Aged care staffing requirements ‘too vague’ NSW inquiry finds

Parliamentary inquiry report calls for minimum staff-to-resident ratios as well as licensing of personal care workers, which providers argue would cost the system $500 million if introduced nationally.

Parliamentary report calls for staff-to-resident ratios and licensing of personal care workers, which providers argue would cost the system $500 million if introduced nationally.

The national regulatory framework governing aged care is not prescriptive enough on staffing requirements in residential care, according to a NSW parliamentary inquiry that has called for staff-to-resident ratios and licensing of personal care workers.

The inquiry’s report, released last week, also called on the NSW Government to urge the Commonwealth to introduce new requirements for facilities to list their staffing skill sets on the My Aged Care website, and for additional federal training funds for registered nurses.

Nurse unions and some seniors groups have welcomed the inquiry’s findings, but aged care provider peaks said they were disappointed with the report, describing some of the findings as “borderline offensive.”

“It’s implying that we are in some way not caring about the quality of care being provided, and that the current system is broken, and we don’t believe it is,” said Illana Halliday, CEO of Aged & Community Services NSW & ACT.

NSW RN report
The NSW parliamentary inquiry report into RNs in aged care

The parliamentary inquiry into nursing staff levels in residential care was prompted by the removal of the high care/low care distinction in the federal Aged Care Act, which impacted on existing NSW legislation that required an RN be on duty at all times in a high care facility. NSW was the only state in Australia with such a requirement.

The inquiry found in support of retaining the current legislative requirement for an RN to be on duty at all times in NSW ‘nursing homes’, but it proposed changing the definition in the legislation to be based on residents’ assessed needs rather than the type of facility.

Responding to providers’ arguments that mandating RNs at all facilities 24/7 would not be financially viable, particularly for standalone and rural and remote facilities, the committee proposed exemptions be available, to be determined on a case-by-case basis.

But beyond addressing the NSW requirement, the cross-party committee also called for sweeping changes to the national aged care regulatory framework.

Acknowledging that the Commonwealth had regulatory and funding responsibility for aged care, the committee said it was “not convinced” that the national regulations “adequately ensures that a high standard of care is delivered to residents in aged care facilities through its staffing standards.”

The inquiry called for the NSW Government, through the Council of Australian Governments (COAG) process, to urge the Commonwealth to introduce minimum staff-to-resident ratios in aged care facilities; establish a licensing body for personal care workers; and to “take measures to address the wage disparity” between nurses in aged care and the public health system.

However in a ‘dissenting statement’ the committee’s three government members said they disagreed with the recommendations on minimum staffing ratios and wage disparity.

Mixed views over current regulations

The report noted there was “deep division” over the effectiveness of the Commonwealth’s aged care regulatory framework among the inquiry participants, which included providers and their peaks, GPs, nurses, unions, seniors advocates and researchers.

Some stakeholders opposed a mandated requirement for RNs on the basis that the Commonwealth framework already provided standards, outcomes, monitoring and sanctions, while others argued there were inadequacies with the system in regards to the accreditation, compliance and monitoring of facilities, and the staffing standards prescribed.

“While the committee acknowledges the flexibility of the current system in allowing aged care facilities to determine and provide the staffing skills and mix to meet the varying needs of residents, [it] shares the concerns of inquiry participants who feel that the staffing standard requiring ‘appropriately skilled and qualified staff’ is too vague and allows for wide latitude in its interpretation,” the inquiry concluded.

The accreditation standards did not prescribe the type of staff, qualifications required by staff or the number of staff who work in an aged care facility, the report noted. The way residential facilities were described by inquiry participants as being monitored and assessed against the accreditation standards was “troublesome,” it concluded.

Recommendations ‘impractical, unnecessary’

Illana Halliday, CEO, ACS NSW&ACT
Illana Halliday, CEO, ACS NSW&ACT

Responding to the findings, Ms Halliday said the committee was seemingly misinformed about the current regulatory framework, and the accreditation process in particular.

There were unannounced visits, which providers were not forewarned about, and assessors were very thorough about talking to residents and families, Ms Halliday said of the findings that the accreditation system relied on paperwork.

Ms Halliday said that providers did not argue about the need for RNs in high care facilities, but the issue was how to amend the NSW legislation so as to exclude low care facilities.

While she appreciated the committee had attempted to provide a solution to this – by suggesting the legislative requirement be based on residents’ needs rather than facility type – Ms Halliday argued the proposed method for measuring this was still too blunt. “I can’t think of a facility it wouldn’t pick up,” she said of the proposed change.

“I agree with going by a resident’s needs, which is why the accreditation standards say they will determine, during an audit and accreditation visit, whether a facility is getting the right mix of staff on duty available for the mix of residents,” she said.

Employing nurses at all facilities would require an additional 2,000 RNs and over $150 million a year in extra funding for NSW, Ms Halliday said. “One third of aged care takes place in this state, so you are looking at $500 million if this cascades across the whole of Australia,” she said.

LASA National chief executive Patrick Reid said the peak body held serious concerns about the report’s recommendations, which would impose significant costs on employers and government, and would unlikely improve outcomes.

“In 2011 the Productivity Commission stated that an across-the-board staffing ratio is unlikely to be an efficient way to improve the quality of care, and LASA supports this view.”

He said other countries such as the UK were investing in improving skills and diversifying training, which was “a far more sustainable approach”.

Federal department defends regulations

Australian Ageing Agenda asked Minister for Aged Care Sussan Ley for her response to the inquiry’s findings regarding the adequacy of the federal aged care regulatory framework, but she referred our request to the Department of Health.

The departmental response said that the recommendations were for “the NSW Government to consider in the first instance, and a matter for them whether they wish to take the matter up in COAG.”

The response went on to defend the current national regulations, reiterating that facilities were required to maintain “an adequate number of appropriately skilled staff to ensure the care needs of recipients are met.”

It also dismissed ratios, saying there was “no single optimum staffing level or mix that meets all circumstances in providing quality residential aged care.”

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Tags: illana-halliday, NSW inquiry, registered-nurses, Sussan Ley,

7 thoughts on “Aged care staffing requirements ‘too vague’ NSW inquiry finds

  1. I work in aged care, I began as a SEN, had a career change and returned as an AIN. In that 30 year period I have seen the ratio of six residents to one nurse (AIN) deteriorate to ten residents per AIN. The problem in aged care has always been the ratio of AIN’s to residents.
    The professionalism in aged care has also disappeared with the down grading of training.
    Aged care ‘on the floor’ work has always been unfortunately production line work and it has got worse, where there is often no time to even ensure your resident’s get a drink of water regularly through the day. In the 1980’s we had time to ensure people got a drink and exercise.
    The large turn over of staff and difficulty of getting staff would be due to the very nature of the pressure to move increasingly heavier people get their basic needs met and poor wages. Infact the pay is so poor there really should be more AIN’s on the floor.
    Yes we need experienced RN’s in aged care but we need more on the floor at the coal face staff.
    The ‘hidden’ world of aged care is rife to elderly abuse and that can be as mild as pretending to shower someone to physical harm etc. Now that RN’s no longer ‘run’ their wards/wings there is no continuity of care, with AINs/PCA/s making up the care and changing it at will. Even cert IV’s are not qualified for leadership as they are too close to cert III.
    Sorry I could go on forever. Basically it’s the old bottom line about money. No such thing as not-for-profit organisations, it’s an oxymoron and insulting. It’s about slight of hand, a hidden world away from the public eye.

  2. 1:10? I worked 1:14.5 AINs last night in what used to be termed a high care facility. Approximately half of the residents are bed bound and therefore require 2 staff to attend. Two thirds of those who aren’t bed bound have some form of cognitive impairment from moderate to severe. Most of the residents are considered high falls risk.
    I do afternoon shift, start after lunch and clock off a couple hours before midnight. My shift deals with more sun-downing than the other shifts. The Diversional therapist finishes at 8.
    Someone was sick. One of the multi-role people who was supposed to be on our wing got switched to DT. So the wing was short staffed.
    We have aggressive residents, bariatric residents, residents who are really sick, residents who paint everything within reach with substances the cleaners ( who finish at 4) aren’t obliged to touch, residents who attempt to abscond at every opportunity, residents who refuse to sit still but can’t walk on their own without falling.
    Incidents occur regularly. It is literally impossible to keep on top of our workload and prevent incidents with our usual ratio of just under 1:10 which apparently we aren’t entitled to, we are just lucky to get it. When we brought up the fact that the impending shift had unsafe ratios we were basically told to suck it up. Despite the fact that the policy ratio for afternoons is an unsafe, but apparently “carefully researched” ratio of 1:12.
    So I find myself apologising to the next shift (whose ratio is worse) and to families and residents when things aren’t done, or an incident happens. And I feel guilty for not providing the care these people deserve. And I go home exhausted and guilty and sore from trying to complete everything. Then the next day I get talked to about paperwork I have left undone because I was too exhausted to remember all the parts of paperwork needed for so-and-so’s ACFI.
    It’s enough to cause burnout.
    On nights like last night, we will accept first refusal, because we don’t have time to convince the client that they need to shower. I’ll admit that we can get snappy at residents, and we apologise for being human. We don’t document every vile threat a dementia patient makes, we just try to ignore it until our break so we can have a moment to process it, and cry if need be. Other non essential paperwork gets put off.
    So many of my workmates are considering quitting aged care. There’s better pay in the home care sector. One’s thinking of studying to be an accountant. I’ve seen at least 4 people who’ve been there for a couple of years quit, and 2 more are working their notice.
    Aged care is in crisis. It shouldn’t be for profit. It should be for best possible care.

  3. All of us working on the floor symapthise with you; we’re all too familiar with your situation.

    I encourage everyone to read the transcripts from the committe hearing. The submissions from provider representatives clearly show they’re the ones who are misinformed, not the committee.

    How else could one explain their unwaivering conviction that the AACQA is diligently monitoring the care standards of residential facilities?

    The public have been treated to yet another example of our peak bodies sabotaging their own credibility. What they say just doesn’t match the way it is. Aren’t they even just a little embarrassed by their suggestion that residents don’t need RNs 24/7 ? Or do they really believe emergency situations only occur during office hours?

    Your track record indicates that you can’t be trusted to do the right thing. Unskilled care staff, dangerously high resident to staff ratios and rosters that schedule one RN to oversee up to 180 residents are proof that we need more legislative intervention and less self-congratulatory backslapping from representatives with no understanding of what it’s really like on the floor.

    Disagree? Go back and read paragraph 4; nurse unions and seniors groups welcome the decision but providers don’t.

    Could that be a clue?

  4. It makes me feel sick to think that people believe in accreditation … people who swoop in once in, tell you all is good with your nursing home, while your heart breaks as you know that the elderly deserve far better than they get. Its even more sad that we are so time poor, that we are like robots, injures occur daily for staff and residents and you get please explain. This is not how our elderly should be treated.

  5. No surprises with the comments, i have been in aged care for 10 years, starting as carer and moving on to nursing also in aged care. I now teach cert 111 and 4 and facilitate students on their placement.With all the students who go on placement the main feed back is always time, or lack of. Having been through the surprise visits by the accreditation teams at both levels,carer and nurse its amazing that the company always know a couple of weeks before they turn up;;; and surprise surprise we have more staff on the floor. My fellow teachers and i are doing the utmost to train good carers but its hard to beat the system that is currently out there. We tell them to do what they can to improve the system and maintain what the government say in their training guides but do not follow up in practice to support carers nurses and the people we look after.All we can do is stay positive and do the best we can at our own level and as most of us in the industry say i hope i do not have to go into a nursing home when i am old, how sad.

  6. Thank you for a very thought provoking read. I am the a resident in an Aged care facility.I was looking for proof to back the conclusions I have formed while just sitting and watching. I intend to take my thoughts to the next residents meeting , not that they will listen to me and they will talk loudly over the top of me but I want to be sure that what I have to say is minited. What I am looking for is to establish a paper trail. The staff here is over worked and in danger of burn out. I just hope I can help in some small way to get them the support they need. XX

  7. Meredith, Nov 2015…even more true today, just getting worse
    I’ve been nursing ass RN for 42 years and very disillusioned with the health system, no moral compass, no responsibility from the top
    Elderly abuse in the most severe form, even in the community the increased co-morbidities are a challenge requiring more intensive assessments, let alone in the nursing home
    My best friend use to be in charge of nursing homes back when funding was from state & commonwealth CAM/FAM before ACFI. There is no accountability under his system, spot checks were run without any notice. ACFI & no behaviour charting is a open to fake reports, these are legal documents, but it is now like every thing in life about “money & numbers” not patient care

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