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ROYAL COMMISSION: “Fundamental failings of clinical governance”

The second half of last week’s hearings for the Royal Commission into Aged Care Quality and Safety, were focused on another case study around the governance structure at another big aged care provider in Tasmania.

​The Aged Care Royal Commission heard another case study last week around the governance and drop in clinical care at a Tasmanian aged care facility.​ [Source: Aged Care Royal Commission]
​The Aged Care Royal Commission heard another case study last week around the governance and drop in clinical care at a Tasmanian aged care facility.​ [Source: Aged Care Royal Commission]

Counsel Assisting Peter Rozen QC described the case study as showcasing the deficiencies in providing clinical care to residents at the South Hobart facility, which was only identified through internal audits and a whistleblower doctor. 

Mr Rozen added that despite the deficiencies, the site still cut nursing staff because the larger business was facing financial difficulties.

Similar to the case study from the start of the week, this study involved corporate strategies implemented between 2016 and 2018 to improve profitability at the South Hobart facility.

Sanctions were imposed on the facility in October 2018 after failing an audit and not meeting 32 of 44 accreditation standards.

On 25 October 2018, a Commonwealth Department of Health delegates said the facility had placed their residents at “an immediate and severe risk to their safety, health or wellbeing” and there was an “extremely high and concerning level of noncompliance”.

Only sanctions improved care says witnesses

Direct witnesses provided evidence about their loved one’s experiences in the South Hobart facility, and most of the witnesses were upset over medical management, clinical care, low staffing and lacking complaint resolution.

The first witness in the case study, Diane, provided evidence around her mother’s time inside the facility, living there since February 2015.

Diane believes for years her mother was not properly fed and the low staffing contributed to her losing the ability to walk.

She outlined times where she complained of rough handling and verbal abuse from staff, which never seemed to be resolved by upper management.

Since sanctions were imposed on the South Hobart facility in late 2018, Diane says she saw her mother receive better clinical care, medication management and communication from the staff.

“Sadly, I think that unannounced visits and the threat of sanctions will continue to be their motivators for change,” says Diane.

Another witness, Merridy, explained the journey of her parents at the same facility, receiving complaints often from her mother on the staff and resident ratios.

Her mother not only had to put in a lot of effort towards caring for her husband but also towards another older woman in the facility.

Merridy says that the other woman was often left in common areas by herself with no help, and resulted in her own 90 year old mum having to help the 90 year old blind woman to use the toilet because no staff was available.

Whenever Merridy expressed her mother’s complaints to carers, they often expressed their own frustration over the lacking staff members.

Similar to Diane’s evidence, Merridy says she only saw real change in the facility after sanctions were imposed.

Two daughters, UQ and US, provided evidence around the care their parents received in the South Hobart facility.

US says her father was subject to multiple small indignities during his stay at the facility, which did not help with his grief after the passing of his wife.

When their father’s dementia started to worsen, US says the facility began suggesting psychotropic medication to help “manage” their father who was beginning to become aggressive and resist care.

The sisters were told by their brother, a psychogeriatrician, that the recommended drugs was like “behavioural euthanasia”.

However, this didn’t stop the facility from constantly asking or encouraging the prescription of the medication, even after they denied the practice.

Resident doctor warned upper management constantly

The Commission heard from Doctor Elizabeth Monks, General Practitioner (GP) at the South Hobart facility. She commenced as a GP at the facility in January 2016.

Dr Monks was looking after 70 to 90 percent of the residents at the facility when she began to raise concerns in writing about the standard of clinical care at the nursing home.

While Dr Monks continues to work at the facility, she believes she was “ostracised from the business by the members of the operations team for bringing to light and questioning their actions around the deterioration of clinical care”.

She described the issues at the South Hobart site as definitely lacking nursing staff and having a paper-based care management system that was cumbersome.

When Dr Monks raised her concerns with any facility staff member from interstate visiting the site, but said the criticism was received on “deaf ears”.

“I felt that there was a feeling amongst those in the central office that I was histrionic, over-reactive, over-passionate and, therefore, my information to them was not valid,” says Dr Monks.

Since the sanctions, Dr Monks says she finally feels like people are listening to her suggestions she brings up, and there seems to be real effort towards improving all the problems outlined in the sanction.

Regional managers stretched thin

A former Regional Director, Stephanie and current Regional Manager, Elizabeth, of the aged care provider expressed satisfaction with the recent change to the amount of facilities they precede over.

Originally, Regional Managers would take care of 10 to 14 facilities, however, that has been reduced to a maximum of seven facilities.

Stephanie says, “The challenge with having so many homes in our portfolios was that we tended to focus on homes that were in need. That was primarily because at any point in time there was a home that needed particular attention. 

“That meant we were mostly reactive to what was happening in those homes, having a lesser amount of homes would have enabled us to spend more time in homes that weren’t displaying issues and challenges that needed our support.”

The South Hobart facility had three internal mock audits checking compliance within three years, which both Elizabeth and Stephanie agreed was not common practice.

Each time, the facility was coming up in “the red” as not meeting specific areas of compliance.

She agreed the mock audits showed consistent failures, revealing a fundamental problem within the South Hobart facility that had not been rectified.

Stephanie said the company attempted extensive initiatives in 2017 to fix the problems at the facility, including flying in nurses from New Zealand for shifts, paying care managers on the mainland 30 percent uplifts to relocate to Hobart for three months, and use as many agency resources as possible.

She says the changes worked and in August 2017 the facility passed accreditation standards on an unannounced visit.

Stephanie also agreed that the new move towards cost-saving strategies may have exacerbated the problems of clinical care at the Hobart facility.

She agrees that the money-saving plans implemented were a misguided strategy and resulting in fundamental failings of clinical governance.

Sanction advisor saw “profits before people”

A former adviser brought into the facility after the sanction, Tiffany, says she found the key factor for the safety and quality issues with care at the nursing home was because the company was putting “profits before people”.

Tiffany believes there was a strong interest in cutting costs rather than caring for people in the facility.

When she started work at the facility, in November 2018, she believes it was difficult to implement new strategies and recommendations due to the disengaged general manager who had resigned from the business following the sanction.

Over her time at the aged care facility, she interviewed families about their concerns, finding the top issues were food, pain management, general basic care and skincare.

Another stand out concern for Tiffany was the lacking leadership from upper management when complaints were raised.

Tiffany says the company was proactive during the sanctions, putting in 35 additional hours of care into the day, which she described as “very responsive”. However, challenges arose around having the staff to fill those hours.

Even though advisors are meant to stay on for six months to rectify the clinical issues within a facility, her position was terminated after three months. She is still unsure why.

An unsustainable financial model

The Managing Director of the company’s New Zealand leg of the business, Carolyn, agreed with Counsel Assisting that the money saving strategies did not have individual circumstances of homes in mind, nor did it take into account the care needs of residents.

“I think the company found itself with a model that was unsustainable financially,” says Carolyn.

“And there were some substantial changes to the funding nationally that impacted on the business. I think that was quite a driver.”

Over the last few years, a lot of senior management staff have left the business, Carolyn believes this is due to the challenging business of aged care and that some people are not suited to the demands of the industry.

The company has changed its board members following the nationwide issues, moving from a specific executive board to an independent nonexecutive board of members.

Carolyn says, “There was a need for greater governance at the aged care board level, and it became clear, that those people that were executives as well as on the board actually have, as part of their roles, had knowledge of what was going on anyway.”

The next Royal Commission hearings will be held in Canberra from the 9-13 of December with a focus on the interfaces between the aged care and health care system.

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