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ROYAL COMMISSION: Poor leadership among upper management

The Royal Commission into Aged Care Quality and Safety is back this week in Hobart, Tasmania, with a focus on aged care operations of selected Approved Providers.

Receiving scrutiny from the Commission was an implemented strategy to save money at their facilities discussed in the case study. [Source: Aged Care Royal Commission]
Receiving scrutiny from the Commission was an implemented strategy to save money at their facilities discussed in the case study. [Source: Aged Care Royal Commission]

The first three days of the Commission heard from multiple witnesses around a case study involving two facilities of a Tasmanian aged care provider and how a money-saving management mechanism resulted in a sanction of one of the facilities.

Receiving scrutiny from the Commission was an implemented strategy to save money at their facilities, that involved a movement towards 60 percent of operational income to be spent on operational costs.

From 2017-2019, Senior Counsel Assisting Paul Bolster says the aged care provider in Tasmania has had a significant governance investigation into the lacking efforts of the Board and upper management, which resulted in substandard care and the Hostel failing 18 of 44 accreditation standards.

Experiences from residents

A number of witnesses appeared to the Commission to provide evidence about their loved one’s experiences in the two highlighted facilities.

First witness on day one was widow, Helen, who outlined her belief that understaffing and poor leadership from the management at one of the facilities resulted in her husband’s “agonising death”.

In 2017, Helen believes her husband, Brian, received good care during the first six months at the facility, but it went steadily downhill after staffing cuts.

Helen says that Brian received inadequate and inconsistent care from care staff at the facility and her experiences with upper management in meetings were never fruitful.

Brian’s health declined in May 2019 and Helen says her husband was not provided proper palliative care, nor was she given a proper explanation around his care changes.

Brian died on August 6th of this year, Helen tearfully told the Commission, “He had an agonising death, which on the information available to me, and subsequently checked, was avoidable, inexcusable and unforgivable.”

On day two, Judith gave evidence on behalf of her husband, Neville, who has been living at the other aged care provider’s facility with Huntington Disease since mid-2018.

She explains that two weeks after moving into the facility, Neville had serious behavioural issues, cognitive decline, and couldn’t walk.

She says there were ongoing issues with getting the facility to provide care to her husband and constant medication issues.

“I’ve been very sick; I don’t know if I will outlive my husband. We’re a little family of two. Neville won’t have an advocate if I’m gone. And I’m so disappointed that people in aged care are being treated in this manner,” says Judith.

“I thought by making a statement for the greater good, because this is very hard to do, hopefully

we’ll be able to change the situation, not only for my husband but for all of us, everybody in this room, because we’re all going to face the same situation.

“It’s a systemic failure and it’s a toxic culture, and it’s Australia-wide.”

Staff critical of upper management

The Commission also heard from a number of former and current staff for the aged care facilities, expressing their unhappiness with upper management from 2017-2019, highlighting they were routinely not included in discussions on reduced hours and staffing rosters.

Clinical Care Coordinator at one of the facilities, Tammy, provided evidence saying one of her facility managers effectively locking himself away in his room and did not interact with anyone on the floor. 

Tammy expressed how difficult it was to hire staff to the facility and that the new staff hired were straight out of training courses.

Most clinical training provided to inexperienced carers only involved the “buddy system”.

Whenever any issues were raised with upper management, Tammy feels they were not heard or the issues were not passed on to upper management.

She says the communication and lack of support from upper management to the ground staff had bred low staff morale.

When the company restructured the staff roster, there was no succession planning in place or discussion with the actual staff about the changes and how that would affect care.

“I feel that the impact wasn’t looked upon at that level… I feel from the facility managers position, he should have been able to voice the impact,” says Tammy.

“I have a lot of respect for my role, but it’s been a difficult role because I do not have the support above me.

“[The company] certainly [have] a vision to save on costs, I feel that that vision was not looked upon about the effect it would have on the facility.”

Multiple facilities managers were not supported

The former facility manager of the facility, Patrick, was not happy with the training and support he received coming into his new position in October 2017.

Patrick admits he had little experience when hired for the job, however, he had been honest about his past experience in the interview and was reassured by the interviewers from the aged care provider that he would be provided support and the facility was clinically stable.

He says at no point was he told that the facility should have been in the hands of a veteran manager.

Patrick says staffing requests for care was sometimes denied on the basis of already losing money.

“I don’t believe that any aged care facility in Australia has too many staff. I don’t really honestly believe there’s such a thing as excess staffing in a care environment,” states Patrick.

Patrick told the Commission he often felt pressured by upper management to make staffing cuts as a “matter of financial sustainability”, saying he often felt like his job was on the line.

Former facility manager at the other site, Peter, was hired at the facility in February this year and left in April because he didn’t believe he could make positive change within the company.

He says from the day he was hired, he was never told about the serious risk assessment and non-compliance at the facility.

The Commission asked why he wasn’t told, Peter believes it was due to difficulty recruiting industry-experienced people in Tasmania and the non-disclosure of problems at the site was a way of ensuring he would take the job.

“You’ve got to have appropriate leadership who is contemporary, who is able to have a humanist approach as well. We’re dealing with people, and often when staff feel unsupported or undervalued or neglected they generally will, you know, not follow process,” says Peter.

“Within the short time that I was the facility manager, it was evident to me that the industry experience and knowledge that I was bringing to a home that needed expert support, I was just not able to influence the executive or the organisation to fix the gaps in governance and systems that were clearly evident to me. 

“I want to be able to change the industry in a positive way, and I didn’t feel like I would ever have that opportunity...”

Another former facility manager of the same site between January and October of 2018, Helen, expressed similar concerns as Peter.

She was extremely unhappy with the implemented money saving plan that was implemented at the facility and openly objected to its implementation.

“I couldn’t compromise anymore staffing cuts, I couldn’t compromise the quality of care to the residents… And I actually said, “If I have to cut one more hour, I will go.” And go I did,” says Helen.

“I felt I could no longer manage the facility under the constant pressure of having to cut staffing and which would impact on the resident care, and I pride myself on not managing a facility that will compromise resident care and I couldn’t stay.”

Upper management “we’re here to serve people”

While the money saving framework was created to prevent the aged care provider from continuously operating at a loss, since 2016, the Board and Executives were allegedly very clear that “we were here to serve people”.

Former Director of Finance at the aged care company, Andrew, says that the framework was not meant to impede on quality of care.

He says there was a lot of conversations with facility managers to understand the model and to advocate whether it was possible to implement in their facilities.

In regards to Patrick, facility manager at one of the nursing homes, Andrew said he specifically told him to speak up if he had any doubts, but never received any communication that the facility was stressed.

Andrew says the financial burden on the company was due to the Government removing funding from the Aged Care Funding Instrument (ACFI) and the framework was a blunt response.

The framework was created by Andrew and Former Executive Manager, Home Care and Residential, North/North West, at the aged care provider, Pauline.

Pauline was extremely unhappy with comments from Patrick, saying she never pressured Patrick into anything and provided him plenty of training and supports over his time in the position.

She says his statement about a poor orientation into the facility was not consistent with their emails allegedly showing a three-month induction program and constant contact with other facility managers.

Pauline adds that it was never communicated to Patrick that his “job was on the line” and that he needed more support than “he was willing to accept”.

Facility re-accreditation cost excess of a million dollars

Chief Executive Officer (CEO) of the aged care provider, Richard, says the Board had to choose between closing the facility or rectifying the non-compliance and maintaining their accreditation, which cost in excess of a million dollars to achieve.

In his evidence, Richard says he never received any complaints from residents or their families about the care provided at either of the facilities.

He went on to apologise to residents and their relatives who had experienced the circumstances that had been portrayed at the Commission. 

“We’re not about providing poor care. Our whole mission, our 47 years of existence is about providing the highest quality of care. So I apologise and I say I’m sorry for them to endure the tension and the anxiety that they have,” says Richard.

Following on, when asked about cutting staff hours, Richard told the Commission he was reassured by recommendations and advice given to him that the reduction in staffing hours would not compromise the care provided.

Richard agreed that Pauline was not a clinician, even though she provided suggestions on staffing levels at one of the facilities, and also admitted that Patrick was very inexperienced to be in a facility manager position.

Counsel Assisting had Richard also admit that the complaint process at one of the facilities was non-existent so he was unable to receive any complaints from residents or families.

Richard conceded on behalf of the board that the company needs to strengthen the reporting and review processes, as well provide better support to facility managers, similar to the case of Patrick.

This set of Royal Commission hearings in Hobart run until the end of this week.

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