All providers are allocated a supervision status under the Supervision Model, based on our assessment of the level of risk to older people in their care. The four supervision statuses, in order of intensity, are risk surveillance, targeted supervision, active supervision and heightened supervision.
We assign case managers to providers with an active or heightened supervision status. Where required, we may also assign a case manager to providers with a targeted supervision status. Case managers engage with providers early and effectively to:
- identify the causes of risk and non-compliance
- set clear expectations for improvement
- set incentives for taking quick and effective action
- monitor their progress.
These case studies detail how we case managed four providers assessed as higher risk.
Case study 1: A provider’s lack of independent board directors adds to concerns about their willingness and ability to manage risk and prevent harm
After a site-based assessment against the Aged Care Quality Standards and an initial period of engagement with the Commission, we issued a non-compliance notice to Dolphin Side*, a small provider with 2 services. We issued the notice because our assessment showed that we needed a structured approach to make sure that the non-compliance and identified risks were addressed quickly.
The provider agreed to fix the problems. However, after receiving a complaint about the service, we organised a second site visit. At this visit we found that the problems were worse than originally reported.
There were high levels of non-compliance, with actual harm to residents. The provider also had a rate of complaints 3 times higher than the sector average and a rate of notifications of unreasonable use of force around 60% higher. This confirmed our view that the provider was not making enough progress to put in place the necessary systems and controls to manage risks.
Our engagement with the provider led us to conclude that the provider’s governance arrangements were a significant contributor to the problems. The board did not have a majority of independent non-executive directors, a legal requirement for approved providers.
This meant that there was less independent assessment and oversight of risks. There were issues around:
- falls
- wound management
- behaviour support
- nutrition and hydration.
It was also clear that the board was not using its data to inform risk or drive improvement. They were failing to make the changes needed in the timeframe that had been agreed to in their response to the non-compliance notice. This led to us putting a sanction in place which made them ineligible for subsidies for new care recipients.
The provider remained under heightened supervision. We continued close contact with the provider and they were required to submit progress reports twice a month for a set period. Through our work with them, the provider learnt and understood:
- how to lift their performance and improve their risk management, including addressing their non-compliance with governance arrangements.
- the consequences if they failed to make these changes, including us possibly revoking their approved provider status.
* Approved provider, not their real name
Case study 2: Heightened supervision helps a service return to compliance, find a buyer and maintain continuity of care for residents
Faraday Cove* has one residential service. There are no other residential aged care services in the town. If the service closes, the residents would need to move up to 100 km away. We increased the intensity of our supervision of this provider, due to a concerning pattern of serious incidents at their service.
These concerns prompted a full on-site audit against the Aged Care Quality Standards, which found that the service was non-compliant with most of its requirements. This confirmed that the provider had insufficient systems, controls and governance in place to effectively manage risk to prevent foreseeable incidents.
We also found that the provider was:
- not financially viable
- having ongoing staffing issues including high turnover.
When we became involved, the provider had the service up for sale.
The non-compliance of the service and the financial viability issues were a barrier to another provider purchasing the service. This uncertainty put residents’ wellbeing and continuity-of-care at risk. Working with the provider, we aimed to:
- make sure the provider immediately implemented safeguards to mitigate risks to people receiving care
- support the provider to invest in strategies to deliver sustainable improvement in their performance. This would also make the service more attractive to potential buyers, thereby helping to maintain continuity of care for existing residents.
As the provider initially failed to assure us that they would fix the areas of non-compliance, we forced them to act by issuing a non-compliance notice and then a sanction which made them ineligible for subsidies for new care recipients. The sanction ensured there was a disincentive for the provider to take in new residents until required remedial action had been taken. We placed them under heightened supervision and worked with the Department of Health and Aged Care (now called the Department of Health, Disability and Ageing) to look at options. We told their board to take a much more active role in managing risk and holding staff accountable for using the required systems and controls.
The board showed that they were committed to managing the needed changes by offering us an enforceable undertaking. The undertaking focused on developing strategies, frameworks and systems to improve:
- staff education
- communication between the provider and residents
- clinical governance
- risk management.
We actively supervised the service to make sure that they successfully followed the actions in the enforceable undertaking. We closely engaged with the board to ensure all non-compliance was fully addressed.
A large provider of residential aged care, respite services and home services has since bought the service. We continued to monitor the service under the new provider and found no issues with compliance, quality of care, or workforce stability.
This case study is a good example of working with the provider to bring them to full compliance and protecting the continuity of service where residents did not have easy access to other services. Our intervention also enabled the service to become viable for another provider to buy.
Case study 3: Home services provider in remote area placed under heightened supervision
Red Sands Care* is an Aboriginal and Torres Strait Islander provider that offers care and services in remote areas. A quality audit of this provider showed that there were issues with their governance of sub-contracted clinical care for the home care packages they delivered. It is the only provider that covers a very large, remote area including many Aboriginal and Torres Strait Islander communities.
Our main concern was that they did not have the structure, capability or capacity to meet the needs of people receiving care with complex needs. This meant there was a critical shortage of aged care services for high-needs Elders in that region.
There were no active complaints with us about the provider. However, we were concerned about information we received from the Department that showed people receiving community and home care packages were not happy with the provider. We placed them under heightened supervision due to the level of risk to the people receiving care.
We worked with:
- the provider to monitor the risk to the people receiving care and learn how they were addressing the risk. We visited all of the provider’s home care services in the affected communities. We spoke with people receiving care, community leaders and service delivery partners to understand more about the risk.
- the provider to understand the issues in the care they were delivering. They agreed to use the expertise of a specialist advisory service (funded by the Department). The service helped the provider to develop a strategy to fix the issues in the quality and the appropriateness of their home care packages for higher risk people receiving care.
- the Department on an emergency plan to enact if the provider suddenly decided to stop delivering services in the area. They had mentioned in the past that this might happen.
While the provider remained at higher risk, the Commission:
- monitored the provider closely with regular meetings
- held them accountable for fixing the issues
- continued to monitor them under the heightened supervision model
- were open to reassessing the strategy if the risk to people receiving care changed.
Case study 4: Targeted supervision successful in reducing high risk
We received 2 complaints about an approved provider, Higher Tide*, about:
- medication management
- the management of a person receiving care who had complex and challenging behaviours.
We considered that these issues posed a potential high risk to all people receiving care. We immediately began a process of targeted supervision.
We engaged with the provider and discussed our concerns and the regulatory actions we would take if they did not address them. We also explained the outcomes if they did engage with us and fixed the risks to people receiving care.
They responded positively by:
- taking appropriate action
- talking openly with us about the issues.
They spoke honestly about struggling to support the person receiving care who had challenging and complex behaviours. They told us that the person was:
- being aggressive to other people receiving care
- putting other residents at risk
- causing complaints from other residents and their families.
We organised an announced visit from our quality assessors and the specialist advisors from our Behaviour Support and Restrictive Practices Unit. We encouraged the provider to have an open conversation with the person with challenging behaviours and that person’s supporter. This triggered the provider to commence and then successfully complete a process to find a more suitable residential facility for the person.
We then removed the provider from targeted supervision.
Positive outcomes can be achieved without the use of formal regulatory powers. This happens when a provider recognises there are issues and is willing to work hard to fix them. We provide guidance and continue to monitor these providers.
Key learnings
Performance and governance
Performance is lifted when governing bodies:
- understand their accountabilities
- ensure that they remain informed about risk levels, including by requiring relevant reports from executives
- have integrated systems, practices and controls
- are invested in improvement.
Provider level regulation
- Risks identified at a service level are considered a symptom of problems at a provider level.
- It is extremely unlikely that all services will be fully compliant all the time. Rather, at any given time, it is likely that there will be some level of transient non-compliance in some services.
- Providers should have risk detection and management mechanisms in place so they know about and mitigate risk before we require them to.
- Changes (that is, improvements) in practices and behaviour at the service level are more sustainable when the provider is the one implementing the reform.