“Oakden: A shameful chapter in South Australia’s history”

It has again emerged that neglect and abuse is systemic in the running of some aged care facilities in Australia. The publishing of the report, titled Oakden: A Shameful Chapter in South Australia's History, gives a damning insight into the treatment of the most vulnerable in our society. To make matters worse, this particular instance was in the duty of care of a government run facility. The ramifications politically will no doubt be extraordinary. But what about on the ground level, for those both providing and receiving care?

The Independent Commissioner Against Corruption (ICAC) sanctioned report, published by the Hon. Bruce Lander on the 28th February 2018, needs to be a watershed moment for this industry and this country. The title of the publication, “Oakden: A Shameful Chapter in South Australia's History”, leaves nothing to interpretation as to the implications of this report.

The government run Oakden older persons mental health facility in Adelaide, South Australia, was last year shut down amid revelations of a culture of abuse and neglect. The report by the ICAC reveals the full extent of the sub-standard practices, as well as how high up the management chain ingrained malpractice went. Consequently, five individuals within the South Australia health network have been reported for maladministration, along with damning findings against the public body themselves, who ran the facility. State ministers have also been named as inadequate, although falling short of indictment charges.

The 312-page report lists evidence of neglect and abuse in multiple examples of malpractice at individual and organisational level. These include but are not exclusive to: under-staffing, below-grade and damaged equipment, evidence of unexplained bruises on resident limbs and excessive restraints on residents with dementia. The report makes 13 key recommendations, many of which are related to management level structural changes, which it firmly states requires immediate implementation.

Reading through the full report provides for harrowing reading. It is like being transported to a bygone era of institutions for the elderly that we thought had been left in the past. Clearly not.

What are the causes of malpractice and cultures of neglect and abuse?

  1. Budget compliance

Pressures from management networks and the funding sources who run aged care facilities inevitably falls on front-line employees. There are multiple facets to this, but the unfortunate trend with each of them is that they all are influenced by the bottom line. Money. Cost-cutting comes from multiple strategies, be that to drive profits in the private sector, or to keep within budget in the public sector.

Under-staffing is the primary method of savings, with huge implications on quality of care for residents. Currently the aged care sector has no law on the maximum number of residents to be cared for per nurse on duty (staff-resident ratio). To put this into perspective, hospital legislation demands a ratio of one nurse for every four patients (1:4) during day shifts. This then moves to 1:7 for a night shift. Hence the temptation for employers is to thin out the number of nurses on duty in an attempt to minimize costs. The implications of a lack of nurses is numerous and potentially fatal in nature. The higher number of residents in the care of a single nurse increases their workload exponentially, causing extreme time constraint. Corners end up being cut, errors end up being made. Such pressures also increase the chance of high staff turnover, as individuals are unable to cope with the huge pressures of day-to-day work. Having nursing staff unfamiliar with the residents in their care increases further the chance of errors.

Chronic under-staffing has a secondary knock-on effect on quality of care for residents too. Decision making by nurse and assistant nursing staff becomes biased. For example, excessive use of physical restraint on residents is implemented. This limits the workload of assistant nurses having to attend to multiple residents wandering unsafely on their own, whilst other residents, for example, require assistance going to and from the bathroom. This knock on effect reduces resident autonomy and independence, which in turn can have negative consequences on quality of life and happiness.

2. Management culture

To deal with the consequences of cost-cutting strategies, a culture of fear and secrecy is created by management to keep matters in house and hidden from public viewing. This takes many forms, including the silencing of staff members who speak up by taking disciplinary action, even to the extent of sacking them. The subsequent internalizing of errors, malpractice and neglect is therefore not resolved and manifested within the culture of the facility. At this point staff become disenfranchised and lose any empowerment to implement beneficial change. Issues are no longer reported and a downward spiral ensues.

3. Individual staff members

Not all problems come from the top. It is an unfortunate truth that a minority of individuals deliberately abuse and neglect residents they are paid to compassionately care for. For an empathetic individual, the reasons for this are unfathomable, as they are for myself. But they happen nonetheless. The above points assist only to compound the neglect and reduce the chance of reporting it. A lack of safe whistle-blowing policy and approach ability to management results in instances of abuse and neglect going on without action. They are likely to continue.

How do we implement change on a national level to prevent tragedies like Oakden from repeating itself?

Funding models of homes need to be well managed and monitored to eliminate the temptation and risk for cost-cutting that places residents in harms way for any of the aforementioned reasons.

For a private or ‘not-for-profit’ (who still strive for profit) company, safeguarding and regulation of the industry is essential. With free roam, it is inevitable that some companies will push the boundaries of commercialism to such an extent that care quality diminishes to unacceptable levels. To achieve this, strict regulation and monitoring is essential. I believe it is imperative that legislation for staff-resident ratios be introduced into the aged care sector to safeguard both residents and staff. Such companies need to demonstrate that re-investment into their facilities is in proportion with profits they are making to maintain high care standards. It is unacceptable for companies to pocket high profit margins whilst simultaneously delivering derisory care standards.

For public organisations, you cannot get away from providing the necessary funding if you want to provide quality care. Anecdotal experience has shown me that publicly provided facilities are often the poorest funded and maintained of all. The inequality this creates for those who cannot afford to pay for aged care further contributes to health inequality in society. Funding aged care is a looming problem that cannot be swept under the carpet for much longer. On a structural level, greater accountability is required on ministers and officials in high ranking health positions to push care standards up via a trickle down effect of improved culture and responsibility.

Safeguarding of residents is another aspect that needs tackling on a more local level. Facilities need to provide safe structures for whistle-blowing and embrace cultures that encourage reporting neglect and abuse. This would also improve greater self-disclosure of errors that could be learned from to avoid re-occurrences.

Those most at risk to neglect and abuse in my opinion are residents with little or no family presence, as well as those with severe mental health conditions or advanced dementia/Alzheimer’s. Abuse is most likely to occur to this demographic as self-reporting and (lack of) family input leaves residents vulnerable and without a voice. How do you protect such residents? There are calls for camera installation in private rooms to improve safeguarding, which I am apprehensive about. However, in instances such as Oakden, you have to consider the potential deterrent factor this would have. A topic that deserves an article for itself another time.

To briefly conclude, we cannot allow the story of Oakden to be repeated. Learning from the errors that happened is non-negotiable. This is an opportunity to push the funding and implementation of aged care to the forefront of political and social debate. Within this, legislation such as the the staff-resident ratio and the regulation of profiteering can help to achieve better care standards and add reinvestment to the sector. Increasing accountability to those in power will force care standards to drive upward via a trickle down effect and with it improve reporting behaviors and cultures to whittle out honest errors as much as deliberate neglect and abuse.

I hope the anger and outcry as a result of the release of this report will be a watershed moment for the aged care industry and the people it cares for.

This article was written by and first published on Aged Care Physio’s blog.