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Staff-to-resident ratios not appropriate, inquiry told


There is no case for fixed staffing ratios in Australian residential aged care, a leading industry consultant has told the royal commission.

Aged care advisory firm Ansell Strategic recently made a submission to the aged care royal commission about its investigation into the practical application of fixed staffing ratios in residential facilities.

The investigation involved extensive consultation with aged care operators and clinical leaders, examination of international research and literature reviews, said Ansell Strategic managing director Cam Ansell.

Cam Ansell

“We found that it’s not a system that is suitable for Australia,” Mr Ansell told Australian Ageing Agenda.

“We completely appreciate and recognise why people are looking for answers, but in answering a very complex problem, it is a simple solution we feel is more likely to make the situation worse and unsustainable,” he said.

Ansell Strategic found that fixed ratios in Australian aged care facilities are not appropriate because:

  • there is a variability in resident needs and staff skills
  • it would lead to an overinvestment in clinical resources
  • models of care are evolving
  • there are a scarcity of registered and enrolled nurses
  • it would create economic and administrative burdens
  • it would negatively affect consumer choice.

As part of the investigation, Ansell Strategic examined the assumptions used by the Australian Nursing and Midwifery Federation and Flinders University in its modelling of costs and benefits of the ANMF proposal to meet recommendations of minimum nurse staffing and 4.3 hours of care per resident per day by 2025.

The Flinders University report found the $5.7 billion cost of implementing the increased workforce and skills mix recommended by the ANMF would be offset by indirect and social benefits (read more here).

Ansell Strategic said in its submission that the ANMF and Flinders University modelling did not substantiate the assumptions underpinning the benefits forecast and that the regime proposed would undermine the flexibility needed for care delivery.

However, it said that the ANMF accurately articulated that the workforce was under-resourced, inadequately trained and undervalued.

“It is undisputed that resident outcomes are enhanced through improved skills mix, training and recognition.

“Delivering on this will require a substantial investment, not only in the workforce, but in the reallocation of our sector’s resources between residential aged care and home care,” Ansell Strategic said.

Ansell Strategic has proposed the following solutions:

  • improve the focus and resourcing of home care and reduce pressures on residential aged care
  • improve the training, education and recognition of the aged care workforce
  • realign the relationship between aged care stakeholders to create a unified partnership.

Mr Ansell said the first point was critical and supported David Tune’s recommendations for a modest increase in means testing and the introduction of level 5 and 6 home care packages.

“If we were to means test properly then we could pay for a stronger staff complement,” he said.

If there is a better balance between user payments and taxpayer contributions the industry will explode, which will improve competition, choice and innovation, Mr Ansell said.

Access the submission here.

To stay up to date on the latest about the Royal Commission into Aged Care and Quality go to our special coverage. We will also be issuing regular Royal Commission Roundup reports which you’ll receive in addition to your weekly e-newsletters.

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22 Responses to Staff-to-resident ratios not appropriate, inquiry told

  1. Steve May 29, 2019 at 11:12 am #

    He has no idea and favourable to the profit owned nursing homes , he should get negative feed back as that it false what he says . What rite has to say that when staff and unions are screaming out for better staff ratios . It makes me mad and the royal commission should not take in what he has said . If anyone knows him please pass on his contact details so he can be bombarded with negative emails .

  2. Peter Stewart May 29, 2019 at 11:27 am #

    Submitted to the Royal Commission based as Ansell Strategic has consulted extensively with operators of residential aged care services across Australia. Interviews have been conducted with the Clinical Leaders (primarily nurses) responsible for the care of over 15,000 people in residential aged care.

    That’s fine for half an consultation (on behalf f the industry) but does not address the bigger question.

    “What do the residents want”

    The submission fails to answer how dignity and respect can be met with an appropriate level of care

  3. Sabine Phillips May 29, 2019 at 12:22 pm #

    Very insightful Cam,

    As we discussed, another issue that is overlooked by the proponents for staff ratios is that where ratios are applied in the public health system and those ratios cannot be achieved they have the ability to close beds, facilitate discharges and not accept patients.

    Closing beds and discharging residents is not an option available to aged care providers.

    Were ratios to be implemented and for unforeseen events, the ratio is not able to be achieved for the shift, the day or even longer what will the sanctions be?

  4. Caring worker May 29, 2019 at 2:57 pm #

    Wow no surprise there. A decision made by an organisation tasked by the industry representatives. I wonder if the investigators spent time in numerous facilities to see what it is actually like on the ‘floor’ or have spoken with residents as to their expectations of care delivery and how it is delivered.
    Money should play no part in decisions made in order to ensure residents are treated with respect, dignity and sufficient staff to meet their requirements.
    Big business and caring are like oil and water – sadly they don’t mix

  5. Dave May 29, 2019 at 5:54 pm #

    Excellent work, Cam.

    Who else would one turn to for expert aged care advice but an accountant and real estate agent?

    A report filled with babble and absurd reasoning..

    Ratios are inappropriate as it ‘would lead to an over investment in clinical resources’. Huh?

    ‘Models of care are evolving’. No mate, they’re devolving thanks to pseudo-experts like you.

    Your ‘proposed solutions’ are simply vague attempts to extract more money from consumers. At least have the decency to be transparent and identify the providers that paid for this rubbish

  6. Donna Schwarz-Nielsen May 29, 2019 at 5:56 pm #

    What a shocking conclusion. Did any of these ‘experts’ actually visit any care homes?

    It doesn’t matter how much training staff members have, logic dictates if there are not enough of them then people are neglected in favour of cutting costs rather than improving benefits!

  7. Janet Pearce May 29, 2019 at 6:54 pm #

    As Ansell Strategic stated ” It is undisputed that resident outcomes are enhanced through improved skills mix, training and recognition”, ie more staff, more attention for residents, reduced staff stress, happier workplace/home for our older people.

  8. Ruth Wagstaff May 30, 2019 at 9:31 am #

    I respectfully disagree with Cam. The problems in the aged care sector are not unique to Australia and are reported the world over.

    There must be focus on staff skill and resident need matching – and this comes down to training. And I know that there is a scarcity of research in this area but it is critical. In the medical system, the staff patient ratio is dependent on patient need. It would be no different in aged care.

    Please define what you mean by an “overinvestment in clinical resources”. Aged care needs people trained in issues pertaining to the care of older adults. That will involve clinical and non-clinical care. There is not enough investment in either type of care. If there was, the Royal Commission would not need to happen.

    Models of care are evolving in every facet of health care and home care. They will never stop evolving. If one waits on to the models stop evolving nothing will change. Evolving care is what happens as a result of research and the general change in needs of each cohort as they age.

    The scarcity of registered and enrolled nurses must be overcome. This is not a reason not to move ahead. It is though a reason to develop the specialist care training programs that older adults require.

    There are already economic and administrative burdens. This is overcome by increased investment, lower profits, and more admin/specialist staff. Admin issues are under-represented in the commission.

    I am not sure how better staffing would negatively affect consumer choice. This needs much more explanation and seems counter intuitive.

    Yes, there is need improve the focus and resourcing of home care and reduce pressures on residential aged care. But to do this there is an even greater need to examine the impact on family and carers. There is an urgent need for residential respite. There is an urgent need for better and more effective home-dementia care. There is an urgent need to support older adults who co-care and self-carers. Please, NEVER underestimate the burden of caring for frail older adults

    The need to improve the training, education and recognition of the aged care workforce goes without saying. But must include nationally recognised and registered workers.

    Sure, there is a need realign the relationship between aged care stakeholders to create a unified partnership. But who are your stake holders? The push for the mighty dollar must go. People who invest must acknowledge that this is NOT and will never be a high profit margin “business”. You are dealing with people with complex emotion, physical, and social needs.

  9. Don Pember May 30, 2019 at 11:04 am #

    Cam is somewhat right but the biggest concern in Residential Care is the loss of independence. Using a wheelchair rather than having elders walk most or part of the way, making a Care Facility a home rather than a Hospital, walk into any CF and it’s so quiet and uninviting.

  10. Care Service Employee May 30, 2019 at 3:23 pm #

    Excerpt from the story…’Ansell Strategic has proposed the following solutions:
    Improve the focus and resourcing of home care and reduce pressures on residential aged care’…

    My reply…
    In-home care, will always be considered, where appropriate to the abilities/resources of the family to maintain the required level of supervision/care – but the reality is, it is not always sustainable.
    Focusing on this aspect will-not/does-not negate the need to concurrently & urgently focus towards adequately staffing of the existing (and foreseeable) Residential Care Facilities.

    Excerpt from article…
    Royal Australian College of General Practitioners, the Australian Medical Association, the Australian and New Zealand Society for Geriatric Medicine and ANMF jointly sent a letter to Prime Minister Scott Morrison urgently calling for legislation to address minimum aged care staffing ratios….including the following comment:
    “Staffing ratios need not stifle innovation. Instead, they can lay the foundation on which better quality standards can be built. And while mandated staffing ratios alone are not the only indicator of high-quality aged care services, it is certain that high quality care cannot be achieved without them,” the letter said.

    This would appear to be from a Nursing staff approach.

    I am approaching from the Care Service Employee aspect of Residential Care Facilities.

    My addition…
    You want more time spent 1S:1R (and increasingly 2S:1R) with each individual? (Staff:Resident)
    You want more documentation completed during a shift?
    You want more time allocated to the care of high needs residents without any impact on the current, and concurrent, needs of all the other residents?
    You want Care staff to maintain their own health in order to maintain their ability to provide care?

    (Sorry, but personally, calling someone a ‘Consumer’ is a highly anonymous approach – insultingly deviating from the Individual that is the focus of the high quality of support)
    The Residents, to whom I have mentioned this term, say emphatically, they do not like the term (label) ‘Consumer’

    The reality is, there is a mixture of low/med/high needs Residents – and the types of care can (and do) change and increase (naturally!!)

    The needs of the Residents change – they increase.
    The concurrent needs of a number of Residents, peaks and reduces throughout the 24hr day.

    Do any of these experts/consultants really know the impact on the Residents, and Staff, to cope with the CONCURRENT needs of a number of Residents, each of whom are unaware of the 5, 6, 7 (whatever) other Residents requiring assistance at that particular time?
    Plus all the other ongoing tasks?

    Wearing a pedometer, between 12,000 and 18,000 steps are regularly counted on a ‘standard’ 8.5hr shift…this does not totally mean we are fitter and more resilient for it…it means the total-task burden of the shift causes fatigue over a number of days, especially when extra shifts are taken on (at short notice) due to other staff being unable to attend.

    And who was the bright spark that changed & instituted that 8hrs between shifts is enough…try finishing at 11pm – drive home – unwind – get ready for the morning – sleep – morning routine – leave in time to travel to work – start at 7am…
    ESPECIALLY when we are one of the industries directly affecting the lives of individuals.

    More responsibility, more accountability, more scrutiny, more focus is being placed on Staff under the unchanging current ‘accepted’ Staff:Resident ratio.

    One primary focus of Aged Care is the Quality of Life of the Resident.
    We (Carers) are in THEIR HOME…trying to give them the time, attention, focus, conversation, reassurance, comfort, acknowledgement that they crave a little more of…but the current system does allow that…without them feeling “they are wasting our time, or keeping us from helping someone else” – a sentiment expressed to me by quite a few Residents, as they realise we are under stress.

    In my opinion, a Staff:Resident Ratio range of 1:8 to 1:10 should be the maximum during morning & evening shifts.

    The cost of the extra staff per shift per average facility = $Lots
    The impact on the Resident’s Higher quality of Life = $Priceless

  11. Susan Watson May 30, 2019 at 6:31 pm #

    I don’t believe there will ever be hard and fast rules on ratios in Residential Aged Care, even though I would love to see it. It is just unaffordable with the current funding and fees. The Stewart Brown report found that 43% of the homes reviewed were not making a profit, and that was a year ago. Staffing is the biggest cost to these businesses, who can afford to ‘up’ the staffing. The consumers and their children don’t want to pay more, the Government and Taxpayers don’t want to pay more. To lift staffing to where it should be would send many providers to the wall, and prevent anyone investing in building and buying nursing homes, any business must make a profit, and a decent one, to allow the ability to put resources back in, or build another nursing home. The compliance costs now are massive, and more will keep piling on I am sure. Unless someone (Government or Consumers) pay more, then nothing will change, as the Government knows that it will cause closures and failures to invest. Let’s hope some answers come out of this Royal Commission.

  12. Old Aged Care Worker May 31, 2019 at 8:03 am #

    Here’s a thought, maybe we should stop farming out the care of our most vulnerable elderly community members to the private sector to make a profit from.

    The old chestnut of competition leading to lower prices and better service hasn’t worked in the energy, water and telecommunications sector so why is it suddenly going to work in the Aged Care Sector?

    Maybe it is time for the Government to become the provider of Residential Aged Care Services with no private sector involvement.

    In response to P. Sabine, as an Aged Care Nurse of many years staff are prepared to work short when they know that adequate numbers of staff are being rostered on each shift and management actually to attempt to replace staff who are sick or on leave. Staff do actually talk to each other and soon realise if managers are actually contacting staff in an attempt to cover sick leave or just telling staff they have tried to find a replacement. I would not expect sanctions to be applied if Accreditors could see that every effort had been made to overcome staff shortages.

    Sufficient staff in Aged Care Facilities would see them as a more desirable work place rather than the hard grind with insufficient staff many of them currently are. We have to put people (both the Residence and Staff) before profit.

  13. Ellie May 31, 2019 at 9:11 am #

    Cam, a managing director at an advisory firm, likely hasn’t set foot in residential care. Nor has he had to consider the complexity of people’s care needs on an actual, tangible level.

  14. Rosemary Blayney May 31, 2019 at 1:13 pm #

    Can I cngratulate most of the other respondents.i am a resident in aged care and can see the fatigue and distress of our very good and professional workers because they are trying to do everything properly.we certainly need adequate staff or we will loose our good nurses. No wonder it is difficult to get staff it is too hard.the last thing we want is untrained unsuitable people to be given jobs because it is hard to recruit trained people.I aso contend that profit should not be the driving force that it appears to be in some instances.The appalling scenes that have been shown show a lack of supervision of new staff,and the careless employment of applicants.government funding needs to be increased Rosemary Blayney,Catholic Aged Care, NSW

  15. Pat May 31, 2019 at 2:10 pm #

    Ellie, I agree that a managing director, CEO or any top level staff would have no idea of the basics of caring for the aged. They will never understand the situation by a quick inspection of facilities. One needs to spend time in a nursing home to realise what staff have to cope with. If short staffed for 1 roster it can be very stressful. Would top level management know that on occasion the food was mouldy and staff had to find a substitute ?

  16. Darren Parnell May 31, 2019 at 6:19 pm #

    It strikes me that Ansell Strategic, and in particular Cam Ansell who, “has specialised in aged care for over 25 years and has led some of the most influential research and lobbying in Australia” have been part of the problem. Ergo, it seems counterintuitive that they could present themselves as part of the solution.

  17. Kim June 3, 2019 at 1:18 pm #

    If it’s this simple, why are people burning out. We can give resident zero choice, we can wheel chair then everywhere in the hone, that way it’s faster not caring but faster. We can also not assist feed residents, that way we can go off and help people go to the toilet. The list goes on. If we want residents to get the most out of their last years, months, days hours it takes time it takes even longer time when they are more critically unwell and dying. Please please give ratios. Please see these people nurses and PCAs the help and support that’s needed to cate properly for our aging population.

  18. Cinderella June 5, 2019 at 11:33 am #

    As a Support worker that started from the bottom rung so to speak….. the regulations governing employment of all so called not for profits, from care staff to the exec directors down, are where things need to change. Aged are not cattle, and a not for profit simply means that those up the top get bigger ever increasing salaries. The obvious inefficencies in the structure of these businesses is the problem. So start with a director that, and here’s a daring concept, actually cares about the residents and as such, make choices and procedures in regards to the hiring of staff not based on pieces of paper saying that a person is competent to do a job. To increase staff would not fix the biggest problem, a lack of care amongst the vast majority of existing staff is the issue. This problem can be resolved by simple implementations, like assessing prospective employees on real skills, transferable or otherwise, the main one being empathy.

  19. David F June 5, 2019 at 6:12 pm #

    So let’s suppose we have mandatory staff to resident ratios and due to staff winter flu, industry workforce shortages or whatever, the ratio for the home could not be met, what does this mean ? Failure to meet the ratio means “Non Compliance” therefore to comply does it mean the home has to discharge x number of residents so it can comply. So where do they go?

    While funding for current staffing numbers is generally very tight, workforce is likely to present a bigger challenge in future

  20. Lynette June 7, 2019 at 7:30 pm #

    David there are plenty of casual nurses and carers who can be taken from agencies or their own staff bank to fill staff sickness in that event. It is not an issue if they want to have the appropriate ratio and staff numbers attend. Thats just an excuse IMO

  21. Andrea June 8, 2019 at 5:42 pm #

    Workforce is a big factor, with migration numbers being scaled back, this will have an impact, the residential aged care industry relies heavily on overseas workers, skilled migrants, who will work for low pay and do hard work, many ‘Aussies’ will not do the work anymore, many nursing homes rely on overseas workers desperate for permanent residency to make a better life for themselves, ratios would bring in higher staff numbers, hence the number of overseas born workers would increase also. Staffing is a constant struggle, and getting good staff is a constant struggle, why would an RN in a hospital on more money and a patient load of 6, drop money and take a patient load of 40 to 70, nursing homes are now becoming like hospitals, full of very sick and frail, co-morbidity patients, very difficult to get GP involvement. Would be easier to attract staff if ratios were in place, but I agree with previous comments, that if you were unable to meet the ratio due to circumstances outside your control, would this attract the attention of the Accreditation and compliance agencies?

  22. Chris July 8, 2019 at 10:40 am #

    Trust your loyal government to pull this rabbit from their magic hat of tricks. Really! STAFFING RATIOS was, and still remains, the howl from the roof tops from all HCW and lobbyists of the RACF. Instead, our trusted leaders implement the Royal commission into the Aged care crisis and what happens?. A total failure at every level addressing the cause, instead asking the residents “what do you want?” Better care was the replies. So to avoid an indebted country stepping on the toes of this savage and tragic private healthcare sector, the 4 old standards are now defunct, and we now have the 8 new standards implemented to canonize an apparent victory. More paperwork, more clinical and person care, and no changes to the causative factor, namely, STAFFING RATIOS. If this Royal commission fails to make some constructive recommendations regarding staffing, then, the modicums of faith I have remaining in Govt, will be thrown into the same bin as their own ignorance and arrogance for this diversionary tactic.

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