This article is part of a series looking into the Final Report from the Royal Commission into Aged Care Quality and Safety. Click here to see the series as it's published.

The Royal Commission into Aged Care Quality and Safety has released its Final Report. Here’s what Residential Care providers need to know and why they should stay calm but act now.

Quick facts about the Final Report

• 8 volumes.
• 148 recommendations.
• Suggested timeframes for implementation vary across the recommendations, from “by July 2021” to “by November 2024.”
• On some issues the two Commissioners presented separate, inconsistent recommendations.
• These are only recommendations, not laws. The government has said it will respond comprehensively to the recommendations when it finalises the budget in May this year.

What’s wrong with the residential aged care system?

The Report noted that the residential aged care industry had been affected by problems beyond the control of care providers, such as community assumptions about ageing, insufficient government funding and an ineffective regulator.

But the Report also noted systemic problems for which aged care providers were responsible, including:

• Poor governance: the Report found that some boards and governing bodies “lack professional knowledge about the delivery of aged care, including clinical expertise” and “focus on financial risks and performance, without a commensurate focus on the quality and safety of care.” The Report also found that many Boards lacked accountability and had failed to model good workplace culture.
• Reactive model of care: the dominant model of care delivery is reactive and task-based, focusing on meeting standardised processes rather than planning around the needs of the individual.

There was some disagreement between the Commissioners about the quality of performance of aged care providers:

Commissioner Pagone considers providers could do more to improve leadership and culture, while acknowledging that many providers have been exemplary in prioritising quality care within the funds available.

Commissioner Briggs considers that providers have been critical contributors to the systemic problems of the aged care system. Some approved providers’ leadership and culture appear not to align with their mission and certainly not with the purpose of the aged care system. With some notable exceptions, Commissioner Briggs observes that providers have demonstrated little curiosity or ambition for care improvement, and have not prioritised enablement and allied health care. [Page 75]

Some key recommendations that directly affect residential aged care providers

Regulation and Assessment

• A new Aged Care Act: change the law from the ground up to effect a foundational shift towards a system of “person-centred care” focusing on the rights and dignity of residents (Recommendations 1-3).
• Civil penalties for failure to provide proper care: impose on providers an explicit legal duty to provide quality care and services. If providers or their personnel fail in the duty, they could be sued by the quality regulator. (Recommendations 1-3, 13, 14, 101, 102).
• A new regulator with more power: the two Commissioners disagreed about some aspects of different agencies that might oversee aged care, but both wanted to see the Aged Care Quality and Safety Commission overhauled or abolished and replaced by a new agency with expanded powers. (Recommendations 5-12, 97, 101-103).
• Review of the Aged Care Quality Standards: urgently review the Aged Care Quality Standards and establish a process for regular ongoing review. (Recommendations 19-21).
• Expansion of the Quality Indicators: develop a “more comprehensive suite of quality indicators” and adopt the quality indicators as a tool for benchmarking the performance of providers against similar providers for continuous improvement. (Recommendations 22, 23).
• New “Star Rating”: introduce a Star Rating for a provider’s performance published on My Aged Care. The Report criticised the existing Service Compliance Ratings system because it gives the highest rating to those who achieve the minimum standard, i.e. it does not differentiate between “providers who just meet the standards and those who are outstanding.” (Recommendation 24).

Governance

• New laws and standards to improve provider governance: require governing bodies to meet reporting and accountability requirements; require Board members to be “fit and proper persons” and the majority to be made up of independent non-executive members. (Recommendation 88, 90).

• Adoption of digital technology and My Health Record: require every provider to use a digital care management system (including an electronic medication management system) meeting a standard set by the Australian Digital Health Agency and interoperable with My Health Record. (Recommendation 68).

Human Resources

• Specialised training requirements: require aged care providers to ensure relevant staff are regularly trained on specialist areas including dementia care, palliative care, trauma-informed care and cultural safety. (Recommendations 30, 48, 80).  
• Mandatory minimum qualification for personal care workers: a Certificate III should be the mandatory minimum qualification required for personal care workers performing paid work in aged care. (Recommendation 78).
• Minimum staff time standard for residential care: require approved providers of residential aged care facilities to meet a minimum staff time quality and safety standard. This requirement should take the form of a quality and safety standard for residential aged care. This recommendation provides a detailed list of recommended minimum times for particular staff along with exemptions. (Recommendation 86).
• Reporting of staffing hours: require all approved providers of residential aged care to report, on a quarterly basis, setting out total direct care staffing hours provided each day at each facility they conduct, specifying the different employment categories. (Recommendation 122).
• Increases in award wages: employee organisations should collaborate with government and employers to vary wage rates in the Aged Care Award 2010, the Social, Community, Home Care and Disability Services Industry Award 2010 and the Nurses Award 2010. (Recommendation 84).

Clinical Care

• Regulation of restraints: use of restrictive practices in aged care must be based on an independent expert assessment and subject to ongoing reporting and monitoring. The quality regulator should be able to sue providers who breach the rules. (Recommendation 17).
• Appointment of care managers: require providers to assign a care manager to each consumer to ensure they access the care they need and to liaise with staff, other health care providers and the consumer’s family. (Recommendation 31).
• Integration with allied health: there was some disagreement between the Commissioners on this point, but both wanted to see allied health care more integrated into residential aged care. (Recommendation 38).
• Restricted prescription of antipsychotics: recommend that government amend the Pharmaceutical Benefits Scheme Schedule so that only a psychiatrist or a geriatrician can initially prescribe antipsychotics as a pharmaceutical benefit for people receiving residential aged care. (Recommendation 65).
• Improving the transition between residential aged care and hospital care: require staff of aged care services, when calling an ambulance for a resident, to provide the paramedics on arrival with an up-to-date summary of the resident’s health status, including medications and advance care directives. (Recommendation 66).
• No younger people in residential aged care: recommend that the Australian Government immediately put in place the means to achieve its commitment to ensure that no person under 45 lives in residential aged care from 1 January 2022, and no person under 65 from 1 January 2025. (Recommendation 74).
• Greater weight to be attached to the experience of people receiving aged care: the regulator to regularly interview residents to get their views and then periodically publish a report on the experience of people receiving care from an aged care service. (Recommendation 94).
• Serious incident reporting: expand the quality regulator’s powers to investigate serious incidents and to require providers to take specific remedial actions within specific timeframes. (Recommendation 100).

Stay calm but start acting now

Big changes are coming to the residential aged care sector. It’s a daunting prospect but the challenges can be met if you start acting now.

Here’s why:

• The (broader) truth is out: yes, the Report contains many confronting criticisms of aged care providers, but it also contains a clear, ringing acknowledgement of the broader complexity of the problems in aged care. It baldly states that funding for aged care is “insufficient” and “insecure” and that the aged care workforce are “underpaid and undertrained.”
• The foundational recommendation is about supporting “person-centred care”: underlying every recommendation in the Final Report is a push for more “person-centred care” focusing on the rights and dignity of residents. This is not new, however it is foundational to the changes that will follow. Particular providers may or may not have lived up to this aim in the past, but they’ve long been familiar with the concept.
• There are simple tools to help you: over the next few weeks ACE will dive deeper into the recommendations in the Final Report and show you some simple tips and tools that you can use to make changes, improve your organisation, simplify the way you work and start responding to the inevitable change.

The place to begin is at the top with your governing bodies and leadership teams. Next week we’ll examine the Final Report’s recommendations with respect to Governance and set out some practical steps you can take to improve your governance systems right now.