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Community Affairs References Committee
10/07/2013
Care and management of younger and older Australians living with dementia and behavioural and psychiatric symptoms of dementia

BROOKS, Mr John, Chief Executive Officer, Presbyterian Care Tasmania

WEEDING, Ms Felicity, Manager South, Presbyterian Care Tasmania

[14:23]

CHAIR: Welcome. I understand information on parliamentary privilege and the protection of witnesses and evidence has been provided to you. I invite one or both of you to make an opening statement and then we will ask you some questions.

Mr Brooks : It was not our proposal in the first place to make a formal submission to the committee, but I was invited to make a response to a submission that has been made to you. I have provided that and I understand that it has been tabled.

As a background, I have been working in health and aged care—government, private and not-for-profit—for just on 40 years, the last 27 years of which have been in aged care in Victoria. During that time I have seen residential, community, day therapy and general aged-care programs change quite significantly from what was a cottage based, institutionalised program to programs that are now outward facing to the community, responsive to community needs and, significantly, run by for-profit organisations as well as not-for-profits, which we represent.

In that process people's expectations have also changed quite significantly. We have gone from a situation where we have had generations past who have been accepting of the services that have been provided without question and without query to one where we now outwardly reach to a more assertive community, a community that has changing expectations. In particular, the children of people who are in care are certainly now far more assertive. I have been in that situation myself and I respect where that is at.

As a provider of aged care, we are trying to change our systems and services not only in purely resident but also in the area of community. We are seeking to drive a better and more informed workforce, provide better and more transparent information to residents and potential clients and ensure that our nursing staff, allied health staff, leisure and lifestyle staff, housekeeping, administration and management staff have skills sets that more match the environment. We have an obligation to ensure that we not only meet minimum compliance requirements which are imposed by government but also set standards which are above that. I think we have an ethical position to try to strive to more than just the minimum service. That is one of the things that motivates me and I like to pride myself on.

In doing that, we are also mindful of the framework within which we live which is imposed by the Commonwealth government, being the primary regulator now. That framework has a number of compliance and financial obligations on it which we cannot avoid. Again, there is always some tension between available resources and when is enough enough as against what community expectations and individual expectations are. I would like to think that, as a provider, in the main we work towards meeting individual needs and then move towards more collective needs and then being able to demonstrate both to individual and the government and through the accreditation agency the required outcomes that are put on us.

Funding constraints will always be with us, no matter what. We do not have an endless bucket of money. We certainly look forward to the challenges that come out of the government's recent changes which have just been approved by the Senate in terms of the Living Longer, Living Better package—in particular, the dementia supplement. Whilst that has, in its transition from theory to reality, changed somewhat from what was originally sold to us, I believe as an industry it is still going to deliver a significant resource which we will be able to apply to improving the outcomes for those who have dementia and behavioural related issues.

The reality is, as I said, that we are faced with those constraints. At the same time, we are also faced with having to be able to provide a service that is viable. That viability has lots of pressures from wage related outcomes, general costs increasing in terms of operations and, in particular, the costs of development. As an industry we are now facing costs in the area of $240,000 to $275,000 per place to develop. I support the government's initiatives towards community places. I am not about trying to create institutions where people are classed as a commodity and you come in with low-level needs and you go out with high-level needs. I do not believe that ageing in place is a reality. It has never been a reality. It has never been properly defined. It has had as many different connotations as the number of people who have been faced with the situation. It is the same with continuity of care. I do not believe anybody elects to live in an institution. Nobody elects to live with 30, 60, 150 or in some cases 500 other residents. We do not pursue that as a lifestyle. Therefore, to say that it is a home-like environment, is I think a fallacy.

What we need as an industry and as a society is to move towards providing flexible, supported resource services in the homes where people elect to live themselves—be that in community, rooming house, high-care or low-care institutional environments or in caravans and camping facilities. There are people who elect to live where they live because of either their circumstances or their choice, and I believe that our services need to be able to enter those environments to deliver right up to subacute-level care. The move towards community care, I think, is to be supported, but the one thing that has to happen is that resources go with it. I was involved some years ago with the deinstitutionalisation of disability care and the failing of that both here in Tasmania and in Victoria, I have to say, was that the resources put there did not match the requirements of those people out in the community setting. If we continue on the path of increased community care packages in aged care, it is beholden upon us all to make sure that those resources accompany the clients out into the community.

Senator THORP: I appreciate your comments, Mr Brooks. Do you think that the small proportion of people who will live with dementia, that small proportion that end up with PBSD, are able to be cared for within the community and, to do so properly, what kinds of resources do you think should be there, or do they need specific facilities?

Mr Brooks : It is really a matter of each person being treated as an individual and the assessment frameworks that we have being able to recognise their individual needs and then the matching of resources to the expectations of their family and their carers, and often that is where the dichotomy occurs. The expectations are not necessarily based in the real-world outcome we live with, and the service providers as well need to be able to think laterally in terms of how they provide and meet those expectations. But in the end, there will always be people who need supported residential care in a controlled and safe environment that probably cannot be afforded in the home.

Senator THORP: Do you think that the carer community, if you like—the people who work both within the facilities that you just described or out in the community providing in-home care—is well enough educated and trained in the area of dementia care?

Mr Brooks : No, clearly not. Whilst a number of toolkits are being put out and the Commonwealth has released various packages in the last few years, and some of the research facilities—and NARI, the National Ageing Research Institute in Victoria, in particular—have produced resources about dealing with restraint and with a number of other aspects of dementia care, when is enough enough? The reality is that the funding instrument, as it currently stands, looks at a number of modalities and provides funding based on that and it is not based on the true assessed cost of delivering care or preparing a workforce to deliver that care. There is a clear difference in terms of what the funding is provided for and what the actual cost components are and the elements of those components.

Senator THORP: I would like to come back to some specific questions about the Presbyterian takeover of Adards—

CHAIR: Let us deal with the general questions first.

Senator MOORE: Mr Brooks, you said that your response was very rushed, but it is very detailed in terms of a response. I am particularly interested in the complaints mechanism and, whilst it is not peculiar to dementia, it is one of the things that families and people talk about regarding how it operates. We have heard concerns, and not just in this inquiry but many others also, about the way the complaints system works and people's knowledge of how it works and how long it takes for decisions. It was something to which you specifically referred in your response. Would you take us through the complaints mechanism and how it should work?

Mr Brooks : The complaints mechanism, as it is, has probably had about as many reincarnations as the decades I have been in the industry. Every government that has come in has decided to impose a new one and then modify the one they have got. I guess that is one of the real failings of it, to my perception. It does not actually ask of both parties what they want out of the process. It has gone through swings and roundabouts; there has been the Australian standard for complaint resolution, which is very academic, detailed and precise, and that is not the way individuals work; through to situations where aged care providers, be they community or residential, have been seen as the big bad ogres, and whatever they have done has been wrong and therefore there is a presumption of guilt and you have to prove innocence. What it really fails to do is come down to the process of resolution on an individual basis of identifying what it is that individuals want out of a resolution process.

The system is not broken as it stands. I cannot comment on the level of training that the complaints officers receive; I know they have a comprehensive handbook. But I do not believe the system serves the needs of either the providers, the staff members of the providers or the complainants, the care recipients or the carers. It is still not there, in my view.

Senator MOORE: What needs to happen?

Mr Brooks : I am not about creating another statutory authority, but I believe that it has to be timely. Complaints, if they are accepted by the department, have to be out to providers on a timely basis without accusation, as is the current framework, and they have to be dealt with fairly openly. In the first instance, before it goes to a statutory body and is formally dealt with by them, they should be encouraging the engagement between the provider and the complainant, and that does not happen at this point in time. It ignores the provider—and there might well be reasons for that—and goes straight to the statutory process, the statutory process assumes that there is something wrong and does not bring the two parties together. It is about filling out paperwork, writing responses and giving feedback, and in some cases you never actually meet with the complainant. That is the way the system is biased at this point in time.

Senator MOORE: In terms of the post-complaint discussion, at the moment do the person who makes the complaint and the provider have a process post complaint, after all the paperwork has been exchanged and so on, to look at how they will work together in the future?

Mr Brooks : My experience of the recent complaints scheme is: no. The feedback goes from the complaints scheme in the department to the individual, and often we do not even know what the resolve is to that. There is no encouragement of communication at the very basic level between the staff of the provider and the aggrieved family or carers.

Senator MOORE: None of those points in your statement, though?

Mr Brooks : No.

Senator THORP: For the purposes of our evidence, could you explain to me from your perspective how it was that Presbyterian Care Tasmania came to take over what was the old Adards reign?

Mr Brooks : I was not in this role at that point—

Senator THORP: I thought you might not have been.

Mr Brooks : so I cannot speak firsthand, but in reading and briefing I understand that there was an approach from a government officer level. Clearly, the viability of the Adards unit, as it was, was questionable. They were within a short time, as I understand it, of being in a position where they were insolvent.

Senator THORP: So it was a departmental contact—that is your understanding?

Mr Brooks : Yes.

Senator MOORE: State or federal?

Mr Brooks : It would have been state. I also understand there was some communication. I am not across the detail of that, and I do not have records of who said what to whom, but I know there was engagement between Presbyterian Care Tasmania and the Commonwealth in terms of suitability, what would be the ongoing structure, what opportunities would be there for Presbyterian Care, additional bed allocations to make the facility viable, and scoping the land and everything else that was available.

Senator THORP: I am just wondering what possible role a state health department person would have negotiating around a Commonwealth aged care facility.

Mr Brooks : State obviously had some sort of a skin in the game, as they say, but state has very much a policy role, even in terms of where a provider might develop a new service. Recently in the ACAR process, both here and in Victoria, I have approached state representatives. They are responsible for feeding into the Commonwealth about planning and priority areas. There is a complex process that happens before the ACAR rounds. They certainly take an interest in services that are happening. Also, the state engages with providers in terms of transitional care programs, contracting beds in aged care facilities, to take long-stay patients out of hospitals and into aged care. So, it is not a firewall. All three, in my experience, clearly work together.

Senator THORP: I appreciate that you were not around at the time, but I am sure the place keeps great records: do you have a copy of the heads of agreement that was signed by Presbyterian Care Tasmania at the time they took over the facility at Warrane?

Mr Brooks : We would have a copy of that with our solicitors, I would suggest.

Senator THORP: My understanding is that the heads of agreement covered off on management of patient care and other issues like that.

Mr Brooks : It may well have. I would suggest that I take advice on that, because I believe it would be commercial-in-privilege. Again, referring to the terms of reference of this committee, I do not believe this is a witch-hunt into the transfer or the acquisition or the changeover of the ADARDS facility.

Senator THORP: Heavens no.

Mr Brooks : And with all due respect, my position that that is in the past; it is water under the bridge. What we are talking about is the structure, the options for services in the future—moving into the community, the training that is needed to support and the resourcing for services going on. So, at this point in time my position would be that that agreement would be commercial-in-confidence, but I can take advice.

Senator MOORE: We take very seriously our role as a Senate committee.

Mr Brooks : I appreciate that.

Senator MOORE: And we are not and never have been in any way part of a witch-hunt. This was a question that was driven by evidence that has been given to our committee.

Mr Brooks : I understand that, but, again, it is a historical matter, and I do not believe in going back over transactions that were not necessarily initiated by my organisation but were brought about by circumstances of another organisation and their relationship with the state or Commonwealth. And it is now some years in the past, with all due respect. I do not think it is relevant to looking forward and looking to the future.

Ms Weeding : Perhaps I could also make a point of clarification. Throughout the proceedings I have heard reference to the 'old ADARDS' in the light that that no longer exists. I would like to clarify that some of the stuff in the media articles published lately were not clarified with us as providers. Things that were claimed as being no longer in existence are actually there. We still have the car for the residents to utilise. In fact, it is a nice new one that has been in a nicely refurbished yard that is now safe for the residents to utilise, with level paths and clear areas of access and egress. We still have the chicken run, with new chooks. We still have the cat. The residents still have the ability to go in and out of the houses. We have refurbished all of our garden areas to make the path areas safe and to make them appropriate for dementia. So, the talk of the 'old ADARDS' no longer being in existence is actually a little bit of a furphy. It actually exists, largely as it did at the point of takeover, with some degree of refurbishment and with some changes made to maintain compliance with federal legislation, which is a non-negotiable standard, as far as I am concerned.

Senator SMITH: Would one of those be around the preparation of food?

Ms Weeding : Absolutely. The kitchens are old domestic-style kitchens with a standard domestic oven, so they are not appropriate for cooking in. The meals are prepared in River View Lodge, another wing of our facility that is a few hundred metres away. They are cooked daily by a qualified chef in the kitchen. The meals are then placed in a bain marie and taken down a walkway to the ADARDS houses and served within 20 minutes. The food is not sitting in bain maries for half a day like it is in a dodgy fish-and-chip shop; it is cooked fresh and served—served at the same pace that it is served to the other residents in the other area of the nursing home.

Senator THORP: My reference to the heads of agreement was because we have received evidence that that heads of agreement included quite clear directions as to patient care and management. And I would like to see that, if that is the case—not anything about commercial moneys exchanging hands or anything like that but purely and simply the specific directions that were in the heads of agreement around patient care and management.

Ms Weeding : We think that those directions may have led to failure to comply.

Mr Brooks : Noncompliance.

Ms Weeding : I would like to see what was in the heads of agreement. If for other reasons they could not be complied with, that is another step. I am failing to see the issue around the cooking of the meals in the kitchens because—

Senator MOORE: I am not from Tasmania. I have never seen the facility. What we have been discussing are models of care for dementia. What we heard was that there was a particular model of care for people with dementia that had a number of components. I would be more than happy to see a statement from PreCare, which is not here, that compares the model of care that was at ADARDS prior to the transfer—I do not use the term 'takeover'—and the current model of care. That would make it really clear for me. You began to provide that with what you just said. That would be a very useful exercise for the committee.

CHAIR: One of the issues that we are looking at is the fact that people are saying that that was the model of care for BPSD and others are saying—

Ms Weeding : BPSD is a subset of symptoms of dementia. It is not a discrete disease. It is a manifestation of a disease.

CHAIR: I understand that but for—

Ms Weeding : There are people with BPSD in the general population in normal residential aged care facilities. The only people who are requiring the facilities of a wing like ADARDS are those who are at risk of leaving a facility and coming to harm as a result of that. There are people within the general population, so to speak, who probably have more severe BPSD—which is a term I hate, because it is a label and it does not focus on a particularly person centred model of care. But that is the terminology put forward by funding bodies et cetera, so we work within that framework.

Mr Brooks : In response to your question about the model of care, I do not believe that that document on my brief reading of it—because it was an historical document and not relevant in the real sense to where we are going—contained the model of care. The model of care as it was was probably something that was documented in operational practice at the time of the changeover. The heads of agreement contained significant things like financial transactions and responsibilities.

Senator MOORE: That is not our interest at all.

Mr Brooks : There was, I believe, something in there about trying to maintain the intent of the service that contains the three houses. It is a hub and spoke model. Clearly, issues about staffing go to the very heart of viability and issues about cost and preparation of meals go to that staffing and viability question as well. In the ADARDS development, the hub and spoke model has been applied in different means in facilities throughout Australia. I acknowledge that base of evidence. In particular, one that I was associated with in Victoria was at a point such that it was not viable operating under that methodology of engaging clients in the preparation of meals and in their domestic duties. Time moves on. Since that initial concept was put into place, we have had ANZFA food regulations that require external monitoring and auditing and enhanced council regulation and inspection of food premises. That for one did not permit that model to continue.

CHAIR: Sure. Ms Weeding, you added a comment before. The point that I was making was that this has been put to us as a particular model of care. Outside of dementia care, I saw this same model being used in Victoria two weeks. It is still currently in use. I accept what you have just said, but it is still happening. Food is being cooked on site in a domestic kitchen in a model of care. I accept what you are saying, but—

Mr Brooks : That comes down to a commercial decision of that provider as to whether they can afford to do it. Good luck to them if they can.

CHAIR: We have been tasked with inquiring into this particular issue. I agree with Senator Thorpe. I heard what you said about the report being commercial in confidence. But if we can have a look at it to make those comparisons it would help us to see what issues we should focus on and what issues that we have heard about are in fact not necessarily pertinent to what we have been asked to look into.

Mr Brooks : I will undertake to take advice on it. If there is anything relevant in that document I can either transcribe it or forward it on to it. But I cannot answer the question of whether I can give you the document at the moment.

CHAIR: If you can do that, we will respond to that.

Mr Brooks : But I do not believe it does contain that.

Senator MOORE: It would be confidential.

CHAIR: Yes. We can take it as a confidential document.

Senator SMITH: Mr Brooks and Ms Weeding, how would other aged-care professionals or aged-care providers in Tasmania describe the sorts of service that you provide at ADARDS now? What is the suburb in which ADARDS is located?

Ms Weeding : Warrane.

Senator SMITH: How would other aged-care providers in Tasmania and aged-care professionals describe the sorts of care that you provide at your home in Warrane?

Ms Weeding : Especially for the ADARDS wing we are very highly regarded by the team at Roy Fagan. Frequently—because I still manage the admissions—they will ring me and liaise with me with regard to taking residents who no-one else could cope with. We are regarded as having the willingness and the capacity to cope with residents that will not fit into any other residential aged-care facility within the state. We have several residents in the ADARDS wing that have been unsuccessful in other residential aged-care facilities and have been transferred to Roy Fagan for assessment and management, and then the decision has been made by the Roy Fagan team that they cannot be transferred back to their donor site, so to speak, and we then take on those residents.

Senator SMITH: So it is well regarded by your peers in Tasmania?

Ms Weeding : Yes.

Senator SMITH: From the aged-care standards agency or the complaints scheme, are there any systemic issues that have been brought to your attention at PresCare in Tasmania?

Mr Brooks : I will answer that. There have been and there are no outstanding issues. There are no compliance requirements. There are no orders, sanctions or other issues imposed upon it. Yes, the environment of the ADARDS building is now tired. In terms of design, it is limited by the space available in the individual rooms, bearing in mind the age of it, but we are continuing to maintain it to a standard which meets the requirements.

Senator SMITH: That would not be the only home in Australia facing those sorts of challenges.

Mr Brooks : That is old and tired.

Senator SMITH: That is right.

Mr Brooks : No, clearly not.

Senator THORP: How many beds are there now?

Mr Brooks : We have—

Ms Weeding : 38.

Mr Brooks : 38, yes.

Ms Weeding : Thirty-six permanent and two respite.

Senator SMITH: We heard some comment earlier today about that number of beds—it being more and more difficult to maintain viability with such a small number of beds. Is that a true statement?

Ms Weeding : We have 48 beds in the other wing, called Riverview Lodge.

Mr Brooks : And part of the process of taking over was a significant capital commitment to the additional allocation of beds and the building of a new facility which is conjoined to the rear of it, so it now has mass and viability in terms of its ability to pay its way.

Senator SMITH: And that was part of the agreement that was struck by PresCare in the agreement to transfer?

Mr Brooks : It was a proposal that was put to the Commonwealth, and they subsequently provided the additional bed allocation and then subsequently a capital grant to assist with that redevelopment work.

Senator SMITH: Right, thanks.

Senator MOORE: So you have over 70 on site—

Mr Brooks : There are—

Senator MOORE: or whatever those two things were together. I could not add them up.

Mr Brooks : 86 on site.

Senator MOORE: Ms Weeding, you said that, through the Fagan facility, you took on people who came back because of the way that your care operates. Is that care specifically in the ADARDS bit—

Ms Weeding : No.

Senator MOORE: or across all of—

Ms Weeding : No, across all of ours.

Senator MOORE: It was not clear. That is what I was trying to get at.

Ms Weeding : We have developed a cohort of younger residents because we have been recognised as having, yet again, the capacity and willingness to deal with that group, including not just those with dementia but those who have sustained brain injuries as a result of strokes.

Senator MOORE: How many facilities do you have in Tassie?

Mr Brooks : We have four.

Senator MOORE: The kinds of clients you have just described would be in each of your four facilities?

Ms Weeding : I cannot speak for the northern facilities.

Mr Brooks : Yes, two of those facilities in the north have secure dementia units. The other one is in rural Scottsdale, and that is just low care and high care with no particular focus.

Senator MOORE: So just three of them would be the kinds of facilities that would take the kinds of patients you have just described?

Ms Weeding : Probably younger onset could be in any.

Mr Brooks : Yes.

Ms Weeding : As I said, the requirement for residing in a secure dementia area is based on your propensity to—

Senator MOORE: But one of your facilities does not have a secure dementia area, from what I just picked up.

Ms Weeding : Yes.

Ms Weeding : Yes.

Senator MOORE: Three of the four do.

Mr Brooks : Yes.

Senator MOORE: So three of the four in Tassie would be at the standard and have the competencies to care for people with significant dementia issues—

Mr Brooks : Yes.

Senator MOORE: or dementia and care facilities?

Ms Weeding : You could have significant dementia needs and not require a secure dementia unit.

Senator MOORE: Sure, yes.

Ms Weeding : A lot of our residents who reside in the Riverview Lodge wing have severe dementia symptoms but do not have a propensity to wander, so they do not require that secure environment. Secure environment is a very finite population.

Mr Brooks : We have approximately 90 secure beds across the three sites.

Senator SMITH: Going back to the question around the evolution, if you like, of aged-care homes and care models, what is the prime motivator? Is it federal and state regulatory requirements or is it the innovation in the industry and the innovation in your own homes that is the primary motivator for having to change the nature of care models or the operation of your homes?

Mr Brooks : It is always said that community requires a government with a commitment to driving changes, and I suppose the Aged Care Act as it is was a quantum change from previous regimes and generated interest professionally and with providers to do things in a different way. Through reviews such as this, government has looked at social norms or changing social norms and decided to commit funding from a traditional institutional model to a more open and flexible model. We have had the introduction of EACH and EACH D and the CACPS packages and transitional care which was not in place 15 years ago, and a range of other innovations. It is a combination, I think, of the community's expectations, government's perception of those expectations but also pressure from within the professional areas through research and development that has been done by the likes of Joanna Briggs, NARI and the Wicking institute here. So you have got a combination of things. It is a bit like tumbleweed. It gathers space and it is moving on. That is where I think we are at. I do not think there is one momentous earth-shattering equation or instance that said, 'We've got to do it differently', but it's evolving and it's moving and it's meeting those expectations.

Senator MOORE: I would like to get something from your perspective about the model of care that you have at PresCare now, as opposed to what was there before.

Mr Brooks : I am not quite sure we can answer that for you.

Senator MOORE: I am putting it as if you can.

Mr Brooks : Others might know what the model of care was before us, but we do not have that historical anecdotal information in terms of records and things but—

Senator MOORE: We will see whether we can get that, because it seems to be an ongoing issue that has come up in evidence today, not just by one person. I think it would be very useful to see and to reinforce the statements you made, Ms Weeding, about the fact that there is a misconception about 'everything's changed'. As an outsider, that would be very useful. So we will see what we can get for you.

CHAIR: If you could send us that information it would be very much appreciated. Thank you very much for your time.