It starts with the fundamentals: adequate staffing, adequate food

There have been 22 public reports and inquiries related to publicly funded aged care in Australia since 1997. Will this be the last? In a year’s time, will we be able to say the latest inquiry – the Aged Care Quality and Safety Royal Commission – was the one that really counted?

Yesterday, commissioners Tony Pagone and Lynelle Briggs handed down their final report, Care, Dignity and Respect, comprising 2828 pages and making 148 recommendations. It is the culmination of statements from 641 witnesses over almost 100 days of hearings and based on more than 10,000 submissions.

The initial response from the federal government, which is charged with funding, accrediting and regulating the sector, was to immediately allocate $452 million to address the most glaring problems made horribly clear in the interim report, Neglect.

At the heart of concerns are what could be considered two fundamentals – adequate care and adequate food.

The commissioners want all staff in aged care to have a minimum level of training in line with the childcare sector. Nursing homes have no minimum legal ratio of staff to residents and no statutory requirement to have a registered nurse – whose training is different to those of carers – on duty at all times.

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Couple that with inadequate diet. The Dietitians’ Association of Australia estimated that between 22 and 50 per cent of people in residential aged care were malnourished and that the average amount spent on food was $6.08 per resident a day.

The final report recommends that daily food budgets be urgently bolstered by $10 a day and insists providers report instances of unplanned weight loss or dehydration.

“Food is also important to wellbeing, providing enjoyment through taste and smell,” the report says.

“Too often we heard that residential aged care providers failed to meet the nutritional needs of people for whom they care and that they provided poor quality and unappetising food.”

Melbourne University senior research fellow Sandra Iuliano, a royal commission witness, said research at 60 nursing homes in Melbourne and regional Victoria found that 68 per cent of residents were malnourished or at risk of malnutrition.

She told Nine she welcomed the recommendation to almost triple spending on food, taking the budget closer to an average spend for older adults in the community, which was just over $17 in 2016.

Royal commission recommendations included:

  • A new Aged Care Act that puts older people first, enshrining their rights and providing a universal entitlement for high quality and safe care based on assessed need. [The 1997 Act, which was intended to simplify funding and increase choice in care, led to nurses being replaced by low-skilled care workers and more nursing homes being run by private for-profit providers.]
  • An integrated system for the long-term support and care of older people and their ongoing community engagement.
  • A System Governor to provide leadership and oversight and shape the system.
  • An Inspector-General of Aged Care to identify and investigate systemic issues and to publish reports of its findings.
  • Up to date and readily accessible information about care options and services, and care finders to support older people to navigate the aged care system.
  • A new aged care program that is responsive to individual circumstances and provides an intuitive care structure, including social supports, respite care, assistive technology and home modification, care at home and residential care. In particular, the new program will provide greater access to care at home, including clearing the home care waiting list.
  • A more restorative and preventative approach to care, with increased access to allied health care in both home and residential aged care.
  • Improved access to healthcare for older people, including a new primary care model, access to multidisciplinary outreach services and a Senior Dental Benefits Scheme.
  • Professionalising the aged care workforce through changes to education, training, wages, labour conditions and career progression.
  • Registration of personal care workers.
  • A minimum quality and safety standard for staff time in residential aged care, including an appropriate skills mix and daily minimum staff time for registered nurses, enrolled nurses and personal care workers for each resident, and at least one registered nurse on site at all times.
  • Strengthened provider governance arrangements to ensure independence, accountability and transparency.
  • A strengthened quality regulator.
  • A simpler and fairer approach to personal contributions and means testing, including removal of co-contributions toward care, reducing the high effective marginal tax rates that apply to many people receiving residential aged care, and phasing out Refundable Accommodation Deposits.
  • Financing arrangements drawing on a new aged care levy to deliver appropriate funding on a sustainable basis.

COTA Australia chief Ian Yates says the evidence is overwhelming.

“Older Australians shouldn’t wait a day longer than needed to be guaranteed choice, dignity and quality in aged care,” he said, adding that the government must ensure all older people get the home care they need, when they need it, by the end of 2022.”

COTA also says a stronger regulator is pivotal to remove bad providers from the system. “We need a tougher cop on the beat to crack down on abuse caused by bad leadership, lack of clinical governance, low staff numbers and secrecy,” Mr Yates said, adding that a star rating system for staffing was also at the top of the action list.

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Law Council president Dr Jacoba Brasch QC says: “A philosophical shift is required that places the people receiving care at the centre of quality and safety regulation.”

Older Persons Advocacy Network (OPAN) chief executive Craig Gear says: “Older people must be actively engaged in this transformation through co-design to reshape the aged care system to place vulnerable older people and older people with diverse characteristics and life experiences at its core.”

Dr Peter Norden, a member of new lobby group Aged Care Reform Now, says the priority is to ensure the recommendations are translated into action.

He told Nine: “It seems to me it’s not just a shortage of money, it’s a system that needs to be reformed.”

Dr Norden, the 71-year-old founder of Jesuit Social Services, prison reform advocate and honorary fellow at Deakin University, said his first experience of navigating the aged care system was after he had an operation last year. He was seeking support in his home and found the process confusing and bureaucratic.

“I’ve been working at a fairly high level – teaching and writing and research – and I couldn’t understand what it was all about,” he said. “… I found it bureaucratic, complex and difficult to feel any sense of control or that I was a partner in this.”

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Pharmaceutical Society of Australia president Associate Professor Chris Freeman says medicine safety problems in aged care need to be addressed urgently.

“Inappropriate chemical restraint, and polypharmacy leading to sedation, falls and avoidable hospitalisations are some of the biggest problems in aged care.

“Putting in place quality indicators, improving clinical governance, increasing accountability, providing better staff training and ongoing professional development are all measures required if generational change to our aged care system is to be achieved.”

Do you have faith that the most urgent recommendations will be acted on quickly? Is the initial funding allocation sufficient given the issues identified?

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Written by Janelle Ward