Aged Care Quality Bulletin #31 – July 2021 | Aged Care Quality and Safety Commission

Elderly couple on bench talking to a worker who is kneeling

Commissioner’s message

July has been a challenging month for many around the country. The COVID-19 clusters in multiple local communities accompanied by lockdowns in a number of states and territories have kept everyone on high alert, and especially in the aged care sector – aged care consumers and their family members, workers and providers.

The increasing supply of, and access to, vaccines is reassuring, as is the growth in the proportion of the population who have had one or both doses. COVID-19 vaccination levels for aged care residents and staff must now be reported by providers as an Australian Government requirement, and of course, we all need to follow the orders from our local state or territory health department. Visitor restrictions are in place for residential aged care services in a number of areas, and as discussed in this edition of the Quality Bulletin, anyone entering a service should expect to undergo routine screening to minimise the risk that the virus is introduced to an aged care home. It is these sorts of essential measures that contribute to protecting the safety, health and well-being of those receiving aged care.

The stronger, clearer legal provisions relating to the use of restrictive practices in residential care have now been in effect since 1 July. The Commission continues to publish information and resources – for both providers and consumers – to increase the level of awareness and understanding of the changes. We are particularly keen to ensure that residential aged care providers know what they need to do to meet their obligations in relation to minimising the use of restrictive practices.

Another area of provider practice where the Commission is continuing to produce informative resources relates to the Serious Incident Response Scheme (SIRS). A range of new SIRS resources for both providers and consumers are now available, as outlined in this Bulletin.

On-entry screening and routine monitoring for COVID-19 symptoms

In light of the current COVID-19 outbreaks across the country, we are reminding providers to undertake routine screening of people entering their services. That includes aged care staff, volunteers, visiting health professionals, family and friends visiting residents, and anyone else who comes into an aged care service.

As a provider, you must familiarise yourself with the relevant screening processes and procedures outlined in your state or territory COVID-19 public health directions. You can find the public health (or emergency management) order relevant to your jurisdiction using an online search browser.

You should also take the following actions to mitigate the risk of, and potential impact on, consumers and staff, of exposure to COVID-19:

Work with all staff to ensure they remain alert to (and take reasonable steps to protect themselves from) risks of COVID-19 exposure away from the service, including through other employment or household living arrangements.
Regularly review human resources services and policies to ensure that staff isolate or stay at home when they feel unwell.
Ensure that staff are familiar with the signs and symptoms of COVID-19.
Routinely assess consumers for respiratory illnesses and COVID-19 symptoms and record the outcomes of this monitoring.
Identify local pathways for COVID-19 testing for staff and for consumers (including understanding the role of the public health unit).

There are a range of COVID-19 resources available on our website for providers and for consumers, in addition to the COVID-19 information provided by the Department of Health. Every provider should also routinely monitor advice from their local state or territory health department.

Limiting the risk that residential staff will need to isolate

When a residential aged care facility identifies a staff member or resident who is COVID-19 positive, the provider should be able to immediately activate their well-drilled outbreak management plan.

Since March 2020, Dr Melanie Wroth, Chief Clinical Advisor in the Commission, has participated in a number of outbreak management meetings with individual residential aged care providers, alongside public health unit staff and Commonwealth and state health department representatives.

Drawing from her growing experience in this area of outbreak management planning, Dr Wroth has the following comments and suggestions to offer in relation to how providers can proactively mitigate the risks of having to furlough a high proportion of staff:

In outbreaks within residential aged care facilities, the number of direct care staff requiring isolation or furlough and testing as close contacts can be very high, sometimes in the order of 80%. This is particularly the case for the highly contagious Delta variant of COVID-19. This can not only pose challenges in terms of urgently replacing this proportion of the workforce but it can also present additional risks to the smooth implementation of the service’s outbreak management plan. There are also risks to consumers when many staff do not know them, or if they are unfamiliar with the layout and systems of the service.

Providers are reminded that there are precautionary measures which can be put in place prior to any outbreak, to mitigate these risks and impacts. The extent to which these measures will be practicable will vary from service to service. Each provider may wish to consider the following guidance, at a service level. The Commission acknowledges that many providers are already implementing these measures in routine practice, or for use in times of local community transmission:

As far as possible, limit staff and residents’ movements between areas within the building and between buildings. The fewer individual staff members that each resident comes into contact with, the lower the risk to that individual. The fewer other staff members each worker comes into contact with, the smaller the circle of potential transmission if a case occurs.

Consider assigning staff to particular areas rather than moving them to different residents and different fellow staff cohorts for each shift.

Consider whether buildings or wings can be isolated from each other so that staff circulate within one area only.

Consider whether areas can be isolated into zones for the purpose of staffing.

Try to divide staff off into smaller separate pods or groups, including avoiding common areas where many staff gather from many areas.

Another planning priority in advance of any potential outbreak is to identify the jobs or tasks in the outbreak management plan that can be assigned to furloughed key staff members. These might include clerical support, communications, rostering, hotline information and phone support for agency staff, shift handover dial-in, tracking immunisation, tracking contact dates, personal protective equipment supply ordering, waste and kitchen supply ordering.

Also, to mitigate risks of discontinuity of care when large numbers of agency staff do not know the residents, all providers should already have ensured that there is easy availability of up-to-date care information for every resident, and means to identify each resident (such as via pre-prepared ID wrist bands).

More resources to support providers in relation to new restrictive practices obligations

As covered in the last edition of the Quality Bulletin, legislative amendments to the Aged Care Act 1997 and Quality of Care Principles 2014 took effect on 1 July regarding the use of restrictive practices in residential aged care settings.

The principal purpose of the new provisions is to ensure that consumers are treated with dignity and respect, and that restrictive practices are only used as a last resort and under very specific conditions.

The Commission held a webinar on 13 July to discuss the legislative changes and help providers to understand the requirements, and the changes they may need to make to their current practices. A recording of the webinar is available on our website.

A number of resources on the appropriate use of restrictive practices are also available on our website. Updates have also been made to the Aged Care Quality Standards guidance resources, including revised information on consent and decision making, behaviour support planning and consumer advocacy. Further resources currently in production encompass an updated decision-making tool, and guidance to support providers to prepare for the further changes taking effect from 1 September 2021 regarding behaviour support planning. This issue is addressed more specifically in the article below from the Commission’s Chief Clinical Advisor, Dr Melanie Wroth.

It is important to note that the term ‘restrictive practice’ introduced through legislative amendment now also applies to the Serious Incident Response Scheme (SIRS). Formerly, one of the 8 reportable incident types in the SIRS was described as the ‘use of physical restraint or chemical restraint’ in relation to a consumer (other than in circumstances set out in the Quality of Care Principles). This incident type is now described as ‘use of restrictive practice’ in relation to a consumer (other than in circumstances set out in the Quality of Care Principles) – where a restrictive practice is any practice or intervention that has the effect of restricting the consumer’s rights or freedom of movement. The Quality of Care Principles define 5 types of restrictive practices. These are chemical restraint, mechanical restraint, physical restraint, environmental restraint and seclusion.

The SIRS guidance material that the Commission has published to date is being updated to reflect the above change in the terms used. More information on the various types of restrictive practices and how the Commission regulates the use of restrictive practices is outlined in our July 2021 Regulatory Bulletin.

Further information on the legislative reforms is also available on the Department of Health website.

From the Chief Clinical Advisor – behaviour support plans

As indicated in the above article, under the new restrictive practices legislative provisions, from 1 September 2021 residential aged care providers will be required to have a behaviour support plan in place for each consumer who requires, or may require, the use of restrictive practices. The amended Quality of Care Principles 2014 outline the requirements of the behaviour support plan and include information on assessment, monitoring, review, evaluation and provision of consent. It is expected that the behaviour support plan will build on existing strategies that a provider has in place to support person-centred care for each of their consumers.

In preparation for this new requirement, providers should already be starting to identify consumers who will or may need a behaviour support plan, and to consider whether sufficient information is available about each of those individuals. Specifically, it is expected that providers will be making preparations for the development of a behaviour support plan for each resident with whom restrictive practices are being used, or where restrictive practices use is being considered, or where behaviour changes are emerging. In undertaking this work, it should be recognised that templates may not capture all the relevant information for some consumers, particularly in a situation that is changing rapidly.

Important elements to inform the person-centred individualised prevention and management of behaviours of concern include gathering information about the person from the person themselves, previous regular and current staff who have cared for them, their family and friends, previous professionals and hospital staff. With a new resident, outside sources of information should be actively sought on their entry to the service. Clearly, much of this preparation also informs good person-centred care and many providers are already proactive in this regard.

The areas of information-gathering relating to individual consumers should include, but not be confined to, the following:

Understand the person

Personality, beliefs and attitudes
Key relationships – family members and friends in past and current life
Education
Occupation and work experience
Culture and language, living overseas
Likes and dislikes
Religious or spiritual perspectives
Interests – sports, leisure, hobbies, musical or TV/film tastes
Language, vision or hearing support needs and preferences
Institutional, disability, trauma backgrounds or other significant life challenges or struggles
Things that have always been particularly important to the person

Understand the behaviour

How does it manifest specifically, what is the person actually doing, how are they behaving?
Is it changing over time, and if so how, and how quickly?
What might the person actually be wanting or trying to do? Can they be assisted to do it? What would they like to do, what do they want, how can you help? (Ask them!)
What appears to have caused or triggered it at different times – time of day, environment (including sounds, what’s in their visual field, movements, lighting), people nearby?
Does the person have any unmet needs around comfort, temperature, environment, sound, hunger, thirst, wet or soiled, boredom or pain?
What normally settles them when unmet needs are addressed – distraction, soothing, pleasure, family, foods, bed, warm shower, companionship, reassurance, conversation, activity?

Understand the risks

Is the person unwell or delirious, especially if the behaviour is a sudden change? (This may need medical assessment)
What risk of harm to self or others is the behaviour posing, if any? Is it actually a problem?
How can the risks be modified or removed? (Risks include physical danger, psychological or emotional harm)
Understand specific risks to that individual of any restrictive practices that are used or considered

Understand the management options

Try to get an idea from the person themselves about what might help on each occasion
Ask family and friends to suggest or advise
Try strategies that are documented or known to have worked in the past
Avoid strategies that have made the individual’s distress or behaviour worse
Consider what you know of the person as an individual to try new strategies relevant to them. Do not expect the same intervention to work with different people
Involve all staff in assisting with ideas and observations, and use staff wisely who residents respond well to as individuals
Involve family in management, for example by visiting at known times of distress or phoning to reassure
If management is difficult, seek advice from a general practitioner, specialists or Dementia Support Australia
In an emergency, seek urgent help from ambulance or police as appropriate
Keep family or substitute decision-makers involved and informed

It is important for every residential service to document the above in a way that helps your service, staff, family, restrictive practices substitute decision-maker and prescriber understand the frequency and extent of the behaviour challenges, and understand what works and what doesn’t. Relevant information needs to be available for all staff, including new staff, on every shift in order to inform person-centred care and behaviour support.

Restrictive practices options for behaviour management are only to be considered as a last resort and must follow the correct processes. Further information on minimising the use of restrictive practices can be found on our website, as can further information on behaviour support planning.

New Serious Incident Response Scheme resources for providers and consumers

We are continuing to support residential aged care providers and consumers with information to help them better understand the Serious Incident Response Scheme (SIRS) that commenced on 1 April.

Resources for providers

A series of new education modules focusing on each of the 8 types of reportable incidents under the SIRS is now available in Alis, our Aged Care Learning Information Solution. These modules are designed for staff who work directly with aged care consumers and also for those with responsibility for reporting incidents under the SIRS. The information will help staff to:

recognise and respond to incidents that happen in a residential aged care service
identify conduct within each of the reportable incident types
recognise the possible signs of each type of incident
respond appropriately to any actual, suspected or alleged incidents
understand when and how incidents should be reported to the Commission.

To help you access the modules available on Alis, all Commonwealth-funded aged care services can obtain up to 4 free registrations to our online learning platform until 31 October 2021. You can also purchase additional registrations, if needed.

To access the new SIRS modules or to register for Alis, go to learning.agedcarequality.gov.au.

Resources for consumers

A series of consumer resources is being developed progressively to help those using aged care and their family members understand the SIRS and the consumer’s rights to receive safe, high-quality care. Resources include videos, facts sheets and posters about a variety of SIRS topics:

What is the SIRS?
SIRS – Understand your right to be safe
SIRS – What does this mean for your care and services?

These resources – and the additional ones currently being developed – are available on our SIRS consumer resources page.

Provider feedback on site visits moves online from 1 August

For many years, aged care services have provided voluntary feedback following a site visit conducted by the Commission’s Quality Assessment team. This has been submitted via a paper-based survey given to providers by the assessment team.

This survey helps the Commission to improve our site visits. It also includes a focus question that is designed to inform the Commission about a particular topic.

From 1 August 2021, it will become much easier for providers to provide feedback to the Commission because the process is moving online. The new online feedback survey:

contains 15 questions
is estimated to take 10 to 15 minutes to complete
includes a new focus question (which is likely to be changed once or twice per year)
allows providers to download a copy of the completed survey for their records
will be managed by the Commission’s contracted survey supplier, Orima.

Aged care providers will continue to have the choice of remaining anonymous or including their contact details if they are willing to be contacted by the Commission for further clarification of their feedback to help us understand particular issues.

After site visits, the Quality Assessment team will provide a web link to providers so they can access and complete the survey online. A flyer will also be provided with additional information, including how to access technical support.

Information about antimicrobial stewardship in aged care

The Australian Commission on Safety and Quality in Health Care has recently updated its Antimicrobial stewardship in Australian health care book with a new chapter on antimicrobial stewardship (AMS) in community and residential aged care.

The new Chapter 16 includes information about:

aged care services in Australia and infectious diseases and ageing
presentation of infections in older people
antimicrobial use in aged care services, including specific areas of concern such as topical antimicrobial usage, asymptomatic bacteriuria and viral infections
AMS program strategies, including program governance, the AMS team, policies and prescribing guidelines, monitoring and surveillance, audit and feedback, education and training, and preventing and managing infections
consideration of barriers to the implementation of AMS aged care settings to enhance its effectiveness.

The Australian Commission on Safety and Quality in Health Care has a range of other resources on AMS in aged care settings on its website, including fact sheets on the use of topical antifungals in aged care settings, and asymptomatic bacteriuria.

Antimicrobial stewardship in aged care is also the topic of the Older Persons Advocacy Network’s upcoming webinar at 11:30 am AEST on Tuesday 18 August. Register for this free event to learn more about this topic.

Updates from the Department of Health

Electronic National Residential Medication Charts (eNRMC)

eNRMC allow safe and accountable medication management in residential aged care.

The Australian Government will support residential aged care providers to adopt an eNRMC to:

decrease medication safety risks
increase visibility of residents’ medication records
support timely provision of medications
provide alerts to advise of allergies, medication interactions, new prescriptions and follow up
reduce the number of daily medications taken.

Several vendors are working to develop eNRMC systems which meet eNRMC technical and legislative requirements. Once these systems are approved, they will be listed on the electronic prescribing conformance register.

Use of eNRMC is not mandatory however residential aged care providers are encouraged to use eNRMC systems to ensure safe and accountable medication management.

Funding will be available to residential aged care providers to cover the cost of implementing a conforming eNRMC system.

Further information about eNRMC benefits, records and what providers need to do is available on the Department of Health website or you can contact the department directly at pbsnrmc@health.gov.au.

New basic daily fee supplement

The new Australian Government basic daily fee supplement provides an additional $10 per day, per resident. This supplement is available to approved residential, respite and flexible (multi-purpose services) aged care providers who formally agree to the undertaking and submit quarterly reports.

What you need to do now:

If you have not already submitted the undertaking form, you need to do so to receive the supplement. For submissions after 21 July, payment will be calculated from the date of submission of the formal undertaking.
Collect quarterly food and nutrition, and daily living services data. The first quarterly report for each service or outlet is due on 21 October 2021 for the period 1 July–30 September 2021.

Further information about this aged care supplement, including reporting requirements, support and a link to the undertaking form, is available on the Department of Health website.