Blog, aged care

Twelve things the Royal Commission won’t cover

Aged care is a fragmented industry, with up to 40% of homes actually facing bankruptcy

Just after Four Corners launched a two part investigation into aged care, and before the newly announced Royal Commission had begun, I had coffee with a long term friend from my nursing years.

Barbara is a Registered Nurse with many years experienced in palliative and aged care.

I asked her thoughts on the commission. Barbara didn’t see any benefit in a Royal Commission into Aged Care which is estimated to cost the Australian taxpayers 75 million.

“They won’t look at the issues that count” Barbara stated flatly.

I asked her to outline the major issues that after her years of experience in this sector, she felt were important.

The facility management sets the tone that determined the quality of staffing care

Sound work practices and quality nursing staff come from good managers. Shabby care and bullying among staff come from bad managers.

Good management means –

  • A deep knowledge of the industry
  • The ability to hire good staff and fire bad ones
  • Good communication skills
  • A belief in lifelong learning
  • Innovation and personal courage
  • A commitment to efficiency

If you want to find a good nursing home for your parent or relative, then first look for a good manager.

“What really matters is the quality of management in aged care, and the decisions they make.”

We need to all accept that basic hygiene is a human right

According to Barbara, limiting incontinence pads to 3 per person over a 24 hour period does occur, on a routine basis, right across the Aged Care sector, and it is disgraceful. It literally means re-applying a dirty wet pad onto someone’s skin and taping it there, so it can’t be pulled off, for hours on end. Nobody would do this to an animal.

Registered Nurses in nursing homes are told to keep the doors of rooms where pads are kept locked, so carers can’t take pads, even when they need them.

Lack of basic hygiene is being linked to a rising tide of errors including hospital acquired infections. In one study the rate of hospital acquired pneumonia decreased by 38% after simply implementing basic dental care ie helping patients brush their teeth.

“When I’m working, I unlock the door to the room where pads are kept, and say to carers, just help yourself.”

Nurses and carers need to be go into the aged care sector, for the right reasons

There is a substantial number of aged care workers from Non English Speaking Backgrounds who can’t communicate with the residents because their English is so poor.

Australian academics have complained to investigative journalists that public safety is being endangered by significant pressure from Universities to pass poor and underperforming nursing students.

Government policies of offering large subsidies for aged care training providers to take on numbers of long term welfare recipients has been questions by the relatives of one nursing home resident, who was murdered by a violent and dysfunctional carer.

“An aged care certificate means nothing if the person holding the piece of paper can’t speak English or care for old people.”

Not all nursing homes are created equal

According to nurses currently working in aged care, is a huge difference in quality of facilities across the industry.

Some are badly run, understaffed and shabby. Others are caring places that hire good staff and have great pride in their work.

The problem for relatives is that they have no way of knowing which are the bad homes and which are the good ones.

Issues raised by people working in the aged care industry are –

  • The shortage of aged care beds causes considerable stress on hospitals. When they are forced to fill their acute beds with elderly people, sick people can’t get a bed and Emergency Departments overflow. This pressures governments to keep nursing homes open even when they routinely breach standards.
  • Inspections have traditionally been planned, giving staff the ability to change their practices while government officials are present, then revert to old practices after they have gone.
  • Dodgy operators are allowed remain in practice, dragging the good operators in the industry down
  • There is a widespread failure of government officials to follow up on complaints, deregister bad staff and shut down bad nursing homes

“There is huge variation in the standard of care that’s being delivered, but the best we can say is that we don’t know the extent of the problem in the aged care sector.” Dr Maree Bernoth, a lecturer in nursing and aged care at Charles Sturt University

When it comes to quality aged care facilities, looks DON’T count

Private hospitals and aged care facilities are falling over themselves to provide hotel style accommodation. This is sometimes ridiculed by nursing staff, who have to push patients in wheelchairs across plush carpet, and constantly race in and out of multiple private rooms, up and down discretely lit corridors.

Just remember, an expensive paint job won’t take an elderly person to the toilet on time. And tailored curtains won’t provide simulating conversation.

“Don’t be fooled by the decor… compared with providing top-level care and a high staff-to-resident ratio, carpeting and paint are cheap. “
Jim Rendon, 10 Things Assisted-Living Homes Won’t Tell You

Aged Care should form a knowledge-sharing group like Health Round Table, where problems are openly discussed and new technology solutions are showcased

Angry relatives complain to faceless bureaucrates with little to no response. Their unanswered complaints about cruelty and neglect in aged care homes leak into the media continuously. Every couple of years a angry politician orders an ‘enquiry’. More rules are passed, more paperwork is created. The result is that everyday workload for the average nurse or carer is made more difficult.

If the definition of insanity is doing the same thing repeatedly while expecting the result to be different, then the fundamental management of industry problems in aged care needs to change.

The Health Round Table is an example of a closed, subscription-based industry group that keeps a low profile, avoiding bureaucrates, the media and politicians. This means hospital executives feel safe enough to admit to errors. Regular workshops are held to showcase new technology solutions. Hospital staff network and learn how new ways of doing things to improve patient care.

‘Roundtables provide a forum for open interaction, and idea and experience sharing. They promote practical education and professional development’. Who Benefits from Roundtable Discussions? Everyone!

Nurse and Carer to patient ratios must become mandatory 

One of the biggest issues in aged care is excessively high resident to nurse or carer ratios. Barbara talked about shifts where 1 carer is allocated to 10 residents.

“Carers just end up running up and down corridors all shift, leaving people sitting on toilets and cutting back on showers. Would you want your relative to be treated like this?”

There is no question that the back end of health care should be automated. Most bureaucrates and administrators could be replaced with cloud software, saving money and being more efficient.

However the nuts and bolts of aged care requires adequate amounts of qualified people – it simply takes a certain amount of time to toilet, wash, feed, dress and get out of bed each elderly, frail person.

Ratios need to be mandatory.

“On night shift I’m in charge of 100 residents. Some of them are very complex and require a lot of care. It’s not safe for them, and it’s very stressful for me” – Aged care Registered Nurse

We need to invest in useful Aged Care Technology, not just trendy toys

The tech scene is dominated by male millennial, talking excitedly about VR, AI and IoT.

Guess what? Residents in nursing homes aren’t asking to spend time shooting up aliens across a virtual reality world that has 3 moons and companion androids.

The latest smart watches are being marketed as able to diagnose Atrial Fibrillation. However 70% of people over the age of 65 have already been diagnosed with this condition.

Elderly residents are asking for more staff to toilet, dress, feed, help them sit them outside in the sun, and talk to them. Oh, and many elderly people would like a cigarette with their tea and a beer with their evening meal. Aged care is a people intensive industry. Technology should be aimed at freeing up nurses and carers so they can spend more time on the floor.

Nurses and Doctors waste hours in each shift documenting irrelevant information, duplicating data and searching for information across poorly designed software packages and paper records. The focus on Aged Care Tech should be to stop duplication, information silos and preventable errors.

“Aging tech as a category is likely to grow, but if it’s to be successful, founders need to think carefully, not only about why people use technology, but why they won’t.”
Tech for the elderly is a growing area, but founders should think more about whether their gadget will be used

We need to make Aged Care sector wages compatible with hospital wages

Nurses working in aged care are currently paid substantially lower wages than nurses working in hospitals. The same qualification, with very similar workload brings a different paypacket, depending on whether you work in aged care or not.

This is unjust, drains nurses away from aged care into hospitals and shows that society values older people less.

“Today private-for-profit and not-for-profit nursing home pay rates for registered and enrolled nurses are between 5 and 17% less than public and private sector hospital rates.”

Old and sick people should have the right to choose euthanasia

‘Old age’ as elderly people have frequently said to me, ‘is not for the faint hearted’.

It brings continuous joint pain, reduced mobility, fear of falls, decreased mental agility and increasing loneliness, as friends and family die off. People often end up on medications for chronic conditions, than have to juggle the side effects.

End of life is a difficult stage of life to go through. It is not a disease that can be cured. It often accompanies financial hardship and social isolation. And the harsh reality of end stage disease can mean distressing symptoms like continuous shortness of breath.

It’s not fair that old people are deprived of the right to decide where and when they will end their life.

This debate is not appropriate for young fit people with mental problems that can be resolved. But it is appropriate for people at the end of their lives, who are living with chronic conditions and want to take control of the death.

“Australian men aged over 85 have the highest suicide rate in Australia, and more than double that of teenagers”.
Australian men aged over 85 have the highest rate of suicide, ABS data shows – ABC news

Ban bingo!

Barbara was adamant that there needs to be an overhaul of the current activities hosted by Aged Care Facilities. She said that many activities are outdated, childish and patronising. ‘

She examples of lining up older people in rows to play old-fashion games like bingo, giving women simplistic craft projects, and having volunteers come in to read to Barbara Cartland style Romances to elderly people.

“What if residents are gay? Or from another culture? How is Australia Day or a plate of lamingtons relevant for them?”

‘A social revolution in residential care could be akin to the civil rights movement in mental health, which rejected the basic premise of traditional care within the medical model, seeing it as a broken system that fostered stigma and discrimination.’
The need for a social revolution in residential care

Make the Aged Care sustainable for the future

And finally, the Aged Care sector needs far more money, to hire more staff and upgrade to modern, tech based services.

The popular media casting Aged Care homes as privately run and highly profitable is incorrect. A recent study showed that the financial performance of residential aged care facilities is continuing to deteriorate. In Australia while the top quarter of nursing homes are making an average profit of $12,000 per bed per year, more than two in five facilities are operating at a loss.

While Governments are trying to set fixed fees, overhead costs are rising, including wages and property fees.

Another issue is that people are staying in their home longer, people going into Aged Care when they have dilapidating conditions like dementia and need more complex care.

In Britain there are currently 4 people of working age supporting each pensioner. By 2050 that number will half, to just 2.

Different models of care are being trialled around the world. In one facility in the Netherlands, students are being allowed to live in Aged Care facilities for free, in return for providing care for a set number of hours a week.

In another model being trialled in Australia, residents are living as part of a vibrant and active household, with up to 20 residents sharing kitchen, dining room and living room facilities.

“In Australia 15% of the population is currently over the age of 65. By 2056 that percent is expected to rise to between 23% and 25%.”

Finally I’d like to dedicate this post to all of those nurses, carers and activity staff who work in aged care. It is a difficult, stressful, poorly paid and thankless task.

The media never show the faces of caring staff, or tell their stories of back breaking work, patience and compassion.

As an ex nurse, who has worked your shifts, and believes passionately in health reform; I salute you.


6 Essential Qualities Training Managers Need – Administrate April 2014
Aging Populations Will Challenge Healthcare Systems All Over The World – Forbes April 2018
Basic nursing care to prevent non ventilator hospital-acquired pneumonia – Journal of Nursing Scholarship 2014
Underperforming nursing students ‘could endanger public safety’, say university academics – ABC News April 2015
Age-old problems – Choice February 2016
Here’s why we need nurse-resident ratios in aged care home – The Conversation
Older Adults At Greatest Risk For Suicide – Forbes
The need for a social revolution in residential care – Journal of Ageing Studies
Trend of loss-making facilities continues – Australian Ageing Agenda

© Wikihospitals 20th September 2018

2 thoughts on “Twelve things the Royal Commission won’t cover”

  1. I think you make some excellent points with thanks. I was not aware that carers are paid a lower salary in public facilities versus private ones and I agree that pay levels should be consistent across the board for a given qualification and that there should also be a performance based component. Minimum staff ratios MUST be explored and made compulsory across the board: my experience with a Private High Level Care Nursing home in Canberra where my mother resides is that staff ratios are less than adequate and particularly at the weekend. The carers are unanimously in agreement with this observation. Finally I believe that All Australian’s should have access to a high and consistent level of care which mens that the framework and rules of a means test on income and assets needs to be reassessed. It’s important that individuals that are in the high income and assets bracket are not able to shift their wealth to family members or others prior to the means test. Inheritance tax and the seven year rule in the UK might be a starting point for discussion. This will be the most challenging part of the debate as we are effectively in agreement that there is not sufficient funds in the Governments coffers, that we are an ageing population and that more funds are required implying significant revisions to the means test Put differently, we are effectively going to be discussing an inheritance tax with the obvious differences being that that the means test and access to funds will take place prior to death. Finally my experience with the “coal face” carers at my Mother’s facility has been mostly positive and they are typically kind, compassionate and try their very best in an environment of inadequate resources. I hope that they will not feel disenfranchised by the findings of the Royal Commission.

  2. Robert, thanks for your comments. When I worked in aged care I saw most of the staff working very hard to do their best, in a very poor work environment. This industry is underfunded and poorly supervised.

    I also came across a small number of abusive people who should never have been passed by their training provider. There is a problem in Australia with training providers being enticed by large sums of money from governments, to shift long term unemployed people off welfare.

    I’ll write about this in my next post.

    Cheers, Delia

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