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Standing Committee on Health, Aged Care and Sport
26/04/2018
Quality of care in residential aged-care facilities in Australia

THOMAS, Ms Cathy, Group Executive, Blue Care, South East Queensland, UnitingCare Queensland

WEBBY, Ms Glenys, Director of Service Reform, UnitingCare Queensland

[11:16]

CHAIR: Welcome. UnitingCare Australia made a submission which we haven't yet authorised for publication. Could a member move that the submission in this pack be authorised?

Mr ZAPPIA: I move that way.

CHAIR: As there is no objection, it is carried. We have representatives from UnitingCare Queensland. Do either of you have any objection to being recorded by the media if they happen to be present today?

Ms Thomas : No.

Ms Webby : No.

CHAIR: I'm required to remind you that these are formal proceedings of the parliament. The giving of false or misleading evidence is a serious matter and in some circumstances could be considered a contempt of the parliament. Today's proceedings will be recorded by Hansard and your evidence this morning attracts parliamentary privilege, which hopefully won't be an issue. I invite you to make an opening statement before we move on to questions.

Ms Thomas : Thank you, Mr Chairman and committee members, for the opportunity to appear before you today. Blue Care is a service stream of UnitingCare Queensland, the health and community service provider of the Uniting Church in Queensland. Over the past 60 years, Blue Care has grown to become Queensland's largest not-for-profit provider of residential aged care. We're committed to providing services to communities in need right across Queensland, including communities located in regional and remote areas where other providers may not be able to provide a sustainable service offering. As a not-for-profit provider, we reinvest our revenue into improving our services each year. Across our 47 aged-care facilities in Queensland, we care for over 4,000 people each year, supported by a highly committed and caring staff of more than 5,000 employees and volunteers. We endeavour to a create an environment that reflects our residents' preferred lifestyle as this is, through circumstance, their chosen home. Every day, Blue Care supports individuals with a diverse range of care needs and requirements. We must be able to respond to an individual's fluctuating care needs and, at the same time, meet their lifestyle expectations and fulfil their wishes.

With an ageing population, we experience residents entering residential aged care at an average age of approximately 85 years, with the majority presenting with multiple health conditions. At Blue Care, we focus on quality of life and our team of people enable residents to achieve their goals by supporting them in a compassionate and dedicated way every day. Blue Care's No. 1 priority has been and always will be the safety and wellbeing of our residents. We take all matters that relate to the quality of care we provide very seriously and, with more than 4,000 residents in our facilities, we believe that Queenslanders see Blue Care as an aged-care provider they can trust.

I would now like to turn to some broader issues. Last week the minister announced a series of policy initiatives in response to the Carnell-Patterson report on quality regulation in aged care. We welcome those initiatives. Transparency is a good thing, and Blue Care welcomes the minister's announcement that several existing government agencies will be amalgamated to make for a more effective and efficient quality standard regime across Australia's aged-care sector. Given we consistently strive to deliver the highest standard of care 365 days per year, we also welcome the recently introduced unannounced audit regime. Our early experience with unannounced visits has, however, proven that they do place a significant burden on our site staff and can be disruptive to our delivery of care when auditors are on site. Adjusting rosters at short notice to accommodate the required interaction with auditors while maintaining high resident-care standards is very challenging and in many instances simply not possible. We recommend the soon-to-be-established commission consider how this can be addressed for the benefit of residents.

Funding is also an ongoing challenge. While we appreciate that the government will always have competing priorities, it should be noted that the funding cuts to the Aged Care Funding Instrument, or ACFI, have, and will continue to have, an impact on Blue Care's residential aged-care operations, especially in regional and remote areas. Despite the fact we anticipate funding across our residential aged-care network will decrease by more than $60 million by 2021 due to ACFI funding cuts, we continue to maintain an appropriate number of staff and skills mix in our facilities. These funding cuts present a significant ongoing strategic challenge for us, compounded by the observed increase in client need and the complexity of operating in regional and remote geographies.

With regard to recent attention on the topic of mandated staff ratios, the committee should note that the assessed need of residents varies greatly between individual residents and facilities, and these constantly fluctuate. Therefore it is incumbent upon providers such as Blue Care to apply flexible staffing models that can deliver an appropriate skills mix for the regularly changing occupancy levels and changing needs of residents at each individual site. While the concept of mandated staff ratios in residential aged care has been discussed for many years, there seems to be no substantive evidence that they achieve better quality outcomes for residents. Indeed, the Productivity Commission itself has also previously stated this.

In summary, Blue Care is fully committed to providing the best quality service and care to all of our residents, based upon our Blue Care Tailor Made service model, which supports residents to be all they can be. We are committed to the continuous improvement of our services in this regard, and we welcome the opportunity to now take any questions the committee may have.

Mr ZAPPIA: Thank you for your submission. In your opening statement I think you said that Uniting Care is a not-for-profit organisation but it reinvests its money into additional services. Does Uniting Care make a profit out of aged-care services?

Ms Thomas : I think it's important to look at this through two lenses. Our regional and remote services are loss-making services, and our South-East Queensland service makes a small surplus which is then reinvested into building and maintaining our current aged-care services.

Mr ZAPPIA: I think you said that you were the largest aged-care service provider. Can you advise what proportion of your residents are non-English-speaking residents.

Ms Thomas : I haven't got that stat, off the top of my head.

CHAIR: Feel free to take it on notice.

Ms Thomas : Thank you.

Mr ZAPPIA: With respect to staff ratios, one of your final comments was that—and I'm paraphrasing you—there was no evidence to suggest that higher staff ratios result in better service. Equally, is there any evidence to suggest that higher staff ratios would have no beneficial effect?

Ms Thomas : If you look at some of the services that do have higher staff ratios, like some of the Queensland Health funded services, you can be led to believe, from what's in the public arena, that they have lesser outcomes in some instances.

CHAIR: Sorry—the state-government-run services have lesser outcomes?

Ms Thomas : Correct—over time I think that has been evidenced through outcomes of various audits by external bodies.

Ms Webby : Going back to the literature that is there, most of the literature that I have seen is really around looking at the link between particular staff ratio in relation to disciplines and it's linked to quality and outcomes. I've not seen any evidence in aged care that actually provides a formula or a recommendation around particular disciplines and arrangements to improve quality and service.

Our position is very much based on the fact that, with residents who have varying needs—which actually change on a day-by-day basis—it is important for the facility to be able to move with those needs of residents rather than be restricted to particular disciplines—in particular, numbers. As Cathy said, our facilities across Queensland range from under 40 beds to over 120 beds. As you could probably imagine, in a facility where we have someone with very high needs but only 40 beds, the nurse ratio would be higher because we are attending to the particular needs of those residents with clinicians. In a facility that has more residents but lower needs, you may not have the same nurse ratio. That is an example of how we need to be able to flex according to the size of the facility, the set-out of the facility and, most importantly, the needs of the residents who are in that facility.

Mr ZAPPIA: Can you tell me how many staff overall you employ throughout all of your aged-care facilities in Queensland?

Ms Webby : There are 5,000 staff and volunteers.

Mr ZAPPIA: How many staff?

Ms Thomas : There would be around 4,500 staff.

Mr ZAPPIA: Can you tell me how many staff you had a year ago?

Ms Webby : We'd have to take that one on notice, but I would suggest that it would be very similar.

Mr ZAPPIA: Can you provide the committee with—

Ms Webby : We can provide you with the detail.

Mr ZAPPIA: Can you tell me how many of those staff were nurses a year ago and how many are nurses today, both enrolled and registered?

Ms Webby : We'd be happy to take that one on notice.

CHAIR: Off the top of your head, do you think that the number of nurses, enrolled and registered, has remained the same, or has increased or decreased?

Ms Thomas : I can talk about that from the area that I'm responsible for. I would say that it has increased at times due to the fact that people are coming in with more complex conditions. In the areas that I have audited lately, the registered nurses and enrolled nurses have increased.

CHAIR: If you could provide the numbers—

Mr ZAPPIA: Yes; I would appreciate accurate numbers on that. We heard earlier today from one of the other witnesses that the level of need has increased from about 13 per cent to 61 per cent over the space of fewer than 10 years. If that figure is correct—I can only assume it is; but I don't know—that would indicate to me that the level of need within aged-care facilities has increased dramatically. If the level of need has increased dramatically, can you advise whether the staffing levels within your facilities have increased and, if not, how you are coping with the level of increased need of residents?

Ms Thomas : From my perspective, the level of staffing would have increased. I was a nurse in an aged-care facility around 10 years ago, and I know that the staffing is at a different level to what it was back then.

Mr ZAPPIA: Is it possible for you to give us the figures from 10 years ago as well?

Ms Thomas : I'm happy to take that on notice.

CHAIR: Noting of course that we are not going to compare apples with apples. I assume the profile of UnitingCare has changed over that time.

Mr ZAPPIA: I'm sure it has.

Ms Webby : Not only has the profile of UnitingCare changed; the entire sector has undergone reform over a 10-year period. Ten years ago we still had high care and low care in place. The ACFI, the Aged Care Funding Instrument, was not in at that time. Generally our low-care facilities, which would have been in the mix of our reporting 10 years ago, would be more akin to independent living in a retirement village today. The high-care areas, which are much closer to traditional residential facilities today, would have been where we had more clinical services and a range of different staff. The model was totally different 10 years ago. With the advent of community care increasing, with all the home-care packages, more people stay at home longer; they come to us with higher levels of need, as we've talked about, and their length of stay is shorter. I agree with Cathy that we have, across the suite of facilities, much higher levels of support services as a result of that. We're happy to provide you with information on that.

Mr ZAPPIA: It would be very useful to see those figures. In one of my discussions with a couple of aged-care providers in my home state, staffing numbers have actually dropped and that seems to go against the trend of higher need. I want to confirm whether that is happening across the board.

Ms Webby : We do see differences between facilities in the acuity levels of residents still. Depending on where you're speaking to facilities, the level of need of clients that will vary according to their experience of who moves into facilities as well.

Mr ZAPPIA: Is Uniting Care today sending more residents to hospitals for acute treatment than in years gone by?

Ms Thomas : While I don't have data on that to compare year on year, I would say that we only send people to hospital when it's clinically indicated or when the family or resident requests it. That is the same today as it would have been a couple of years ago.

CHAIR: Do you have the statistics?

Ms Thomas : Admissions to hospitals?

CHAIR: Yes.

Ms Thomas : We do.

CHAIR: Are you able to provide them to the committee?

Ms Thomas : I'll take that on notice.

CHAIR: I have a couple of questions on issues we've already covered. One of the most topical issues presented to us is whether there should be mandatory staff ratios. This morning the union put the proposition that there should be three mandatory requirements: firstly, on average, residents receive 4¼ hours of individualised care each day; secondly, for every 20 residents there be one registered nurse available 24/7; and, thirdly, there should be a staffing mix of 30 per cent RNs, 20 per cent ENs, 50 per cent support staff. That would be a minimum standard, and so this goes to the issue of differences between the profiles of residents in aged-care centres. I'm wondering whether you have a response to that. Why is the concept of minimum requirements not a sound proposition?

Ms Webby : Our position, as we've briefly alluded to in the opening statement, is not in support of staff ratios, predominantly because, firstly, we have not seen anything in the evidence to support that kind of split and, secondly, we have a view, and the evidence supports it, that it's a multidisciplinary team approach that people need in an end-of-life care situation, which involves a range of people other than just nursing. Allied health staff, for example, are one particular group that is heavily involved in supporting people in their end-of-life care. We believe that it's important for residential facilities to look at what the needs of their residents are, to work with that resident group and to be able to flex their staffing up and down, notwithstanding the fact that you've said a minimum ratio may not exclude the ability to do that. However, it is our view at this point in time—we've not done any financial modelling or anything around those particular figures—that that particular staff ratio model is not something that we are able to support.

CHAIR: Let me drill down a little bit. At any of your facilities, would you not have 24-hour coverage with at least one registered nurse present?

Ms Webby : There would potentially be some facilities at some times that would not have a registered nurse onsite, but they would have access to a registered nurse on call. That would depend on the needs of that particular facility.

CHAIR: Leaving aside the precise numbers, the argument goes to the fact that you've increasingly got, as we've discussed, over a 10-year period the profile of residents in aged care changing dramatically. You're talking about people with more acute medical needs. Effectively, you're almost a halfway point between a home and a hospital. Why wouldn't it be a reasonable proposition when you look at that profile generally that, as a bare minimum, having a registered nurse present is a good idea?

Ms Webby : In the majority of our facilities we would have registered nurses onsite for 24 hours. Cathy and I were talking downstairs earlier, and in the SEQ area that is probably the case. But there are certain sites where the level of need that people have is not such that a registered nurse is required 24 hours a day. As I said, we always make sure that we have on-call nursing available, using a process called remote clinical monitoring and also in the community. We run quite large community services, as you may know, across the state. We have staff on call there that can do the drop-in for community and the drop-in to the residence in exactly the same way. So it is about us looking at the best way to staff a facility in a way that meets the needs of those residents. That's been our approach.

CHAIR: Is there clinical guidance provided to aged-care facilities about when the profile of their residents would give rise to a need for a particular staffing mix? Is there a common understanding across the sector, based on clinical need, as to how you assess when you need an RN physically present 24 hours a day?

Ms Thomas : It would be based on clinical need at the site. You've got clinicians working at these sites all of the time. By far, most, if not all, of our service managers are registered nurses.

CHAIR: But there aren't, for example, practice guidelines that are issued by the government or someone?

Ms Thomas : Not specifically.

Ms Webby : There are scopes of practice in terms of defining what the different levels of staff, if you're talking about nursing, can and should do. They give a guide as to the tasks or the roles that registered nurses need to do and what enrolled nurses can do. So there are those kinds of documents there that actually provide some context for making those sorts of decisions.

CHAIR: You referred to there being no literature which pointed to increased or mandated staff ratios having outcomes—you referred specifically to the 16 state-run aged-care facilities which have higher staff numbers not generating outcomes that are quantifiably better than other facilities. Are you able to provide the committee with any supporting material that can guide us?

Ms Webby : I'm happy to do that, yes.

CHAIR: That'd be great. This is the last question on this issue. You're a not-for-profit community based provider. Some of the witnesses have put to us that for the private providers obviously there is a greater profit motive, which could be seeing pressure put on staffing numbers. Have you witnessed that in your dealings in the sector in Queensland?

Ms Webby : I think it's clear that—

CHAIR: Do you believe there's a quantifiable difference between the quality of services provided in an NFP aged-care facility as distinct from a private one? That's another way of putting it.

Ms Webby : No, I couldn't categorically say that that is the case. I think there are different approaches and value propositions offered by the for-profit providers than there are by the not-for-profits.

CHAIR: What does that mean?

Ms Webby : What that means from my perspective is that Blue Care would be absolutely known in the sector as a trusted provider of care—the provision of care services to support people. In some instances, but not all, I think the for-profit providers would probably be known as providing perhaps better facilities, more modern, contemporary facilities, and also a different selection of a range of staff.

CHAIR: So they might have a better physical environment?

Ms Webby : Yes. I think there are those differences that are very clear for for-profit and not-for-profit.

CHAIR: But you wouldn't say the care is better?

Ms Webby : I would say that our service model drives very clearly what we do from a care perspective, and we design facilities in a way that, when we are talking about new facilities, is very care driven, whereas perhaps the for-profits don't have quite the same link in all instances. But I couldn't quote articles that would say one is better than the other, no.

CHAIR: I want to turn to a couple of other issues, particularly the mandatory reporting requirements for complaints and incidents. One of the things that were put to us earlier in the inquiry is that you have an obligation to report incidents that have triggered, for example, the police being called to an incident. But then there is no requirement—you report the incident but not report the outcome of any subsequent investigation, say, by the police. Would it be unreasonable to expand mandatory reporting to that? It struck me as a little bit odd that you report the incident but then not what the outcome of that was—for example, an investigation conducted by the police in relation to action of a staff member which found that they had been culpable or not culpable and led to charges and that type of thing. Do you think there's a case for expanding mandatory reporting to have a more longitudinal look at particular incidents than currently seems to be the case?

Ms Thomas : Like you said, currently we're required to report to the police and the department within the 24-hour time period, and then from an organisational perspective we have strong processes and policies around how we deal with that and what happens, depending on what has happened as a result of that incident. There would be a full investigation, a comprehensive investigation, with a substantiated or non-substantiated outcome. So it's that outcome I guess that you're saying is then not reported publicly. From a view of transparency, I'm not across the level of detail, but it's my understanding that the announcement by the minister last week about the new commission will bring a higher level of transparency, of which that may be a part.

Mr ZAPPIA: I have one other question. You don't necessarily have to provide an answer now but could do so at a later stage. I would be curious to know what ratio of high-care to low-care residents you have within your facilities. In other words, of the total number of residents, how many are low care and how many are high care? I assume that trend has been changing over the years.

Ms Webby : Absolutely.

CHAIR: Do you distinguish residents by some kind of categorisation?

Ms Webby : The assessment tool—the ACFI, which we mentioned—is an independent way of being able to assess the needs of residents. There's a rating scale within that that we would use, absolutely. It is quite complex.

CHAIR: Part of the problem with these inquiries is you get distracted by the first two people who give you evidence, and that becomes the focus for everything else! Could I ask what your policies are in relation to the use of restraints, chemical and physical, because this was an issue that was raised with us more extensively in earlier hearings?

Ms Webby : We have quite extensive policies across our organisation. It's about least restrictive practice. We really choose—

CHAIR: Do you ever use physical restraint?

Ms Webby : I would say that our use of physical restraint is very, very limited. It's only done after a significant case discussion involving all of the significant stakeholders, including the GP, the family, the person themselves—if they are able to participate—and the relevant staff. Similarly, we've done a major process in the last couple of years to reduce chemical restraint as well—to reduce psychotropic drugs—to get better outcomes for people.

CHAIR: So you would say the usage of chemical restraints has fallen within—

Ms Webby : Absolutely. We've presented papers on that, and we can provide you with that information.

CHAIR: That'd be fantastic. So how have you driven that? How have you managed that change? Were you finding that staff were simply overprescribing, if I can put it that way, because it was the easy solution?

Ms Webby : The doctors prescribe—GPs are the prescribers.

CHAIR: Sorry, yes.

Ms Webby : In our instance, in terms of managing residents, the registered nurse is generally following the prescriptions that have been written by the GP. However, what we have done is looked at ways that we can use alternative activity programs to support people to have richer lives and, therefore, manage behaviours in a different way. It's been a very broad program based in evidence that has been working with the GPs and families, as well as our staff, to do things differently for people; to lessen the need for any of the medication that may have been used to assist with behaviour management, et cetera.

Similarly, we've done that with things like falls as well. Physical restraint, for example, has often been something where you are concerned about people falling. We do a whole range of different things around falls like having beds down low on the ground, but also having very clear conversations with families, the person themselves and the GP about whether it is worse for a person to be restrained—and, therefore, even have behaviours—or for them to be active and living life and participating in activities, but also about accepting the fact that there's a risk of a fall and what's the balance around a good life for people at that point in time. They're very difficult conversations to have. At different times you end up in different positions, depending on what the individual circumstances are. We do try to treat every single client as an individual, with their significant others around them, because we need a different solution for each person.

Ms Thomas : It is the essence of our tailor-made service model. We have had some amazing outcomes with people who have come to us on a high level of psychotropic drugs just by getting to know that person—even if they've got advanced dementia—talking with their families, looking at their behaviours and the things they like. We've had retired plumbers who have come in who just want to tinker with a toilet all day, so we take the top off of a toilet for them—the maintenance guy sets it up for them, and fixes the toilet at the end of the day. But this guy actually did no damage. The family wrote amazing letters to us saying that it really helped them through their period of guilt as well. Not only did this gentleman come off his psychotropic drugs, but he actually led a much better life. Like Glenys said, people in aged care don't have to lead a bad life. It's all about knowing that person, understanding their specific needs and what they like, and assisting them to have a good quality of life in residential aged care.

CHAIR: I have one last question on the staffing issues, which that discussion reminded me of. One of the propositions that's been put to us is that it is bad practice that in some aged-care facilities medication is being dispensed and administered by staff who are not registered or ENs—by support staff. What would you response to that proposition be?

Ms Thomas : Firstly, it's important that anyone who is assisting with medication has the appropriate training and education to undertake that activity. There is always a place for registered staff in administering medications, but there is also a place for personal carers to be able to assist residents with medications.

CHAIR: Thank you for your time this morning. You will be provided with a Hansard transcript of today's hearing. If there are any corrections that you'd like to make, let the secretariat staff know. Thanks for also agreeing to take a number of those questions on notice. If it is possible, could you provide that information by 10 May to the secretariat. That would be very helpful. Thank you for your time today; we appreciate it enormously.