Accreditation

The Australian Aged Care Quality Agency (AACQA - the Agency) is the body established by the Australian Government to accredit residential care services. From 1 July 2014, the Agency also conducts quality reviews of home care services. It also registers quality assessors and advises the Secretary of the Department about aged care services that do not meet the Standards. In addition to its regulatory role, it also provides an educative function to industry.

The new Agency is no longer an independent Agency and operates within the Department of Social Services, firmly under the thumb of the Minister. It retained much of the same staff and culture as it's predecessor, the Aged Care Standards and Accreditation Agency.

The Agency monitors compliance of aged care homes. Accredited aged care homes are required to meet standards which are known as the Residential Aged Care Accreditation Standards in order to receive government subsidies.

The main problem with the current accreditation process, is that it fails to collect, collate or publish objective data about failures or standards of care. The Agency are consequently not able to prove that accreditation is effective (although it is likely that for motivated providers the processes taught are helpful).

The Agency is not structured to measure standards and their marking system is so far off a bell curve that hardly anyone fails to get full marks so it is of little value to customers, whether these be potential residents, their families, the community or government. They create the illusion that all is well in aged care and allow rationalisations.

Some facilities prepare for assessments with the help of outside contractors. Clearly if the same contractors are retained by both the facility and the Agency, then there is a conflict of interest, since the contractors are effectively working for two masters. Needless to say, one can predict the outcome of such a situation.

The Budget 2015 announced a raft of measures - including plans to privatise provision of accreditation services, allowing providers to choose their own agency to accredit their facility.

The risk of compromising objectivity of audits by offering services in addition to certification auditing is high. Many agency auditors provide consultancy and other services as well as auditing. As most of the auditors are independent contractors, agencies have limited control over what they do outside the audits they carry out on the department's behalf.

Risks: Under this proposed new regime, the public could not be confident that any audits, evaluations or reports provided are truly independent or free from conflict of interest. Paying private contractors to accredit services could open the door to payment for a more 'lenient' certification - or worse, 'paying the umpire' twice.

The other risk will be that data collection would be obfuscated given that private companies will be holding various records of information. This will be a disaster for family members wanting to make informed decisions about care and for researchers or government needing to make informed decisions regarding aged care policy.

Update - Jan 2015: Documents released under Freedom of Information show that nearly one in five new nursing homes failed to meet quality standards last financial year. The revelation comes as the Federal Government looks to cut red tape in aged care, including reducing the aged care complaints system. These changes are being promoted as part of an "Innovation Hub" in South Australia. The changes include:

Reduction of audits: Less frequent audits (eg, site audits reduced from once every three years to five years);
Self-regulation of complaints: Complaints by residents or family member to the Aged Care Complaints Scheme will be referred back to the home in question for resolution, including those that identify serious risk to resident health and safety
Reduction of ACFI reviews: reduced Aged Care Funding Instrument reviews by the department

Source: Documents relating to the South Australian Innovation Hub released under FOI - [Disclosure log: 14/15 – 065 (19 Dec 2014)]

Foxes guarding the hen house?

In Australia the Agency claimed to be an independent organisation, but since it's inception, there have been a revolving door of industry-friendly appointments. It is clear that aged care ministers have imposed their will and control over the Agency.

In 2009: The Agency were plagued by criticism when critics highlighted that the (then) Agency was governed, in part by aged care providers and their representatives. It was revealed that nearly nearly half (5 of 12) of the agency board were made up of members of the industry and this included a director who is also the CEO of a home that was being investigated by the department over the death of a resident.

In 2014-2015: Prominent members of industry bodies were appointed to be the assistant minister's adviser and to be CEO of the newly rebadged "Australian Aged Care Quality Agency" which inherited the task of accreditation. The minister's adviser came from a background with the industry supporting organisations ACSA, NACA and COTA. The new CEO of the Quality Agency, moved over from his position as CEO of LASA, one of the main organisations representing providers of aged care.

The new CEO will be reporting on the groups that, only a year ago, he was supporting and acting for. They may be sanctioned. The Quality Agency is a major component of the regulatory process, the one the public depends on. Putting it under the control of someone who comes directly from the organisation representing the industry is truly the fox guarding the hen house.

The General Manager Corporate Affairs and Human Resources of the Quality Agency, worked in the same position for the old agency. The web site states that he "Previously conducted strategic advisory services consultancy providing advice on reputation management, crisis management and stakeholder programs."

Key roles: The two key people responsible for the new Quality Agency are the previous CEO of the body representing the industry and someone whose primary experience is in reputation and crisis management. One is left wondering whose reputation and whose crises he will be managing. Is he there to seriously address allegations made about the agency and fix problems ... or is he there to manage and minimise the fallout when failures become public.

Accreditation: An industry friendly initiative

The Agency was not setup as a regulatory body, but primarly as a body to assist nursing homes to improve standards. There is no problem in a cooperative body assisting nursing homes to improve, but it is problematical when that body is also assessing and publishing results into the marketplace. Its positive assessments are used in marketing and this creates a conflict of interest for the Agency. It is put under pressure to accredit by its supporters, and is at risk of criticism if it does not.

Industry input has had a potent influence on its design and its operation. They have been consulted at every point and their acceptance of any changes has been crucial. Without industry agreement, the government would not act and without intense public pressure and adverse publicity the industry would not go along with any restrictions on their freedom to operate as they thought fit.

It is possible for an aged-care home to pass accreditation and yet still provide poor care:

"... Many people who contact Aged Care Crisis are shocked to learn that it is still possible for a home to breach its responsibilities as an approved provider under the Aged Care Act, have serious complaints substantiated against them, including assaults, and yet still manage a perfect accreditation score and avoid any public scrutiny whatsoever.

Family members wanting to make informed decisions about a residential aged-care placement for their loved ones, especially those with dementia, are often unable to do so.

The Quality Agency, as it is currently structured, has two conflicting roles: a regulatory function and an educative function. Such a conflict of interest cannot be sustained and acts against the wellbeing of frail people in residential care.

The critical roles of education and the establishment of exemplar processes and practices within aged-care homes must be separate from the roles of oversight and regulation. A body independent from the industry would better accomplish the latter roles. This would address a number of other conflict-of-interest situations ..."

Source: Aged Care Crisis to Senate Community Affairs References Committee, 14 Feb 2014

Data collection: Show me the data!

The majority of reports published by the Agency are the result of planned cyclical three-yearly visits - known as "Site Audits" which are planned at the request of the nursing home and at a mutually convenient date and time. The home has often spent weeks or months preparing. They are a costly and wasteful exercise if it is intended to measure standards.

Such reports tell us that the management of the aged-care home knows what it is supposed to do but gives no information about what happens on the other 1,093 days of the cycle. They tell us nothing about the ordinary day-to-day provision of services, or whether processes are being regularly followed.

Even the published reports have been 'sanitised': There are two versions of the site audit reports - one is for public consumption, the other is for the aged care service and kept "confidential". It contains staffing roster information, additional commentary by assessors on findings at the service, and other information.

Unannounced visits - 'confidential': Yearly "unannounced visits" by the agency (or department) tell very little about the remaining 365 days - and these findings are never made publicly available. The community are left to ponder over reports that are not a true measure of performance and may be up to three years old - or even more under proposed changes:

Show me the information: Consumers are entitled to disclosure of all past, as well as current, reports. Information needs to be presented in a digestible format and not the current long and indigestable format. Despite technology advancements, the AACQA website functionality bears resemblance to websites that were setup in the 1980's.

Information should be presented in a readily comparable way. Frail older people are one of the most vulnerable groups in society and their protection should outweigh all other considerations. The current process for their protection fails on multiple counts.

How a home responds to an adverse report is a critical part of understanding the practices and policies of that facility. We believe the practice of not publishing provider responses detracts from full transparency and accountability.

Much of our correspondence reflects the following - although there have been name changes and departmental responsibility changes since, the following statement is still a valid concern for many:

"…The Minister for Ageing announced on the 1 July 2009 that a new register is available on the Department of Health and Ageing website which displays the number of non-compliances found for each aged-care facility. This initiative however, does not reveal any of the breaches found by the Department of Health and Ageing's Aged Care Complaints Investigation Scheme (CIS), the main body to whom complaints are made.

I only found this out when I found that my mother's Hostel, which had a finding of 3 breaches of the Aged Care Act against it by the CIS in May 2009 following a complaint of mine, showed a clean record on the new website register.

I find this particularly concerning for prospective aged care residents and families who are deciding on options for the best care…"

Prior to 2005, the Agency used to publish all current and previous reports on aged-care homes, making it possible to track a particular home's scores over successive assessments. This was discontinued - although the public is invited to obtain further reports via special request.

The difficulty in obtaining older reports removes the accountability of the Agency to explain large variations in assessment scores or other anomalies over varying time frames and denies consumers and statisticians easy access to information.

Compared to the UK's Care Quality Commission, every visit is published, reason for the visit, including complaints and any failures, and what the provider did in detail for fix the problem. This is the type of information that should be accessible.

Assessor qualifications

There are no formal qualification requirements prior to selection however, only persons who are registered aged care assessors are permitted to conduct assessments. Training courses for assessors are inadequate – for example, some training courses for aged care assessors run for 5 days and appear to have no pre-requisites apart from a willingness to learn.

The Agency employ a bank of assessors full time - around half of them are registered nurses, and additional contractors are used to supplement the permanent assessors, especially during peak times.

Administrative Appeals Tribunal: industry-friendly system

This system protects the rights of providers if they feel they have been unjustly assessed. ACC again draws attention to the power imbalance between residents and providers and asks how residents can have their rights to quality care protected. Thus, providers have legal protection and several avenues of reviewing their arguments, while it is very hard for frail residents to achieve the same.

ACC notes that when there are media reports of poorly performing aged-care homes, providers and their associated organisations are generally unwilling to acknowledge any failings in their homes. They tend to respond aggressively to criticism - citing various incidents as isolated occurrences, or blaming regulatory systems.

As in the USA, such groups challenge the sanctions aggressively through the appeals process and frequently succeed in overturning sanctions on appeal. ACC acknowledges the need for natural justice but notes that the same is not generally provided for families seeking redress for neglect of residents.

Undue emphasis on documentation

The most common criticism received by ACC of the current accreditation system relates to its undue emphasis on documentation. We receive much feedback about the inadequacy of a system that depends on what is written rather than what is actually done.

A system which takes considerable staff time away from residents in order to complete a myriad of bureaucratic tasks fails both residents and staff. In the current system, documenting the minute details of a person’s life has become more important than actually helping them live their lives. Documentation and keeping of records is an important part of care – as is developing well-formulated care plans. However, the current system is out of balance.

For example, much has been written in recent times about the malnutrition experienced by up to 40 per cent of nursing home residents. We question the point of documenting a person’s weight, diet and food intake in detail if there is neither the time, nor resources, to provide nutritious, tempting meals or the assistance required to encourage and assist residents to eat them.

Timing and preparation for inspection visits

The ACC receives numerous complaints from aged-care workers and from the families of residents about the extensive notice given to providers prior to a site audit. As already noted, such advance notice does not give inspectors the opportunity to accurately review the life of the home on a daily basis. Families do not want to know how homes perform on special occasions. They are interested in having knowledge of day-to-day care.

Elaborate preparations are made by some providers prior to inspection. Staffing rosters are sometimes changed. In some instances, additional staff are rostered and extra furniture is hired in order to create a good impression.

We also draw attention to the fact that, evening or weekend visits rarely occur. Yet this is the very time when aged-care facilities have notoriously low, even dangerous, staff/resident ratios.

Aged Care Act 1997 - Accreditation Grant Principles 1999: 9.1 Publication of original decisions (2)

Use of technology

ACC notes that, in general, the aged-care sector has not used the advances in new technology to any great effect. Keeping resident records is one area where the benefits of technology are immense. Records should be captured electronically.

Technology is vastly improved with a myriad of technical gadgets that make it easier than ever before to capture information 'on the go', for example, using tablets. That way, any care notes, dietary requirements, medications, etc., could be captured and recorded in "real-time" for each resident and then easily referenced. This would go some way in eradicating anomalies that currently occur with current practice.

Benefits would include:

The prevention of the duplication of I.T. efforts: This could assist in the prevention of duplicating efforts amongst individual providers, saving outlay on expensive bespoke systems, as well as ensuring uniform information and consistency of data collection.
Minimum effort for all staff working in the sector: One global system would mean that any staff working or moving around within the aged care in Australia, would already understand how to use the system - leaving more care time for residents.
Reliable data and statistics: Reliable data relevant to aged care is currently lacking. An online/app system would enable the collection of data into a central system – thus producing some meaningful statistics and information about people residing in aged-care facilities across Australia.

Community Affairs References Committee: 14 February 2014

Aged Care Crisis spoke around their concerns regarding the protections around vulnerable residents in care at the Community Affairs References Committee - Care and management of younger and older Australians living with dementia and behavioural and psychiatric symptoms of dementia in 2014.

We highlighted the inadequate protections afforded to vulnerable people in care in relation to the Complaints Scheme, including the accreditation of homes, and the reasons for this in the following parts of the Transcript, below:

Care and management of younger and older Australians living with dementia and behavioural and psychiatric symptoms of dementia

SALTARELLI, Ms Lynda, Communications Advisor, Aged Care Crisis

SPARROW, Ms Linda, Committee Member, Aged Care Crisis

Evidence was taken via teleconference — (Link to Transcript)

CHAIR: I welcome representatives from Aged Care Crisis, who are appearing via teleconference. Thank you for appearing. I appreciate that it is a little more difficult on teleconference, so thank you.

I understand that information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. We have your submission, thank you very much. I would like to invite one or both of you to make an opening statement and then we will ask you some questions.

Ms Sparrow: In a moment, Lynda Saltarelli and I will be doing a joint presentation on behalf of Aged Care Crisis. I will speak now about the prevailing culture within residential care and some of the very urgent staffing needs which we believe must be addressed to achieve the sort of care we would all wish for those living with dementia and BPSD. After I have finished, Lynda Saltarelli will speak about the issues relating to the current complaints scheme and the need for greater transparency in the aged-care residential sector.

Ms Saltarelli: One of the cornerstones of providing good dementia care and care for those with behavioural and psychiatric symptoms of dementia is information for family members seeking to provide care. The regulation of aged care is the mechanism whereby the public develops trust in the system. Confusion about how regulation works and who takes responsibility for it and how it performs makes this trust very hard to achieve.

The current complaints scheme is the fourth reincarnation for Australian aged care. Like its predecessors, this one is embedded within the now Department of Social Services under the Office of Aged Care Quality and Compliance. We believe the complaints scheme should not fit under the same body responsible for funding approvals and setting policies. We feel that successive reviews and inquiries have ignored the logic of various submissions and cherry-picked items that have then been incorporated into policy and practice, adversely influencing the way in which the aged-care system operates.

An example of this is the way in which the review of the Aged Care Complaints Investigation Scheme, the Walton review back in 2009-10, virtually destroyed the utility of the whole complaints system by embracing our recommendation to place more focus on local resolution, but critically ignored supporting information on the logic behind this and the essential linked recommendation that the complainant should be supported and advised by a trained local facilitator with investigative powers.

Not surprisingly, this unequal barrier — in which there is a gross imbalance in power, where victimisation is possible — has proved to be an effective barrier to lodging a complaint as well as resolution, leading the disaffected even more disillusioned.

Under the current system, after a complaint has been investigated and found to be valid, aged-care homes are simply required to agree to make some amendments to policies and procedures. Residents with dementia, especially, may have suffered injury; their health may have been seriously affected or perhaps they may have been wrongly physically or chemically restrained. In such cases the complaints scheme is entirely incapable of providing any satisfaction. An ordinary person with full rights would be entitled to seek redress and compensation. Frail, aged residents have no such rights, despite the Aged Care Act implying otherwise. To the contrary, these instances perpetuate a system where, judging by the numerous stories of neglect, abuse and premature death, poor care is endemic.

The complaints scheme generally fails to provide any remedy to individual complainants or to resolve issues for residents. This is because it deals primarily with systemic defects in process and breaches of standards. Consumers need to be fully confident that the current scheme, and any future scheme, will protect the residents of our aged-care homes. How a home responds to an adverse report is a critical part of understanding the practices and policies of that facility, as is publishing the findings of the investigation of complaints. The publication of all relevant information is an essential part of achieving transparency. Privacy is an important consideration but should not be used as an excuse or a barrier to transparency and accountability or as a way not to protect those who are unable to protect themselves.

Many people who contact Aged Care Crisis are shocked to learn that it is still possible for a home to breach its responsibilities as an approved provider under the Aged Care Act, have serious complaints substantiated against them, including assaults, and yet still manage a perfect accreditation score and avoid any public scrutiny whatsoever. Family members wanting to make informed decisions about a residential aged-care placement for their loved ones, especially those with dementia, are often unable to do so.

Aged Care Crisis are concerned about the proposed extended scope of the Aged Care Standards and Accreditation Agency, renamed the Australian Aged Care Quality Agency from 1 January this year, with regard to regulatory powers previously vested in the Department of Health and Ageing. The Quality Agency, as it is currently structured, has two conflicting roles: a regulatory function and an educative function. Such a conflict of interest cannot be sustained and acts against the wellbeing of frail people in residential care. The critical roles of education and the establishment of exemplar processes and practices within aged-care homes must be separate from the roles of oversight and regulation. A body independent from the industry would better accomplish the latter roles. This would address a number of other conflict-of-interest situations.

The then agency, in its second submission to the Productivity Commission's inquiry into caring for older Australians, emphatically argued that the Department of Health and Ageing was—and the agency should not be—the principal regulator. It clearly stated the danger of the duality of the roles. To quote directly from their submission:

"... The accreditation agency's responsibility is to support and encourage a quality environment that supports quality care and improvement in aged care while identifying where homes have failed to meet the standards. This approach is in the interests of the residents, who are usually frail, vulnerable and elderly. To do this role adequately requires a strongly collaborative approach with their stakeholders. This does not align with an inspectorial policing approach ..."

The agency goes on to say:

A change to an enforcement and compliance-monitoring arrangement, as suggested in the Productivity Commission report, seems to be underpinned by a belief that enforcement will promote continuous improvement. It would be a return to the practices of the late 1990s. This is a retrograde step that is contrary to international trends and would undo what the current arrangements have achieved.

Source: Agency submission DR763 to PC Inquiry Caring for Older Australians - Pg 5

Aged Care Crisis concurs. Logic dictates that the new agency should have been relieved of this burden and a new, more appropriate, non-conflicted system built around community surveillance substituted.

Aged-care providers receive billions of dollars of taxpayer funding. There should be full disclosure as to how that money is being spent. As well as providing increased transparency for consumers, such disclosure would undoubtedly encourage improvement in residential aged-care services.

The vast majority of reports on aged-care homes published on the agency website are the cyclical three-year accreditation site audits. These are the reports of planned visits performed at a convenient time and after the homes may have spent months preparing for the audit. Such reports tell us that the management of the aged-care home knows what it is supposed to do but gives little information about what happens on the other 1,093 days of the cycle. They may be nearly three years out of date for those seeking information about prospective homes. Other reports, as a result of unannounced visits, are never published nor made publicly available. For example, if failures are identified during an unannounced site visit, these details are not publicly disclosed nor subject to public scrutiny. The agency is also FOI exempt (apparently, the NEW Agency isn't – yet to test it)

In order for frail aged people to achieve full protection, the community must be able to see what the company or provider is capable of when no-one is watching, not just when they have been given time to prepare for an inspection and not simply after providing a response to an adverse finding in order to stay in business. It is critically important that there be regular, informed, ongoing surveillance within the community by trained individuals closely linked to both to each accreditation visit and to groups advising and supporting recipients of care and their families. All accreditation and inspection reports should be published and available publicly so that residents and their representatives can make their own informed assessments.

The current accreditation system does not adequately measure the delivery of care to frail Australians in our aged-care homes. The agency concentrates on processes rather than on measurable adverse events. These often remain hidden. Measurable levels of real care or performance, such as bed sores and weight loss, are not recorded nor reported publicly. Instead, the agency refers to indicators and looks at whether processes are in place to prevent and treat these failures in care. Their success in doing so is neither evaluated nor reported. While these processes are important for improvement, they are not the measures of performance with informed regulators, researchers or citizens. That concludes my statement.

CHAIR: Thank you very much.