Submission to the Senate Committee on Community Affairs – Effectiveness of the Aged Care Quality Assessment and accreditation framework

CPSA's response to the Senate Committee on Community Affairs 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 practiced.

More information about the inquiry can be found on the Parliament of Australia website, along with CPSA's submission

CPSA's Submission 

CPSA welcomes the opportunity to provide comment in relation to 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. CPSA represents pensioners of all ages and low income retirees. As such, CPSA has an interest in ensuring that the aged care system is able to deliver high quality care and support to all those who need it, regardless of their capacity to pay. This requires a robust and transparent quality assessment and accreditation framework that centres on the care needs of residents. In an increasingly market-based aged care system, the quality assessment and accreditation framework is critical in ensuring that all residents have access to safe care that meets their needs. CPSA has some serious concerns about the current framework.

a. 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;

A 2005 parliamentary inquiry 'Quality and equity in aged care' made a number of recommendations, including that the Aged Care Accreditation Standards be reviewed to include a clear definition of the expected outcomes associated with each of the standards[1]. Despite some changes to the Accreditation Standards in 2014, they do not currently consider the care outcomes for residents.

The system does not evaluate the actual care and support residents receive as the emphasis is on systems and processes, with the assessment process focusing heavily on paperwork, rather than care outcomes for residents. A quality system that assesses processes and systems is not actually assessing quality at all, as these processes and systems are not necessarily tied to the care outcomes which clients experience. The same processes and systems can lead to vastly differing outcomes for two clients based on their own needs and preferences. This means that the accreditation system is ill equipped to detect and respond to systemic failures in the delivery of care as the accreditation process is so disconnected from the actual care and services residents receive.

In the absence of objectively measurable indicators or specific standards, the current system is overly reliant on the assessments of individual Quality Assessors, who may be ill-equipped to make such judgements particularly in relation to clinical matters. For example, under the accreditation standards, Quality Assessors looking at staffing are required to determine whether there are 'appropriately skilled and qualified staff sufficient to ensure that care and services are delivered in accordance with these standards'. However, the Australian Aged Care Quality Agency (AACQA) does not have a specific methodology that Quality Assessors can use to determine the sufficiency of staffing levels based on the care needs of residents.

CPSA is concerned that the current accreditation framework for residential aged care facilities is insufficient to ensure that residents receive safe care, let alone care that aligns with clinical best practice. It is critical that the monitoring and assessment of the aged care sector is revised to focus on client observation and feedback rather than processes. It is also critical that the assessment of compliance against the quality standards is based on a set of objectively measurable care outcomes.

Recommendation 1: That the aged care accreditation standards be rewritten to focus on the expected care outcomes for residents.
Recommendation 2: That the aged care accreditation standards should be based on clinical best practice.

The nature of the current accreditation process means that it is only able to provide an assessment of care quality at a particular moment in time. Often aged care providers are aware of an upcoming quality inspection well in advance and can prepare accordingly. The current system is unable to pick up systemic care deficiencies. For example, CPSA notes that of the nine approved aged care providers currently under sanction, three had received a perfect 44/44 score at an AACQA inspection in the four months leading up to being sanctioned. Given that these sanctions were applied in response to an identified immediate and severe risk to the health, safety and wellbeing of care recipients at these facilities, CPSA is concerned that these care deficiencies weren't picked up at the previous inspection less than four months prior.

CPSA is of the view that these particular cases warrant further investigation in order to determine what, if anything, changed from the aged care providers perspective in terms of care systems and processes between the first and second inspections, why any deficiencies in care were not picked up at the initial inspection and how the audit process could be changed to prevent this kind of an occurrence in the future.

There is a need to increase the transparency around the quality assessment process and to improve public access to audit reports. CPSA notes that of the nine approved aged care providers currently under sanction, the audit report detailing the sanctions which should be published on the AACQA website can only be found for four of the providers. There are no records of any audit reports for two sanctioned providers on the AACQA website. For the three remaining providers currently under sanction, it is possible to obtain previous audit reports on the AACQA website, but not the audit report detailing the sanctions. There is an urgent need to streamline the MyAgedCare and AACQA websites so that the public is able to easily access information about sanctions. CPSA is of the view that the relevant audit reports should be included on the MyAgedCare sanctions page. Important information about the quality of aged care services is hidden from the public by needless complexity.

CPSA also notes that there is quite often a disconnect between the service name published on the MyAgedCare sanctions page and the service name associated with the audit reports on the AACQA website. There is also quite often a disconnect between the service name people are familiar with and the service name published on audit reports and notices of sanction, making it very difficult for people to find and access this information.

Recommendation 3: That in the interests of transparency, AACQA should be required to publish all audit reports immediately where sanctions have been imposed.
Recommendation 4: That the sanction detail summary page on MyAgedCare should include a copy of the relevant AACQA audit report to promote transparency and support client access to information.

b. the adequacy and effectiveness of complaints handling processes at a state and federal level, including consumer awareness and appropriate use of the available complaints mechanisms;

The current complaints system does not account for or address the inherent power imbalance between aged care providers and clients that limits a client's capacity and desire to make complaints. Clients are dependent on the services and support they are receiving from their residential aged care provider, which means they are less able to openly provide feedback or make a complaint. Many clients are fearful of speaking out or making a complaint due to fear of retribution from the aged care provider or a worker, or out of not wanting to rock the boat. Staff and those employed by an aged care provider are also limited in their capacity to blow the whistle or speak out when issues arise as they may face dismissal for doing so. There must be avenues available to clients, their supporters and aged care staff to provide feedback anonymously.

Further, clients, their supporters and staff must be able to make a formal complaint to the Aged Care Complaints Commissioner without having their identity revealed to the aged care provider against which the complaint has been made. This is a critical step in transitioning away from the current culture of fear, cover-up and repression towards a more open culture where aged care providers are readily open to feedback and take complaints as a serious impetus to improve services, rather than as attempts to 'defame' the organisation as is the case now.

Recommendation 5: That the Aged Care Complaints Commissioner should be able to investigate a complaint without revealing the identity of the complainant to the residential aged care facility.

CPSA notes that many people who have gone through the complaints processes report dissatisfaction with the outcomes. The focus is on conciliation, however CPSA questions whether this is an appropriate outcome goal for more serious complaints, particularly those involving allegations of serious care deficiencies contributing to or causing the deterioration or death of a client. There must be harsher penalties for aged care providers who fail to deliver appropriate care and support, which in turn results in the serious injury or death of a client. These sorts of failures should be viewed as cases of abuse and neglect and CPSA is not of the view that aged care providers who have failed to protect clients from abuse and neglect should be allowed to retain their accreditation.

Recommendation 6: That the Aged Care Complaints Commission pursues harsher penalties for aged care providers who fail to safeguard clients against abuse and neglect.

There is a need to include the broader community in providing feedback to drive improvement in the quality of aged care support and services. The vast majority of care for older Australians is provided informally through the community rather than through the market-like structure established via Australian Government policy. The broader community has strong views on what is and is not acceptable when it comes to caring for older Australians and should be both encouraged and supported to provide these views. Anyone who has had any interaction with an aged care service provider should be able to make a complaint to the Aged Care Complaints Commissioner if they see something that worries them.

Recommendation 7: That any member of the public who has concerns about an aged care service provider should be able to make a complaint to the Aged Care Complaints Commissioner.

c. the adequacy of medication handling practices and drug administration methods specific to aged care delivered at Oakden;

CPSA is unable to comment specifically on the medication handling practices and drug administration methods at Oakden, but offers a number of reflections regarding medication in residential aged care more broadly. CPSA is of the view that medications must be overseen by an appropriately skilled and experienced member of staff that has the clinical knowledge to assess how a person's medications may interact with each other and whether particular medications should be commenced or ceased based on a person's condition. Within a residential aged care facility, medications should be administered either by a Nurse Practitioner or Registered Nurse (RN).

CPSA is very concerned about the increasing use of dose administration aids such as Webster packs, which are being administered to residents by Personal Care Workers/Assistants in Nursing (PCAs/AINs). A 2008 study of the packaging of dose administration aids in 42 NSW nursing homes found packaging incidents in 34 of the facilities at rates between 1% and 54%[2]. PCAs/AINs are not trained to identify these sorts of errors, nor are they trained to know how particular medications interact. Further PCAs/AINs do not have the clinical expertise required to assess a person's condition in order to determine whether or not it is safe to administer all prescribed medications. If there is no RN administering and monitoring the effect of a medication, there is a risk that an adverse reaction to a drug will not be identified by other care staff. For example, the incorrect administration of insulin in a diabetic resident can very quickly become a medical emergency requiring immediate intervention to ensure survival.

CPSA is concerned about the administration of pro re nata (PRN) medicines, particularly for pain relief. In NSW, PCAs/AINs are not legally allowed to administer schedule 4 or schedule 8 PRN medicines without the direct supervision of an RN[3]. What this means in practice is that in the absence of an RN, the strongest pain relief that can be administered by a PCA/AIN are over-the-counter medications including paracetamol and ibuprofen. CPSA is concerned that in the absence of an RN or Nurse Practitioner to administer schedule 4 and schedule 8 PRN medicines, residents cannot receive the medicines they need and are left to suffer in pain. This is a particular concern for those receiving palliative care, who are more likely to require PRN medicines overnight and on weekends, when it is less likely an RN will be on duty to administer the medicines.

Recommendation 8: That the administration of medications must be overseen and administered by a Registered Nurse or Nurse Practitioner.

d. the adequacy of injury prevention, monitoring and reporting mechanisms and the need for mandatory reporting and data collection for serious injury and mortality incidents;

As far as CPSA is aware, there is no formal process for collating or reporting against serious injury and mortality incidents across the entire residential aged care sector. This means that there is no systemic approach to injury prevention or mortality reduction. It is essential that a framework is put in place to ensure that all serious injury and mortality incidents within the residential aged care sector are recorded and regularly monitored. Without a rigorous reporting and monitoring framework, it is not possible to identify, let alone understand and respond to systemic failures in the delivery of residential aged care. CPSA notes that a recent study estimated that there has been a 400% increase in premature deaths among nursing home residents since 2000[4]. This clearly highlights the need for a national policy framework to reduce the number of premature deaths within the residential aged care sector.

Recommendation 9: That the Australian Government introduces a national policy framework to reduce the number of premature deaths within the residential aged care sector.

There are a number of indicators that suggest the need for significant improvements in the quality of residential aged care services. CPSA is concerned that a failure to implement a national system to record incidents of serious injury and mortality has perpetuated the delivery of sub-standard care. CPSA notes that a recent discussion paper released by the Department of Health estimated that the prevalence of pressure injuries among those living in residential aged care to be between 26% and 42%[5]. This figure is completely unacceptable and warrants immediate intervention to reduce the incidence of pressure injuries.

Within the hospital system, pressure injuries have been recognised as an issue of patient safety, given that the majority of pressure injuries are preventable if appropriate measures are put in place. Public hospitals in Queensland face penalties of between $30,000 and $50,000 for each incident of a stage 3, stage 4 or unstageable hospital-acquired pressure injury. Since the introduction of these penalties, there has been a significant reduction in the incidence of hospital-acquired pressure injuries[6].

CPSA is of the view that financial penalties are required within the residential aged care sector to reduce serious injury and mortality incidents. The competitive market environment that residential aged care providers operate in necessitates a focus on financial viability over all else. Providers are under pressure to minimise their operating costs, which often leads to cut backs in spending on resident care. By virtue of the competitive market structure, residential aged care providers are far more likely to respond to financial incentives than any other form of regulation. CPSA notes that the current aged care funding instrument (ACFI) for residential aged care has been earmarked for replacement, most likely with an activity-based funding model. Financial incentives to reduce serious injury and mortality incident – such as penalties for pressure injuries – must be embedded within the new funding model.

Recommendation 10: That the Australian Government introduces a system for the mandatory reporting and monitoring of serious injury and mortality incidents that occur in residential aged care.
Recommendation 11: That the Australian Government introduce financial incentives for residential aged care providers to reduce serious injury and mortality incidents.

CPSA is concerned that the Department of Health does not have sufficient power to compel aged care providers to act in the best interests of residents. Where a particular practice or resource has been identified as a risk to the wellbeing or safety of residents, then the Department of Health must have the power to compel aged care providers to avoid that practice or resource. This is a particular issue when it comes to the use of restraints. For example, CPSA notes that the KA524 bed pole has been identified as unsuitable for use in a number of coroners' reports. In response, the Department of Health has issued two notices to aged care providers advising of this risk, however they do not have the legislative power required to ban providers from using the KA524 bed pole. It is unacceptable that the use of a restraint that has been implicated in the deaths of a number of residents is allowed to continue.

Recommendation 12: That the Department of Health should have the capacity to ban the use of practices and resources where there is evidence that such practices and resources present a significant risk to the health, safety and wellbeing of residents.

In addition to the above recommendations, CPSA highlights the Australian Law Reform Commission's (ALRC) proposal to replace the current reportable assaults scheme with a serious incident response scheme, which emerged as part of the Elder Abuse Inquiry[7]. The proposed scheme would ensure that all serious incidents are referred on for investigation so that steps can be put in place to minimise the risk of a similar occurrence. It is critical that all incidents are routinely investigated and followed up and it is very concerning that this isn't happening at the moment.

Recommendation 13: That the Australian Government fast-track the overhaul of the current reportable assaults scheme in line with recommendations 4–1, 4–2, 4–3, 4–4, 4–5, and 4–6 of the ALRC's final report on Elder Abuse.

CPSA is concerned about the potential links between the rise in premature deaths of nursing home residents, the rising acuity of residents in terms of their care needs and the declining number of RNs providing direct care. The number of RNs working in residential aged care has declined significantly as a proportion of the overall residential aged care workforce. According to the National Aged Care Workforce Census and Survey, RNs comprised 21% of the residential aged care workforce in 2003, dropping to just 14.6% in 2016[8]. This decline in RN numbers is even more concerning given that the majority of these RNs now spend less than one third of their time providing direct care[9]. RNs provide a higher level of skill and expertise than enrolled nurses (ENs) and PCAs/AINs. This is important in residential aged care, where, unlike hospitals, there is generally no immediate access to a doctor.

CPSA notes that the care needs of residents have increased significantly since the 2000s, which makes the decline in RN numbers even more concerning. In 2004-05 62.9% of those in residential care were classified as having high care needs[10]. In 2016 this had increased with 92% of those in residential aged care being classified as having high care needs[11]. While the majority of PCAs/AINs hold tertiary-level qualifications[12], their job is to provide basic personal care and support. RNs are charged with providing specialised clinical and medical care to residents, including the provision of palliative care, changing catheters and ensuring that changes in a resident's condition are picked up and acted upon.

CPSA is concerned that without an RN on duty at all times, residents with high care needs do not have access to the level of care they have been assessed as requiring. If there is no RN on duty to provide the care required, then the only option is to transfer the resident to a hospital emergency department. Residential aged care providers who accept residents with high care needs receive funding to provide a high level of care, components of which can only be delivered by an RN. Accordingly, CPSA is of the view that all residential aged care facilities looking after residents with high care needs should be required to have an RN on site at all times.

Recommendation 14: That residential aged care facilities looking after residents with high care needs should be required to have a Registered Nurse on site at all times.

One RN is not sufficient to ensure that those living in residential aged care receive the care that they need and CPSA notes that its members and continents are shocked to learn that there are no mandatory minimum staff to resident ratios in aged care. A study conducted by the Australian Nursing and Midwifery Federation highlighted that residents living in Australian nursing homes received an average of 2.84 hours of direct care per day[13]. The study found that residents require at least 4 hours and 18 minutes of care per day, delivered under a skill mix of 30% RNs, 20% ENs and 50% PCAs/AINs to ensure safe care. While there is no strong evidence to suggest that more than 4 hours and 18 minutes of care per day leads to better outcomes for residents, it is clear that fewer care hours are associated with adverse outcomes. The introduction of mandatory minimum staff to resident ratios is a critical step in ensuring the safety of residents. CPSA is of the view that these ratios should cover all direct care staff, including allied health professionals to ensure residents receive holistic care.

Recommendation 15: That mandatory minimum staff to resident ratios are introduced for all direct care roles, including nursing, personal care and allied health staff.

Many aged care industry bodies have rejected the call for minimum staff to resident ratios on the basis that ratios are a blunt instrument and that they may stifle innovation. CPSA anticipates that these minimum staffing ratios would be flexible, varying with reference to the care needs of residents. Given that ratios are intended as a basic minimum requirement to ensure the safety of residents, it is difficult to see how they could be viewed as an impediment to innovation.

The ALRC's final report on Elder Abuse recommends that the Department of Health commission an independent evaluation of research on optimal staffing models and levels in aged care, the findings of which would then be used to assess the adequacy of staffing as part of the accreditation process[14]. This study would provide much needed guidance on staffing and form the basis of minimum staffing requirements.

Recommendation 16: That the Department of Health commission an independent evaluation of the research on optimal staffing models and levels in residential aged care in line with recommendation 4 –7 of the ALRC's Elder Abuse Inquiry.

Given the importance of staffing models in the delivery of safe care that meets the needs of residents; residential aged care providers must be more transparent about the staffing levels they operate under. Currently, there is no way of knowing how each facility is staffed and providers have no obligation to inform prospective residents of actual staffing levels. CPSA has heard from many residents and families who have been promised 24 hour access to RNs, only to find that RNs are only rostered on during business hours. In order to address the issue of insufficient staffing and drive improvements across the residential aged care sector, providers should be required to publish the staffing ratios they operate under via MyAgedCare. Given that current staffing levels fall well below community expectations, increasing transparency in and of itself is likely to drive at least some improvement in staffing levels.

Recommendation 17: That aged care providers be required to publish the staff to resident ratios they operate under through MyAgedCare to promote transparency.

References 

[1] Senate Standing Committee on Community Affairs (2005) ‘Quality and Equity in Aged Care: Recommendation 14’ Commonwealth of Australia available at: http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Completed_inquiries/2004-07/aged_care04/report/index  

[2] Carruthers, A. Naughton, K. Mallarkey, G. (2008) ‘Accuracy of packaging of dose administration aids in regional aged care facilities in the Hunter area of New South Wales’ Medical Journal of Australia 188 (5)  

[3] NSW Poisons and Therapeutic Goods Regulation 2008 https://www.legislation.nsw.gov.au/#/view/regulation/2008/392/part3/div4/subdiv2/sec47  

[4] Ibrahim, J. et al (2017) ‘Premature deaths of nursing home residents: an epidemiological analysis’ Medical Journal of Australia, 206(10), pp1-5  

[5] P22: Department of Health (2017) ‘Single Aged Care Quality Framework: Draft Aged Care Quality Standards Consultation Paper’ https://consultations.health.gov.au/aged-care-access-and-quality-acaq/single-quality-framework-draft-standards/supporting_documents/Single%20Aged%20Care%20Quality%20Framework%20%20Draft%20Quality%20Standards%20Consultation%20Paper.pdf  

[6] Miles, S. Fulbrook, P. Nowicki, T. Franks, C. (2014) ‘Decreasing pressure injury prevalence in an Australian general hospital: a 10-year review’ Wound Practice and Research, 1, pp148-156. Available: http://www.woundsaustralia.com.au/journal/2104_01.pdf  

[7] ALRC (2017) ‘Elder Abuse – A National Legal Response’ ALRC Report 131. Available: https://www.alrc.gov.au/sites/default/files/pdfs/publications/elder_abuse_131_final_report_31_may_2017.pdf  

[8] Table 3.2: Mavromaras, K. et al (2017) ‘2016 National Aged Care Workforce Census and Survey – The Aged Care Workforce, 2016’ Available: https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/03_2017/nacwcs_final_report_290317.pdf  

[9] Table 3.36: Mavromaras, K. et al (2017) ‘2016 National Aged Care Workforce Census and Survey – The Aged Care Workforce, 2016’ Available: https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/03_2017/nacwcs_final_report_290317.pdf  

[10] P13: Cmth of Australia (2005) ‘Report on the Operation of the Aged Care Act 1997 - 1 July 2004 to 30 June 2005’ Available: http://webarchive.nla.gov.au/gov/20140802094453/http://www.health.gov.au/internet/publications/publishing.nsf/Content/ageing-reports-acarep-roaca04-05.htm 

[11] Australian Institute of Health and Welfare (2017) ‘People’s care needs in aged care’ GEN Aged Care Data. [Accessed 14 August 2017] Available: https://www.gen-agedcaredata.gov.au/Topics/Care-needs-in-aged-care  

[12] Table 3.12: Mavromaras, K. et al (2017) ‘2016 National Aged Care Workforce Census and Survey – The Aged Care Workforce, 2016’ Available: https://agedcare.health.gov.au/sites/g/files/net1426/f/documents/03_2017/nacwcs_final_report_290317.pdf  

[13] Willis, E. et al (2016) Meeting residents’ care needs: A study of the requirement for nursing and personal care staff. Australian Nursing and Midwifery Federation. Available: http://www.anmf.org.au/documents/reports/National_Aged_Care_Staffing_Skills_Mix_Project_Report_2016.pdf  

[14] Recommendation 4–7: ALRC (2017) ‘Elder Abuse – A National Legal Response’ ALRC Report 131. Available: https://www.alrc.gov.au/sites/default/files/pdfs/publications/elder_abuse_131_final_report_31_may_2017.pdf