Respect, Care and Dignity: A Summary of the Royal Commission into Aged Care Quality and Safety

The executive summary of the final report from the Royal Commission into Aged Care Quality and Safety contains significant and sweeping proposals for reform of the aged care sector.

The government has responded by pledging $452million to support the implementation of what it sees as five key pillars for reform. This article summarises some of the key points from the summary of recommendations.

The aged care system in Australia

The Australian aged care system provides subsidised care and support to older people. It is a large and complex system that includes a range of programs and policies. It has evolved over time, including during the Royal Commission’s inquiry. Some changes to the system have been far-reaching and others incremental, but all have contributed to the development of the aged care system.

Changing demographics

Australia’s changing demographics significantly influence the demand for and provision of aged care. The aged care sector is facing an ageing population with increasing frailty. Australians are living longer than ever before. It is projected that the number of Australians aged 85 years and over will increase from 515,700 in 2018–19 (2.0% of the Australian population) to more than 1.5 million by 2058 (3.7% of the population).

Older people are more likely to have more than one health condition (comorbidity) as their life expectancy increases. As the population of older people increases, more people are expected to have memory and mobility disorders.

In 2019, there were 4.2 working age (15–64 years) people for every Australian aged 65 years or over. By 2058, this will have decreased to 3.1. This decline has implications not only for the financing of the aged care sector but also for the aged care workforce. There will be relatively fewer people of working age available to pay taxes to fund the aged care system and to meet the growing demand for services.

1. Aged care services

These changing demographics, together with changes in the patterns of disease and dependency, and in the expectations of older people and society, will impact on demand for aged care in a number of ways. These include the length of stay in residential aged care, the increase in care needs, the demand for a variety of care choices, and the desire of older people to remain in their own homes for as long as possible. Aged care is not a single service. It is provided over a range of programs and services. The care ranges from low-level support to more intensive services.

Aged care is provided in people’s homes, in the community and in residential aged care settings. People commonly think of nursing homes, or residential care, when they think about aged care. However, while most of the aged care budget is spent on residential aged care, more than two-thirds of people using aged care services do so from home.

The aged care system offers care under three main types of service: the Commonwealth Home Support Programme, Home Care Packages, and residential care.

The Commonwealth Home Support Programme is intended to provide entry-level services focused on supporting older people to maintain their health, independence and safety at home and in the community.

Home Care Packages can, and often do, contain many of the same support services that are available under the Commonwealth Home Support Programme, but they may be provided as a more structured and comprehensive bundle of services. They are delivered on a ‘consumer directed care’ basis. This means that people can choose the provider to deliver their services and can choose to change providers.

In 2018–19, aged care services were delivered to around 1.3 million people. The most commonly used service in 2018–19 was the Commonwealth Home Support Programme (about 841,000 people), followed by residential aged care (about 243,000 people) and Home Care Packages (about 133,000 people).

Aged care categories

Home Care

A constant theme the Royal Commission has heard throughout their inquiry is that people want to remain at home. For older people to remain safely in their homes, they must have access to aged care that meets their assessed needs.

The care at home category should support older people living at home to preserve and restore capacity for independent and dignified living and prevent inappropriate admission to long-term residential care. Based on assessed needs, it should provide an entitlement to care at home with a personalised budget which allows for a coordinated and integrated range of care and supports. These could include: care management; living supports (for example, cleaning, preparation of meals, shopping, gardening and home maintenance); personal, clinical, enabling and therapeutic care; and palliative and end-of-life care. There should be a lead provider, chosen by the older person, who would be responsible for ensuring that services are delivered and adjusted in accordance to the older person’s changing needs.

Residential Care

Residential care must meet the full range of older people’s physical, emotional, mental and spiritual needs. It must provide care that preserves each person’s capacity for dignified living to the greatest extent possible in their circumstances, and enable each older person to have what they consider to be a good death. The residential aged care setting has changed over the years. People now enter residential services later in their lives. Consequently, many more are frail or have chronic or complex health conditions, including high levels of dementia. Currently, however, the delivery of care in residential aged care is influenced by the funding arrangements, which are aimed at tasks and not a person’s care needs.

The Commission recommends that the System Governor should implement a residential care category that provides high quality and safe care based on assessed needs. It should allow for personalised care and an integrated range of supports across these domains: care management; social supports; personal, clinical, enabling and therapeutic care and support; and palliative and end-of-life care.

Reablement and rehabilitation need to be a central focus of aged care. The Royal Commission recommends that care at home should include the allied health care that an older person needs to restore their physical and mental health to the highest level possible—and to maintain it at that level for as long as possible—to maximise their independence and autonomy

Workforce and providers

Aged care is one of Australia’s largest service industries. The most recent National Aged Care Workforce Census and Survey found there were around 366,000 paid workers (84%) and 68,000 volunteers (16%) in the aged care sector in 2016. The data on the paid workforce excluded non-pay as you go workers—that is, agency, brokered and self-employed workers. During the relevant fortnight of the survey, about 28,000 non-pay as you go staff were engaged across the aged care sector.

High quality care must be the foundation of aged care. There must be a universally shared understanding by government, providers, and by older people and their family and friends of what high quality aged care means in Australia.

The Commission proposes the following definition: High quality aged care puts older people first. It assists older people to live a self-determined and meaningful life through expert clinical and personal care services and other support, provided in a safe and caring environment.

High quality aged care is respectful, timely and responsive to older people’s preferences and needs and assists them to live a dignified life. High quality aged care is provided by caring and compassionate people who are educated and skilled in the care they provide.

It enables older people to maintain their capacities for as long as possible, while supporting them when they experience functional decline or need end-of-life care.

Systemic problems creating sub-standard care

The report has revealed the extensive sub-standard care exists, with at least 1 in 3 people accessing residential aged care and home care services—or over 30%—have experienced sub-standard care.

The delivery of aged care in Australia is not intended to be cruel or uncaring. Many of the people and institutions in the aged care sector want to deliver the best possible care to older people, but are overwhelmed, underfunded or out of their depth. This is why significant change is required.

Systemic problems are serious and recurrent issues that stem from problems inherent in the design and operation of the aged care system. They may be funding, policy, cultural or operational issues. These systemic problems are interconnected. None of them exist in isolation and they often have a compounding effect on the quality and accessibility of aged care. The systemic problems the Royal Commission has identified include inadequate funding, variable provider governance and behaviour, absence of system leadership and governance, and poor access to health care.

It should be easy for older people to access the aged care they need. Having easy access means a person can get the information, support or care they need, when they need it. It also includes getting aged care appropriate to a person’s individual needs, including care that is culturally appropriate and safe.

Ineffective arrangements for older people to access aged care services mean that people may not know where to turn for help. They may have to make decisions which are difficult emotionally, financially and practically, without the benefit of accurate and timely information and support. In some cases, people do not receive the care they need, when they need it.

2. Foundations of the new aged care system: A new Act, purpose and principles

Placing people at the centre of aged care

Much has been said during the inquiry about the need to ‘place people at the centre’ of aged care. To achieve this, the Commission is convinced that a new Act is needed as a foundation of a new aged care system. The new Act must focus on the safety, health and wellbeing of older people and put their needs and preferences first. It should provide an entitlement to the support and care each individual needs to prevent and delay the impairment of their capacity to live independently.

Common themes for reform of aged care

Over the course of the inquiry, the Commission has identified clear common themes in what the community expects from the aged care system: dignity and respect, control and choice, the importance of relationships and connections to communities, and the desire for a good quality of life and ageing at home.

A new Act: a rights-based approach

The Royal Commission identified two paramount principles for the administration of the new Act: to ensure the safety, health and wellbeing of people receiving aged care, and to put older people first so that their preferences and needs drive the delivery of care. The purpose and the guiding principles should be embedded and evident in every part of the system, from aged care policy development through to on-the-ground aged care service delivery.

Governing for older Australians

Better system governance is crucial to the reform of aged care. Effective governance of the aged care system requires ongoing guidance and direction, steering the system towards long-term policy outcomes, monitoring performance, addressing emerging issues and holding players in the system accountable for performance. The overall objective of system governance must be to ensure that people receive safe and high quality aged care according to their needs.

Ensuring quality and safety: the imperative

High quality care must be the foundation of aged care. There must be a universally shared understanding by government, providers, and by older people and their family and friends of what high quality aged care means in Australia.

The Commission proposes the following definition: High quality aged care puts older people first. It assists older people to live a self-determined and meaningful life through expert clinical and personal care services and other support, provided in a safe and caring environment. High quality aged care is respectful, timely and responsive to older people’s preferences and needs and assists them to live a dignified life.

High quality aged care is provided by caring and compassionate people who are educated and skilled in the care they provide. It enables older people to maintain their capacities for as long as possible, while supporting them when they experience functional decline or need end-of-life care. High quality aged care delivers a high quality of life. It enables people to engage in meaningful activities that provide purpose, and provides the opportunity for people to remain connected to their community.

Currently, there is no clear statement in the Aged Care Act of the basic responsibility of approved providers to ensure that the care provided to residents is safe and of high quality. This is a major gap in the legislation.

Areas for immediate attention

While the evidence before us has reflected a wide range of concerns about aged care quality and safety, the Royal Commission has singled out four concerns for immediate attention:

• food and nutrition
• dementia care
• the use of restrictive practices, and
• palliative care

Many witnesses gave evidence about the inadequacy of the quality and quantity of food in residential care. This is an area in urgent need of improvement.

A representative study of 60 Australian residential aged care services conducted in 2017 concluded that a staggering ‘68% of residents were malnourished or at risk of malnutrition’.1[i] Poor nutrition in aged care is related to falls, fractures, pressure injuries and unnecessary hospitalisation.

As a critical first step, increased spending to improve the quality of food can be achieved as part of an immediate conditional increase in the Basic Daily Fee of $10 per resident per day the Commission recommends

Dementia care

It is estimated that more than half of the people living in permanent residential aged care in 2019 had a diagnosis of one of the forms of dementia. The real percentage is likely higher, given the prevalence of undetected dementia. Despite this, the Royal Commission’s inquiry has revealed that the quality of aged care that people living with dementia receive is, at times, abysmal. The Commission heard time and time again that staff members do not have the time or the skills to deliver the care that is needed. The quality of dementia care in the aged care system needs significant and immediate improvement. All mainstream aged care services should have the capacity to deliver high quality aged care for most people living with dementia—dementia care should be core business. This includes having the right number and mix of staff who are trained in dementia care, having the right physical environment (in residential care), and having the right model of care. The Commission recommends mandatory dementia training in residential aged care and in care at home. Ensuring people living with dementia receive the support and services that they need does not begin when they access aged care services.

The overuse of restrictive practices in aged care is a major quality and safety issue. Restrictive practices impact the liberty and dignity of people receiving aged care. Urgent reforms are necessary to protect older people from unnecessary, and potentially harmful, physical and chemical restraints. Deficiencies in regulation of restrictive practices have been identified as a significant human rights issue in Australia. A strong and effective regulatory framework to control the use of restrictive practices should be implemented as a matter of priority.

Palliative care

High quality palliative care is essential to ensuring that an older person can live their life as fully and as comfortably as possible as they approach death. Compassionate, respectful and individualised support for older people approaching the end of their lives is a necessary component of aged care services.

A number of the Commission’s recommendations will contribute to ensuring high quality palliative care becomes core business for aged care services. These include a right to fair, equitable and non-discriminatory access to palliative and end-of-life care, improved access to specialist palliative care services and requirements for regular staff training. Urgent consideration should also be given to how palliative care is reflected in the Aged Care Quality Standards.

Quality standards

Quality standards are a powerful tool to maintain and improve quality of aged care. They are statutory-based obligations of services, which identify the characteristics of aged care and the care environment that contribute positively to, or alternatively place at risk, the safety, health, wellbeing and quality of life of people receiving care. Such standards can motivate providers to achieve the expectations for quality. They also set the regulatory parameters for assessment of provider performance.

The formulation of suitable quality standards is central to achieving and measuring high quality care. The existing Aged Care Quality Standards do not define quality, or high quality, aged care. By their nature, they set out the minimum acceptable standards for accreditation.

3. An entitlement to care: a new aged care program

Older Australians should have an entitlement to aged care. Alongside Medicare, the Pharmaceutical Benefits Scheme and the age pension, older Australians should be able to rely on the aged care program for support when and where they need it.

Putting people first: simplicity, accessibility, choice and inclusion The Royal Commission has heard of the challenges posed by the current multiplicity of programs and services in aged care, each with their particular eligibility criteria, assessment processes and budget allocations. The disparate aged care programs should be consolidated and simplified in a new aged care program.

The Commission recommends a new aged care program aimed at achieving seven essential outcomes:

• Person-first—care and supports which address physical, social, psychological, cultural and spiritual needs, supporting people to function independently for as long as possible
• Simplicity—one aged care program, one set of eligibility criteria and one assessment process
• Accessibility—information that is easy to locate and understand with face-to-face supports
• Universal entitlement—once entitled to care, guaranteed access to the care and supports assessed as needed
• Timeliness—assessments and reassessments of need occur when required and services commence within one month of assessment
• Choice of settings—in the home, community and residential care
• Inclusiveness—recognition of a person’s diverse characteristics and delivery of culturally safe and trauma-informed care.

Access to the new aged care program should be facilitated by better information, a single avenue of assessment and personalised assistance to gain services. Information about aged care services should be easy to understand, access and use. To ensure that people have a genuine entitlement to aged care, older people must be able to find and use the care and supports that they are assessed as needing.

The Commission recommends that the System Governor should fund and support strategies to:

• Improve public awareness of the resources available to assist people to plan for ageing and potential aged care needs
• Improve knowledge about aged care among health professionals with whom older people have frequent contact, particularly general practitioners
• Encourage public discussion about, and consideration of, aged care needs.

In response to the Royal Commission report, the Australian Government will immediately invest an additional $189.9 million for residential care providers to provide stability and maintain services while the Government considers the recommendations of the Royal Commission’s Final Report.

4. A workforce to deliver quality, safe care

A highly skilled, well rewarded and valued aged care workforce is vital to the success of any future aged care system. The Commission has heard about the dedication and passion of aged care workers. While many excellent people work in aged care, there are systemic workforce problems that must be addressed.

In a large number of residential aged care facilities there are not enough workers to provide high quality, person-centred care. In many cases the mix of staff who provide aged care is not appropriately matched to the care needs of older people.

The staff in aged care are poorly paid for their difficult and important work. The evidence is clear that the quality of care and the quality of jobs in aged care are inextricably linked. This points to the need for policies and practices to drive a ‘virtuous circle’, where good working conditions, supportive and visionary management, an empowering work culture, collaborative teams, relevant education and training, structured career progression, and job satisfaction among care workers underpin high quality, person-centred care.

Strategic leadership and workforce planning

The number of older people in Australia will grow significantly in the next 30 years, resulting in a substantial increase in people needing different types of aged care. This will have a big impact on the number of people necessary to deliver that care and the required size of the aged care workforce.

Australia is likely to have an undersupply of aged care workers, and measures will need to be put in place to deal with it. A Summary of the Final Report Modelling by Deloitte Access Economics estimated that the number of direct care workers needed to maintain current staffing levels would be around 316,500 full-time equivalent by 2050, based on demographic trends and rates of use of aged care. This is a 70% increase—more than 130,000 additional workers—compared with the current baseline number of 186,100 full-time equivalent in 2020. The number will be significantly higher if the Commission’s recommended reforms are implemented.

Building an aged care profession

The Australian Council of Professions defines a ‘profession’ as: a disciplined group of individuals who adhere to ethical standards and who hold themselves out as, and are accepted by the public as possessing special knowledge and skills in a widely recognised body of learning derived from research, education and training at a high level, and who are prepared to apply this knowledge and exercise these skills in the interest of others.

The Australian Government, the aged care sector and unions must work together to professionalise the personal care workforce. This will require cultural change and improvements to education, training, wages and labour conditions for nurses and personal care workers. Aged care workers should have a clear vision for career progression, and importantly, clarity about what they need to do to progress.

Educating and training

The Royal Commission is keen to ensure that all care workers, but particularly personal care workers, are equipped with the skills and knowledge needed for current and future aged care needs. Although significant numbers of personal care workers and home care workers hold a Certificate III qualification or equivalent, the Commission has heard about inconsistency in the quality, delivery and duration of the courses leading to that qualification.

The Aged Care Services Industry Reference Committee has responsibility for developing training packages to ensure that industry skill requirements are reflected in the national training system. The Commission recommends that the Committee should review the need for specialist aged care Certificate III and IV courses. It should also regularly review the content of the Certificate III and IV courses to determine if any additional units of competency should be included in the core modules of the courses.

As many as 70% of people in residential aged care could be living with dementia. The Royal Commission have been told that many nurses and general practitioners do not have a full understanding of the symptoms and needs of people living with dementia. While this is presently of greater need in the residential aged care sector, over time it will become more important in home care. The Commission also heard that residential aged care staff tend to be under-skilled and under-educated in palliative care, and there is a lack of suitably qualified staff to manage palliative care adequately.

High quality dementia and palliative care should be considered core business for aged care providers. The Australian Government should implement as a condition of approval of aged care providers that all workers who are involved in direct contact with people seeking or receiving services in the aged care system undertake regular training about dementia care and palliative care.

Improving pay

A wages gap exists between aged care workers and workers performing equivalent functions in the acute health sector. Successive governments have made several failed attempts to address that gap by providing additional funds to providers in the hope that they would be passed on to aged care workers by way of increased wages. They were not.

Getting staffing right

There are many ingredients that enable the provision of high quality and safe aged care, but it cannot be achieved without having enough staff with the skills and time to care.

Leadership and culture

Good leadership and culture provide a necessary foundation for workforce development and growth—to being an employer of choice. Leaders in aged care have a shared responsibility to help the sector emerge from what Professor Pollaers described as a state of ‘adolescence’. The Commission agrees with his observation that the sector’s leadership capability has not kept pace with the growing size and complexity of organisations within it.

The challenge for strategic and operational leaders and managers within aged care organisations will be to lead their organisations through the reform process in the years to come with confidence. To support and drive the reforms the Royal Commission envisage, consistent and confident leadership at all levels of aged care organisations is essential. While this is reinforced through strategies, policies, practices and behaviours, it begins with a genuine commitment to the core values and philosophies on which high quality and safe care are built.

5. Good governance practice

Better system governance is crucial to the reform of aged care. Effective governance of the aged care system requires ongoing guidance and direction, steering the system towards long-term policy outcomes, monitoring performance, addressing emerging issues and holding players in the system accountable for performance. The overall objective of system governance must be to ensure that people receive safe and high quality aged care according to their needs.

Contemporary good governance practice in Australia is to have, where possible, a majority of members on an organisation’s governing body who are independent of the organisation. An independent member of an organisation’s governing body is one who is free of any interests that might influence, or might reasonably be perceived to influence, their capacity to bring an independent judgment to issues and to act in the best interests of the organisation.

Funding for the new aged care system

Public funding is critical to the aged care system. The Australian Government spent $19.9 billion on aged care payments in 2018–19, and $21.2 billion on aged care payments in 2019–20. Despite these large expenditures, the current system delivers services that are all too often substandard, and sometimes unsafe. In many instances, the current system fails to deliver services simply because there is not enough funding to meet the assessed need.

In response to the Royal Commission’s Final Report, the Government will immediately invest $30.1 million to strengthen the governance of aged care providers and legislative governance obligations on the sector.

Aged care and COVID-19: a special report

The COVID-19 pandemic has been the greatest challenge Australia’s aged care sector has faced. Residents, their families and aged care staff have all suffered. The suffering has not been confined to those homes which have experienced outbreaks. Thousands of residents in homes that have not suffered outbreaks have endured months of isolation which has had, and continues to have, a terrible effect on their physical, mental and emotional wellbeing.

As a result of this health crisis, the Royal Commission prepared a brief special report which included six recommendations to address specific COVID-19 issues.

To read the Royal Commission into Aged Care Quality and Safety’s Final Report in full, please click here.

 

[i] Exhibit 6-47, Darwin and Cairns Hearing, Statement of Sandra Iuliano, WIT.0204.0001.0001 at 0001–0002 [9]–[10]; S Iuliano et al., ‘Dairy food supplementation may reduce malnutrition risk in institutionalised elderly’, British Journal of Nutrition, 2017, Vol 117, 1, pp 142–147.