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New insights from notifications of unreasonable use of force in residential care

  • Media Release

The Aged Care Quality and Safety Commission has published a report featuring case study insights from Serious Incident Response Scheme (SIRS) ‘unreasonable use of force’ incident notifications.

The unreasonable use of force incident type accounted for nearly two-thirds of all incidents notified to the Commission by residential aged care providers in the first 15 months of the SIRS (1 April 2021 to 30 June 2022). The vast majority of these incidents (86%) involved interactions between residents, which are the subject of this Insights report. Providers reported severe cognitive impairment for more than half of affected residents and more than 60 per cent of residents using unreasonable force. While this profile points to some of the challenges in preventing and managing serious incidents of this type in residential aged care, many incidents are avoidable and further efforts must be made by providers to identify and mitigate risks to consumers in their service.

The report aims to provide insights and guidance using case studies to help providers and their staff to better understand the response, impact assessment and management of incidents. Using case studies as a learning tool can help providers and their staff to reflect on incidents at their own services and make changes that can reduce the chance of incidents recurring.

The SIRS was introduced for residential aged care services in April 2021, strengthening existing provider responsibilities to prevent and manage incidents of abuse and neglect in aged care. The SIRS was expanded on 1 December 2022 to include home care and flexible care and is bringing greater visibility to serious incidents in aged care.

The SIRS requires aged care providers to notify the Commission of serious incidents impacting consumers. Providers are also required to have an effective incident management system and to identify how they understand, respond to, and learn from serious incidents when they occur.

Since the introduction of the scheme, the Commission has continued to publish a range of resources to support providers’ understanding of incident management and improve their capability to meet their obligations to prevent and respond to all incidents.

In 2021-22, the Aged Care Quality and Safety Commission received 37,833 serious incident notifications from residential aged care providers under the SIRS.

Aged Care Quality and Safety Commissioner Janet Anderson says SIRS notifications give the Commission another way to understand how effectively individual providers are managing risks in aged care. The notifications serve as additional intelligence about provider performance that, when combined with other Commission data, assists the Commission to better identify and respond to provider and service level risk.

At a sector-wide level, the Commission uses the SIRS data to shape our education, information and guidance products. Consumers can use these resources to learn about common risks that can impact the quality and safety of care, and to ask providers how they are managing these risks. For providers, the resources offer an opportunity to examine and benchmark their service’s performance and to take any actions to reduce the risk of, and/or improve their response to, serious incidents.

“Information we receive from SIRS notifications shines a light on the incidents that are occurring in aged care services and, importantly, the actions that providers need to take to mitigate the risks that come with caring for frail older people,” Ms Anderson said.

Reducing the chance of a serious incident occurring requires providers to identify, manage and mitigate risks to consumers, to learn from every incident and to introduce preventative measures to avoid any recurrence. As providers’ ability to manage incidents improves, the Commission expects to see improvement in providers’ identification and response to incidents, including more careful analysis and better recording and reporting.

“We know we need to be realistic about how quickly it will happen, but we definitely want to see improvements in care and in the prevention of incidents, with the rate of incidents declining over time,” Ms Anderson said.

The number of serious incident notifications does not necessarily relate to the number of instances of harm to an aged care recipient. Reports can include multiple notifications about the same matter, suspected incidents, and situations where incidents occurred, but injury was avoided.

“In many cases where a serious incident is reported, the aged care provider has already dealt very effectively with the incident - taking all necessary steps to address any issues for the person concerned and making the changes required to prevent these incidents from happening again,” Ms Anderson said.

However, as the case studies show, there are aspects of managing incidents where some providers still need to improve at an operational and governance level.

“We are concerned, for example, that 9 out of 10 providers are assessing incidents involving unreasonable use of force as having minor or no impact. It’s possible that they are not considering less obvious impacts which may be harder to identify where a resident isn’t able to reliably relate what happened, or delayed impacts where a physical injury becomes apparent later.

“We are also concerned when we see the same type of incident reoccurring in the same residential service or with the same resident. This raises questions about whether the provider has an effective incident management system that they are using to identify and address such undesirable patterns.  In these situations, the Commission may undertake a targeted investigation that could lead to regulatory action,” said Ms Anderson.

The SIRS data tells us that aged care residents involved in incidents of unreasonable use of force are much more likely to have severe cognitive impairment than those involved in other serious incident types. This can be very challenging for providers, however such incidents should not be considered unavoidable, said the Commission’s Chief Clinical Advisor Dr Melanie Wroth.

“Providers who are genuinely interested in improving things for those in their care can deliver a better experience for every resident, irrespective of their cognitive functioning.

“Staff who see things going wrong and who have clear processes to take action and/or escalate a response at their service can make a dramatic difference. Every person working to care for older people, at whatever level, has the potential to make a difference, “ Dr Wroth said

Ms Anderson said that in aged care, as in any form of social care, there is no “acceptable” level of serious incidents involving the abuse or neglect of individual consumers. Older Australians should be cared for respectfully, safely and with dignity; that is their right and the community’s expectation.

“Aged care providers are required by law to do everything possible to prevent abuse or neglect and to act quickly if there is an incident to minimise its impact and prevent it from happening again,” Ms Anderson said.

Where the provider fails to take appropriate action in relation to a serious incident, or where the Commission identifies a provider’s non-compliance with its incident prevention and management responsibilities, we can respond using a range of regulatory powers. This can range from using compulsory information gathering powers, requiring a provider to take certain actions or issuing them with a compliance notice, to enforcement actions including applying sanctions, and in cases of significant and wilful non-compliance, revoking a provider’s approval to provide subsidised aged care. These actions are aimed at compelling the provider to act to address quality and safety risks and to comply with its responsibilities as quickly as possible.

Notifying the Commission of serious incidents does not replace the provider’s obligations to report any incidents to police that are suspected criminal offences.

Anyone with a concern about an aged care provider or the quality and safety of the care they are providing should contact the Commission by telephone on 1800 951 822 or via our website at:

The report is published on the Commission’s website here

Information on the SIRS is available on the Commission’s website here

Download the PDF version of this media release.

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