability for government subsidies. The lack of transparency in the aged care sector leaves the consumer unable to make an informed decision about nursing homes, and what may be best for them or their relative. Importantly, it stymies public scrutiny. The lack of public information on a home’s financial activity undermines public confidence in a system that is heavily subsidised by public funds. Indeed, it precludes informed public debate about aged care policy. To better inform the public, information about a home’s fees and charges should be freely available. In addition, the audited accounts of each nursing home should be publicly available.              

Similarly, there is very little information available to the consumer about audits. Only the Agency’s site audit report or accreditation report is made public. A review audit report may be published on the Agency’s website, but this is very rare. Once a new accreditation report is uploaded on the Agency’s website, the previous report is removed, and not archived. As a result, only a very small percentage of Agency’s reports are publicly available and consumers have very limited information about quality of care and lifestyle in individual homes.               

Recommendation 3: Information about individual home’s fees and charges be made publicly available.

Recommendation 4: The audited accounts of homes be acquitted against actual expenditure and made publicly available.  

Recommendation 5: All reports compiled by the Agency on homes be made publicly available.

Resident, relative and staff input into the monitoring of homes

As the Karingal Nursing Home example shows, residents, relatives and staff will not always alert assessors to problems in a home during a site visit. Currently, assessors must interview at least 10 per cent of residents and/or relatives during a review audit and a site audit. This requirement does not apply to support contacts. Anecdotal evidence suggests that interviews with residents and relatives are time consuming for assessors. Given that the duration of a support contact is a day, it is safe to assume that assessors would have difficulty interviewing a meaningful number of residents or relatives. If a home has been accredited for three years, annual support contacts will be the only other contact a home has with the Agency, unless the home is one of the few that receive an unannounced review audit, [8] has been the subject of complaint/s, changed key personnel, or reduced/increased bed numbers. As at March 2009, most homes were of medium size (comprising between 30 and 79 beds) and most of these were accredited for three years (as were most homes). [9] Therefore, it is entirely possible that most individuals in many nursing homes go for years without an interview with an assessor, if ever.  

Residents should be at the centre of the monitoring process. Homes should be required to inform residents and relatives about review audits and support contacts so that they are better prepared to participate. This would also assist residents who do not speak English well or have sensory loss when it is necessary to enlist an interpreter for communication with assessors to take place. Furthermore, the Agency should expand the number of residents interviewed during visits. By way of comparison, the Dutch assessment model of nursing homes requires that all residents in a facility be interviewed. The resident’s/relatives’ experience and points of view are entrenched in the Dutch accreditation process, through systematic interviewing and data collection. As a result, partiality in assessment is reduced, and residents’ and relatives’ input is better employed in the accreditation process. 

At the same time, there must be greater recognition by the Department, Agency and homes that some residents, relatives and staff do not complain, as they do not wish to ‘make a fuss’ or be a burden. This is especially the case for residents and families who may have had considerable difficulty gaining entry to a home because of the few beds available. Additionally, many fear reprisal, and whether that fear is founded or not, it prevents complaints being made. For this reason, the complaint avenue available to residents and relatives cannot be relied upon to recognise lapses in care in homes where accreditation fails to do so. Interviewing most residents in a more organised way would reduce the possibility of issues going unnoticed. This data could then be used more efficiently in the decision to accredit, and to inform the home on its strengths and weaknesses.   

Staff should be able to make comment to the Agency or the Department in confidence. Current legislation allows residents and relatives to make comment or complaint to assessors without their identity being disclosed to a home’s management. However, this same protection is not afforded to staff. This may inhibit staff to make comment or complaint because their identity may be disclosed to their employer and as such, staff may fear reprisal. Confidentiality should be provided to all who give information to assessors.

Recommendation 6: Monitoring recognise the vulnerability of nursing home residents and the possible inability and/or reluctance of residents to complaint about quality of care and lifestyle in a nursing home.

Recommendation 7: The ability to disclose the identity of staff who make comment or complaint to the Agency be abolished. Staff must be able to make comment in confidence to the assessors.

Complaint avenues

CPSA believes that the Aged Care Complaints Investigation Scheme (CIS) forms an integral part of the complaints process. However, CPSA questions the current scheme’s effectiveness in investigating complaints. CPSA understands that the CIS receives a large number of ‘contacts’ per annum, of which a majority become ‘in-scope’ cases, warranting investigation. In the last financial year, the CIS considered 7,496 as ‘in-scope’ cases. However, in only 930 or 12.4% of these cases was a breach of the approved provider’s responsibilities under the Act identified.

This seems to be an incredibly low percentage. Either thousands of people make false accusations to the CIS, or investigation techniques are insufficient to find fault.

CPSA recognises that an investigation scheme will never be perfect and therefore, the inability of the Aged Care Commissioner to override decisions made by the CIS is an alarming weakness of the system. If recommendations to adjust a decision made by the CIS do not have to be acted upon, then the role of the Commissioner is effectively void. CPSA calls for reform of the role of the Aged Care Commissioner to make the Commissioner's decision binding.

For these reasons, CPSA considers an independent inquiry into the operation of the CIS to ensure that adequate complaints avenues are in place to protect some of the most vulnerable members of our society in residential aged care facilities. The Office of the Aged Care Commissioner should be independent of the Department.

Recommendation 8: An inquiry be undertaken to assess the efficacy of the Complaints Investigation Scheme by the Commonwealth Ombudsman.

Recommendation 9: The Office of the Aged Care Commissioner be independent of the Department of Health and Ageing. 

Involvement of independent stakeholders and clinicians in the monitoring process

Approximately 70 per cent of residents in aged care facilities require a high level of care (and are classified as ‘high care’). [10] These residents generally have complex care needs that may necessitate management by a team of health professionals both inside and outside the home. About half of residents in residential aged care facilities have dementia, and the majority suffer from some form of sensory loss. [11] Residents are entitled to have a complex medical assessment annually, and the GP that undertakes the assessment is required to provide the patient with a copy. [12] However, there is no requirement that nursing homes keep a copy, nor is there a requirement that homes use the assessment to formulate a care plan for the resident. [13] In addition, there has been criticism about the lack of coordination in some homes for people with complex health needs. This is in contrast to the Department of Veteran Affairs’ system, where residents are assigned a care coordinator who acts as the first point of call for health professionals concerned with the resident’s care. [14] This minimises miscommunications, and strengthens care delivery. 

As a matter of course, monitoring should expand its scope to include individuals who are in regular contact with the home, but are not part of management or employed by the home. For instance, a greater involvement of general practitioners, podiatrists, pharmacists, and others independent of a facility would improve the robustness of monitoring processes.

Accreditation does not require independent examinations of the health of residents. There are no medical checks as part of the monitoring process and clinical care outcomes are primarily measured by a home’s documentation of the processes employed to support clinical care ‘expected outcomes’. For example, the accreditation process does not necessarily register whether a resident’s oral health is good or bad – it registers whether a home has a system in place to maintain a resident’s oral health. Therefore, even if a resident’s oral health is unsatisfactory; if the home’s oral health maintenance system is in place that is enough. An aged care or health background is not a prerequisite to become a qualified assessor, although some assessors do have such backgrounds.

Inclusion of clinicians in assessment teams would improve the accreditation process’s ability to detect poor health outcomes, especially for very frail or elderly residents with complex needs. For this to be effective, the clinician would have to be able to examine most residents, especially in facilities with a large high level of care population. 

Recommendation 10: As a matter of course, monitoring expand its scope to include individuals who are in regular contact with the home, but are not part of management or employed by the home. For instance, a greater involvement of general practitioners, podiatrists, pharmacists, and others independent of a facility would improve the robustness of monitoring processes.

Recommendation 11: Clinicians be part of the assessment process, to examine the health of most residents in aged care facilities.

Clinical care and quality of life indicators

Accreditation must not separate clinical care and quality of life indicators. Clinical care and quality of life must not be treated in isolation, but viewed as inherently linked, by both providers and the assessment process. For example, a resident’s fall history may show that their rate of falls is low. However, what may not be clear are the methods in place to prevent falls, such as the use of a restraint. Use of the restraint would most likely decrease the resident’s quality of life, but, clinically, the reduction of the resident’s falls would be seen as a positive development. It is important that both clinical care and quality of life are assessed in conjunction with one another.         

Recommendation 12: Standards of clinical care and quality of life not be treated in isolation, rather viewed as inherently linked, by both providers and assessors.

Unannounced visits

CPSA supports unannounced visits by the Agency. Currently, each nursing home in Australia must receive one unannounced visit annually. Most unannounced visits are in the form of a support contact and a home is given half an hour’s notice that a visit will take place. A home has the ability to refuse entry of the assessor/s. However they run the risk of not complying with their responsibilities under the Act if they choose to do so. It is unclear if homes exercise their right to refuse entry to assessors because such information is not documented publicly.

Of concern to CPSA is that most unannounced visits are in the form of a support contact. The Agency can carry out a support contact by phone. CPSA is concerned that the legislation therefore allows so called unannounced visits to be conducted over the phone, as the definition of an unannounced visit is a support contact (or a review audit). CPSA considers support contacts by phone as an unsuitable means of monitoring quality of care and residents’ lifestyles in a home. Phone support contacts must be abolished, and all support contacts must be carried out on-site.

People receiving care are often incredibly vulnerable. Many do not have outside supports (family and friends) to assist if there is an issue regarding quality of care in a home. It is anyone’s guess as to how many issues go unnoticed by the Department or the Agency because they have not been reported. We also do not have a clear idea of the quality of nursing homes over a 24-hour time period, unless complaints are made by staff, residents or relatives. This is due to legislation generally restricting Agency visits to homes for the purposes of accreditation and compliance checks to ‘business hours’ – between 9am and 5pm. It is not uncommon to hear of homes rostering only one or two staff members to cover night shifts for a large home, staff members being overworked during dinner time because there are not enough staff rostered on to attend to residents appropriately, and residents not being toileted in a timely fashion because of inadequate staff numbers. For these reasons, unannounced visits to nursing homes outside business hours would better enable the Agency to detect problems in care delivery over a 24-hour period. 

NSW has an Official Visitors Program that monitors conditions of psychiatric hospitals, units and community services. This program employs people with a medical or allied health background to visit mental health facilities and act as an advocate for residents and monitor conditions and quality of lifestyles in these facilities. Visits take place once every two months and visitors liaise with residents, carers and relatives “to ensure that standards of treatment and care and the rights and dignity of people being treated under the NSW Mental Health Act (2007) are upheld”. [15] Visitors are appointed by the NSW Minister for Health, for a period of three years. Residents are free to contact visitors between 9am and 5pm, Monday to Friday. CPSA considers such a model worthy of exploration vis à vis aged care monitoring. Employing an independent scheme whereby residents and the conditions in which they reside are the main area of focus, would strengthen resident input (and that of relatives and carers), and place greater attention on residents’ quality of life.    

Recommendation 13: Unannounced visits that concern the wellness and wellbeing of residents be increased to ensure that homes are meeting their obligations under the Aged Care Act.

Recommendation 14: Support contacts by phone be abolished. All support contacts must involve a visit to the home.

Recommendation 15: Unannounced visits and audits not be restricted to business hours. Night and weekend unannounced visits should be a standard part of the monitoring process.

Nomination of assessors

CPSA calls for the removal of the provision that allows homes to nominate assessors to conduct a site audit. Such a provision creates a clear conflict of interest and undermines the integrity of the monitoring process. Site audits are the system’s most extensive review of a home’s operations, and therefore, independence of assessors should be paramount.

Recommendation 16: The ability for homes to nominate an assessor for an accreditation audit be abolished.

Culturally and linguistically diverse and Aboriginal and Torres Strait Islander residents and the assessment process

Culturally and Linguistically Diverse (CALD) and Aboriginal and Torres Strait Islander (ATSI) residents are a significant minority in the aged care system. The Australian Institute of Health and Welfare shows usage rates for residential aged care facilities by overseas-born people whose main language is not English is 46.5 per 1,000 persons aged 75–84 years and 192.5 per 1,000 aged 85 years and over. [16]  Usage rates by the Aboriginal and Torres Strait Islander population, are 17.7 per 1,000 Indigenous persons aged 65–69 years, 27.5 per 1,000 aged 70–74 years, and 110.2 per 1,000 aged 75 years and over. [17] Research commissioned by Alzheimer’s Australia in 2006 shows that 12.4% of people with dementia do not speak English at home. [18] Around half of Australians with dementia reside in a nursing home. [19] While the majority of the residential aged care population is proficient in English, the prevalence of residents without such proficiency is considerable. With regard to monitoring, the Agency ‘may’ employ an interpreter during a visit to a home. However, the Agency concedes that this is not always practical. It is reasonable to assume that during visits, (especially an unannounced support contact), the probability of enlisting an interpreter to conduct an interview with a resident/residents is even less because of time constraints.

The Aged Care Standards do not sufficiently address quality of life for people without a proficiency in English, who reside in a home without staff and fellow residents who speak their language. The main outcome against which CALD residents’ social interaction is assessed is “individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". [20] This standard is incredibly indistinct, and consequently, is open to broad interpretation by assessors and homes alike. It appears that assessment against this standard does not necessarily involve residents’ and relatives’ views, but rather whether the home has systems in place to ‘foster’ cultural practices. For instance, a home may provide newspapers and television programmes in languages other than English, have a culturally relevant menu, engage staff who speak residents’ language (other than English) or provide access to an interpreter service, and comply with the expected outcome. Indeed, if the assessors were unable to communicate with a resident, through lack of an interpreter, assessment of that residents’ satisfaction with the home would be overlooked altogether. It also must be noted that use of relatives as interpreters for residents is inappropriate. It compromises a resident’s right to privacy, and may result in misinterpretation. Independent interpreters should be used for communication with residents who need it.

There is evidence that homes do not adequately employ interpreters for residents. The cost of such services may act as an inhibitor, and interpreter services may be seen as ‘unessential’ in the broader scheme of care provision. Homes may enlist aids to assist staff to communicate with residents where a common language is not shared. However, living in an environment where there are inadequate avenues for communication greatly compromises one’s quality of life and care. Assessment of homes must consider resident’s ability to communicate with staff and fellow residents and greater effort should be made to incorporate non-English speaking residents’ opinions.    

Nursing homes should also ensure staff are proficient in a common language for all residents, which at most times would be English. Management must be held responsible for ensuring that staff in need of language training receive it.  

Recommendation 17: Monitoring of a home’s ability to meet the cultural and communication needs of residents (including CALD and ATSI residents) be made part of the standards for accreditation and compliance.

Recommendation 18: All staff be able to communicate effectively with all residents, and receive appropriate language training as required.

Staff to resident ratios and skill mix

Adequate staffing levels and correct skill mixes improve care and quality of life outcomes for residents in homes. As such, mandatory staff to resident ratios must be employed in aged care facilities to ensure quality of care and lifestyles of residents are achieved and maintained.

It is unclear how the accreditation process can objectively assess whether a nursing home has adequate staffing levels and appropriate skill mixes under the current standards. The current accreditation system relies on an assessor’s determination of what would be appropriate for a home to carry out care for residents. This is open to assessor bias. Assessment of staffing levels involves in part looking at rosters and observing activity in the home during the visit. As there are no checks on homes at night, the only way to examine night staffing levels is to look at rosters and question staff about their workloads. As there is no mandatory staff to resident ratio for aged care facilities, assessors must, at best, make an ‘educated guess’ about adequate staffing. This also makes it impossible for residents, relatives, as well as the broader public to gain an indication of various homes’ staffing levels. For prospective residents and relatives, adequate staffing is a key issue when deciding on a home. However, the current standards and accreditation process shed very little meaningful light on staffing in aged care facilities.

Quality care requires adequate numbers of staff with appropriate skill mixes. If staff are time poor or staff lack correct skills (or both), quality care is undermined. As approximately 70 per cent of residents in aged care facilities are classified as ‘high care’, the vast majority of residents have significant care needs. CPSA recognises workforce issues in the industry. However, staff cut backs are not uncommon in the industry, which, in CPSA’s view compromises quality care and lifestyle outcomes for residents.

The Victorian Government has mandatory staff to resident ratios in its hospital system. It also gives aged care facilities the option of signing up to this system. For an aged care facility, the care staff to resident ratio is 1:7, with a supervising staff member alongside. Such a ratio gives facilities a clear measure for their staffing requirements. It also provides residents and relatives an assurance that an adequate number of care staff will be rostered on.  

Good care requires adequate numbers of staff with appropriate skills. Considering adequate staffing levels and skill mixes are critical to quality care and lifestyles, this method of assessment lacks rigour. Mandatory staff to resident ratios that outline appropriate skill mixes would bolster both the accreditation process and better protect residents receiving care. 

Recommendation 19: Mandatory staff to resident ratios be employed in aged care facilities to ensure quality of care and lifestyles of residents are achieved and maintained.

 

References

1. Aged Care Standards and Accreditation Agency  Report to the Minister for Ageing on the mouse infestation in the Karingal Nursing Home in April 2009, June 2009

.2. Aged Care Standards and Accreditation Agency  Report to the Minister for Ageing on the mouse infestation in the Karingal Nursing Home in April 2009, June 2009 p. 15

3.. Aged Care Standards and Accreditation Agency  Report to the Minister for Ageing on the mouse infestation in the Karingal Nursing Home in April 2009, June 2009

.4. Aged Care Standards and Accreditation Agency Decision to accredit Karingal Nursing Home, 11 September 2009

5. Aged Care Standards and Accreditation Agency, http://www.accreditation.org.au/residents-relatives/continuous-improvement/

6. Clode, Danielle (2008) The role of accreditation in clinical standards for Residential Aged Care Facilities p.17

8. 49 review audits were unannounced in the 2007/08 financial year, out of a total of 87. In the same year, 4,731 support conducts were conducted, of which 3,056 were unannounced (Report on the Operation of the Aged Care Act 1997; 2007/2008).

9. Aged Care Standards and Accreditation Agency, National Data Set, March 2009 

10. Residents in residential aged care facilities are classified as ‘low care’ or ‘high care’ according to their care needs.  

11. Clode, Danielle (2008) The role of accreditation in clinical standards for Residential Aged Care Facilities

12. Clode, Danielle (2008) The role of accreditation in clinical standards for Residential Aged Care Facilities p.11

13. Clode, Danielle (2008) The role of accreditation in clinical standards for Residential Aged Care Facilities p.11

14. Clode, Danielle (2008) The role of accreditation in clinical standards for Residential Aged Care Facilities p.11

15. Official Visitors Program, NSW Mental Health Act 2007 http://www.ovmh.nsw.gov.au/index.php/about-us

16. Australian Institute of Health and Welfare (2008) ‘Residential Aged Care in Australia’ Aged Care Statistics Series No. 28, p.17

17. Australian Institute of Health and Welfare (2008) ‘Residential Aged Care in Australia’ Aged Care Statistics Series No. 28 p. 17

18. Access Economics report prepared for Alzheimer’s Australia (2006) Dementia prevalence among people who do not speak English at home     

19. Clode, Danielle (2008) The role of accreditation in clinical standards for Residential Aged Care Facilities

20. Aged Care Standards and Accreditation Agency (2009) Accreditation Standards http://www.accreditation.org.au/residents-relatives/the-accreditation-standards/