Introduction

1. The Australian Government subsidises residential aged care places to assist with the cost of care and accommodation services for eligible older Australians. As at 30 June 2010, there were approximately 183 000 government funded residential places, provided at a cost of $7.3 billion, or approximately $40 000 per recipient.¹ Almost one in four persons aged 85 years and over is in a residential care facility.² The importance of residential aged care is increasing rapidly, with the number of persons aged 85 years and over estimated to increase by 120 per cent over the 20 years to 2030.³

2. The Aged Care Act 1997 (the Act) and related legislative instruments (Aged Care Principles) establish the framework for financial support for residential aged care places and regulate the conditions of that support. The Act also specifies a number of objects that relate to the quality, type and level of care to be provided in aged care facilities, and provides for a complaints scheme.

3. The complaints scheme was introduced as a means to help ensure that providers meet their responsibilities to provide high standards of care to aged care recipients, who can be among the most vulnerable members of society. As with other complaints schemes, effective handling of aged care complaints assists in resolving problems before they become worse, providing a remedy to clients who have suffered disadvantage, and nurturing good relationships between service providers, government agencies and the public. Complaints also provide useful information about potential program weaknesses and service delivery faults.

4. The complaints scheme is one component of a broad framework established by the Act to promote quality in residential aged care. This framework includes: accreditation and monitoring of providers against the accreditation standards; monitoring by the Department of Health and Ageing (DoHA) of service providers’ compliance with their responsibilities under the Act; the provision of internal complaints mechanisms by service providers; government funded advocacy services to support care recipients in exercising their rights; and the Aged Care Commissioner who reviews DoHA’s complaints decisions and processes, and the conduct of the accreditation processes.

5. There have been three distinct complaints schemes for aged care since the commencement of the Act:

• the Aged Care Complaints Resolution Scheme (CRS) commenced in 1997 and aimed to improve the quality of Commonwealth-subsidised aged care services. The focus of the CRS was on the resolution of complaints;
• the Aged Care Complaints Investigation Scheme (CIS) replaced the CRS on 1 May 2007, giving departmental officers greater investigatory powers to determine whether the provider had breached its responsibilities under the Act. A Senate committee report   published in 2009 identified providers’ concerns with the administrative burden arising from the CIS, and the Australian Government subsequently commissioned an external review, known as the Walton Review, to identify areas for improvement⁴; and
• the current Aged Care Complaints Scheme (the Scheme) came into operation from 1 September 2011 in response to the Walton Review, with the Australian Government committing $50.6 million from
• 2010–11 to 2013–14 to reform the management of aged care complaints.⁵

6. Key measures adopted to improve the management of aged care complaints through the Scheme include: providing a wider range of options for resolving complaints; focusing on the resolution of complainant concerns rather than on whether the provider had complied with accreditation standards; streamlining complex management structures; providing extra resources and enhanced staff training to improve the responsiveness, fairness and consistency of complaint resolution; and improving monitoring, reporting and feedback mechanisms. Reflecting the scale of the reforms, implementation has been planned over four phases and four years, as set out in Table 1.

Table 1 Annual schedule for implementing the Scheme

Source: Department of Health and Ageing, Strategic Plan 2010–14: Aged Care Complaints Scheme.

7. From the commencement of the Scheme on 1 September 2011 to 30 June 2012, DoHA’s systems recorded receiving 3195 complaints. Complaints can relate to any aspect of a service provider’s responsibilities that requires the Scheme to facilitate resolution.⁶ The main categories of complaints have concerned: health and personal care; interactions with staff; consultation and communication; and the physical environment. Within these categories common topics have included: infection control; the quality of meals and cleanliness of laundry; staff skills; provision of information; and occupational health and safety. While many complaints involve relatively routine lifestyle and personal care issues, there is a spectrum through to serious health issues such as errors in administering medication. The effective resolution of complaints is of particular importance for aged care recipients, many of whom are among the most frail and vulnerable in the community.

8. The Scheme is managed by DoHA’s Office of Aged Care Quality and Compliance which is based at DoHA’s Canberra headquarters, and has staff working from offices in each other capital city to manage complaints received in the respective state or territory. Management and operational committees are also in place to facilitate communication and consistency between locations. DoHA’s budget estimate for administering the Scheme in 2011–12 was $26 million, with 237 staff employed in the Scheme in that year.

Audit objective, criteria and scope

9. The audit objective was to assess DoHA’s implementation and ongoing management of the Aged Care Complaints Scheme and the effectiveness of DoHA’s complaints management systems in supporting service delivery and regulatory outcomes.

10. The audit focused on DoHA’s management of complaints from residential aged care recipients and their representatives⁷, and examined whether DoHA has:

• effectively progressed the current reform program in line with the Australian Government’s response to the Walton Review;
• effectively promoted the complaints management arrangements and ensured accessibility for complainants;
• implemented fair and responsive processes and practices to resolve complainants’ concerns; and
• established appropriate monitoring and reporting arrangements, and analysed aged care complaints to support systemic improvement in residential aged care, regulatory outcomes and the transparency and accountability of the Scheme.

Overall conclusion

11. The Aged Care Complaints Scheme (the Scheme) is a key element of the Australian Government’s framework for promoting high standards of care for the large and potentially vulnerable cohort of aged care recipients.⁸ As at 30 June 2010, there were approximately 183 000 government-funded residential places, provided at a cost of $7.3 billion. The Scheme was introduced in response to the Walton Review⁹, an external review of the then Aged Care Complaints Investigation Scheme conducted in 2009, with the Government providing $50.6 million from 2010–11 to 2013–14 to fundamentally reform the management of aged care complaints. Implementation of the Scheme was planned over four years and four phases, with Phases 1 and 2 scheduled for completion by July 2012, and Phases 3 and 4 scheduled for completion by the end of June 2013 and June 2014 respectively.¹⁰

12. DoHA has made good progress to July 2012 in the implementation and ongoing management of the Scheme, with Phases 1 and 2 completed largely in line with the deliverables and timing agreed by the Australian Government in response to the Walton Review. At the commencement of the Scheme on 1 September 2011, the new complaints resolution options were available¹¹ to complaints officers and potential complainants, and around 3200 complaints were finalised through the Scheme between its commencement and 1 July 2012.

13. Drawing on a program of consultation with industry stakeholders and a mostly well-managed project planning approach, DoHA has changed the focus of complaints management away from a concentration on the investigation of non-compliance with accreditation standards to a focus on the resolution of complainants’ concerns, as proposed by the Walton review. To address the review’s concerns about a lack of natural justice, responsiveness and fairness, the department has developed initiatives to improve national consistency in the administration of complaints processes. In particular, DoHA has delivered an extensive, nationally-coordinated training program to complaints staff since the approval of the Scheme, and has promulgated detailed guidance to assist them to consistently apply complaint processes. The department has also introduced new governance arrangements to improve national oversight and liaison between offices in different jurisdictions.

14. Stakeholders, representing both industry and consumers, have provided generally positive feedback about the implementation and administration of the Scheme to date, including the renewed focus on the care recipient and the more responsive resolution of complaints. A further indication of the improved responsiveness of the Scheme has been the reduction in the time taken to resolve complaints, as a result of the additional complaint resolution methods.¹² However, DoHA could not confirm the advice of many stakeholders that complaints were being resolved more appropriately and the Scheme’s processes, practices and outcomes were fairer, as it had not compiled relevant data or performance measures.

15. At the time of audit fieldwork to July 2012, the Scheme was in the early stages of establishment, and there was scope for DoHA to improve aspects of its administration as processes and practices evolve over time. While the department had generally promoted the Scheme effectively, it should consider options to improve access, particularly for isolated care recipients who generally do not have someone available to represent them in a complaint. To further improve monitoring and reporting of Scheme performance, there is scope for DoHA to increase the coverage and response rates for the satisfaction survey sent to the relevant parties after the finalisation of each complaint.¹³

16. To implement Phases 3 and 4 of the Scheme, DoHA has undertaken planning and commenced activities to communicate Scheme outcomes and lead good practice in complaints management. Key deliverables planned for 2012–13 include a report on the operation of the Scheme to communicate outcomes around Scheme learnings, and the further development and dissemination of a complaints handling toolkit to support better practice in handling complaints at the provider level.¹⁴ Notwithstanding these projects, it will be challenging for DoHA to successfully conduct the systemic analysis of aged care complaints that is required to complete Phase 3 of the Scheme by 30 June 2013. Despite managing various aged care complaints schemes since 1997, the department has limited experience in using complaints data to identify and address systemic issues.¹⁵ Further, there are acknowledged problems with the integrity of data held on the electronic complaints management system and the system’s capacity to support analysis. Consequently, DoHA has established a small project team to complete these tasks, relying on largely manual processes. Given the extent of these challenges, it is important that DoHA monitors the strategies and activities proposed to fully implement the Scheme on schedule, in order to support service delivery and regulatory outcomes for the benefit of aged care residents.

17. The ANAO has made two recommendations relating to the implementation and ongoing administration of the Scheme. The first is aimed at improving access to the Scheme for isolated care recipients and the second is aimed at increasing the level of confidence in feedback obtained from complaints satisfaction surveys.

Key findings by chapter

Progress in Implementing the Scheme (Chapter 2)

18. As previously discussed, DoHA has made good progress to July 2012 in the implementation and ongoing management of the Scheme, having completed Phases 1 and 2 largely on schedule and in line with the funding received.

19. A key factor in the implementation of the Scheme has been the consultative process employed by the department. DoHA adopted a sound approach to communicating with key stakeholders via ongoing engagement throughout the reforms, providing consistent messages, tailoring information to suit the audience, and improving web-based communication. Implementation was further supported by the development of a detailed project implementation plan, which included a list of actions to be addressed that were tracked in the first two project phases.

20. The Walton Review reported that the ‘lack of a clear management structure for the national complaint scheme and the overly complex reporting and accountability requirements has led to different complaints management arrangements developing across the state and territory offices.’¹⁶ While operational structures have not been altered¹⁷, the department has established four committees, comprising management from state and territory offices and central office, and revised the structure of the Aged Care Complaints Branch, to improve national oversight and liaison between offices in different jurisdictions.

21. The Walton Review also concluded that there was a need to change the focus of complaints management away from investigation and towards complaint resolution focusing on the care recipient. Accordingly, DoHA has encouraged the consistent application of the principles of procedural fairness, responsiveness and proportionality when conducting extensive training and recruitment, and through the release of new guidelines.

22. To further support the change in focus towards the care recipient in resolving complaints, government funding was provided to increase the number of complaints officers, in order to reduce the average case load per officer. Despite an increase in total Scheme staffing across Central Office and state and territory offices in 2010–11, the number of staff decreased by 30 nationally in 2011–12 when the funding allowed for an increase of 15 staff over this period. As the number of complaints is likely to increase following the transfer of the administration of the Commonwealth HACC Program from most state and territory governments to DoHA from 1 July 2012¹⁸, there would be merit in the department reviewing the allocation of resources for managing aged care complaints in light of other departmental and program priorities.

Operation of the Scheme (Chapter 3)

23. An important aspect of complaints management is to facilitate clients’ access to complaints schemes through promotion and service arrangements. DoHA’s approach to promoting the Scheme has been generally effective. The department has widely distributed information on the Scheme and is adjusting its promotion activities to take into account feedback on stakeholder preferences for receiving information.

24. As most complaints are made by telephone, private access to telephones for care recipients facilitates their access to the Scheme. Alerting service providers to the benefits of enabling private access for all care recipients is particularly important in regional and remote areas where access to Internet services may be limited and care recipients have fewer options to relocate if they fear adverse treatment after making a complaint. To improve access to the Scheme for isolated care recipients who generally do not have someone available to represent them in a complaint, DoHA should consider options to support this group, including making use of existing programs that target isolated care recipients.

25. DoHA receives complaints and determines options for their management through detailed intake and assessment processes. However, unlike many call-based operations, DoHA does not monitor the quality of intake call interactions to gauge the extent to which the intake officer is satisfying the relevant service requirements. Monitoring a sample of complainant calls would help strengthen the Scheme’s client communication practices, with the results potentially being used to provide performance feedback to staff, and more broadly to guide training and refinement of the Scheme Guidelines.

26. During intake and initial assessment, complaints officers apply a risk assessment and resolution planning process that guides them in identifying the level of risk and determining the most appropriate method to resolve the complaint. This approach supports officers to identify cases that represent serious risks to the health, safety and wellbeing of a care recipient, and prioritise these cases for resolution.¹⁹ The risk assessment and resolution planning process focuses on determining approaches to resolving the particular complaint but does not explicitly take into account the likelihood of the complaint issue occurring—either again for the respective care recipient or for other aged care residents. Including the likelihood of a similar incident occurring, together with its consequence, in the risk assessment and resolution planning matrix would support complaints officers to consider systemic issues when assessing complaint risk and determining the resolution method.

27. As discussed earlier, DoHA has implemented the resolution methods recommended by the Walton Review and agreed by government, namely: conciliation; service provider resolution; investigation; and mediation. Stakeholders generally advised that these options have provided a fairer, less adversarial process, with complaints being resolved more promptly, appropriately and proportionately.²⁰ While appreciating these positive qualitative views, the department could not confirm the effectiveness of the various resolution methods, as it had not compiled relevant data or performance measures—such as the number and proportion of cases resolved, referred or not resolved through each resolution method.

Continuing to Full Implementation of the Scheme (Chapter 4)

28. As already noted, DoHA has conducted planning and commenced activities to implement Phases 3 and 4 of the Scheme. In 2012–13, the strategies focus on communicating outcomes of the Scheme and influencing industry to improve the quality of residential aged care. If delivered effectively, the strategies and priority activities have the potential to support the successful implementation of the Scheme.

29. As discussed earlier, it is important that the department monitors the progress of strategies to implement these latter phases, particularly to address challenges associated with conducting systemic analysis of complaints, and to consider emerging issues such as broader sectoral reforms affecting the administration of aged care complaints.²¹

30. DoHA’s capacity to readily conduct systemic analysis of complaints has been affected by the limitations of the existing electronic complaints management system²², and delays in introducing the new National Complaints and Compliance Information Management System (NCCIMS). When fully operational, DoHA expects that NCCIMS functionality will enable: the collection of substantially more business information; regular and ongoing analysis of complaint trends at a national, state and territory and agency level; and the ready production of reports. NCCIMS was initially planned to be operational at the commencement of the Scheme in September 2011, but is now expected to ‘go live’ in December 2013, which is over five months after Phase 3 is due for completion.²³

31. Delays in implementing NCCIMS have also postponed the development of reports drawing on Scheme data to identify trends in complaints about residential aged care services. While internal business reports have provided data on a number of areas, they do not fully align with the processes used in the Scheme and could be better used to identify, analyse and address provider performance issues.

32. DoHA uses a customer satisfaction survey at the finalisation of each complaint to assess and report on the Scheme’s performance. Survey results for 2011–12 showed high levels of satisfaction, including 82 per cent satisfaction with the overall operation of the Scheme. However, there has been a moderate response to these surveys, with 34 per cent of aged care complaints satisfaction surveys being returned in 2011–12. Taking actions that increase the response rate would provide DoHA and other stakeholders with greater confidence in the results of the finalised complaint surveys.

DoHA’s response to the audit

 33. The Department of Health and Ageing notes the audit report and agrees with the recommendations.

Footnotes

[1] Australian Institute of Health and Welfare, Residential Aged Care in Australia 2009–10: a statistical overview. Aged Care Statistics Series Number 35, p. vii, and Australian Institute of Health and Welfare, Australia’s Welfare 2011, p. 186.
[2] Productivity Commission, Caring for Older Australians, 2011, p. 42.
[3] ibid., p. 39.
[4] Walton, Associate Professor Merrilyn, Review of the Aged Care Complaints Investigation Scheme, 2009. See <http://www.health.gov.au/Internet/main/publishing.nsf/Content/6E29D85E6… 257703000 36CB1/$File/ReviewCIS21009.pdf> [accessed 26 June 2012].
[5] Australian Government, A National Health and Hospitals Network for Australia’s Future: delivering better health and better hospitals, 2010, pp. 122, 127. See <http://www.health.gov.au/Internet/yourhealth/publi shing.nsf/Content/report-redbook/$File/HRT_report3.pdf> [accessed 27 June 2012].
[6] Complaints can be made by any person or organisation, including: care recipients and their family or friends; staff members or volunteers/carers; advocacy services; other areas of DoHA; and external organisations.
[7] The work undertaken by the Aged Care Commissioner, the Aged Care Standards and Accreditation Agency, and advocacy services in relation to the Scheme was not covered in the audit; however these stakeholder organisations were consulted during the course of the audit.
[8] Other elements of the framework include an Aged Care Commissioner, the Aged Care Standards and Accreditation Agency, and aged care advocacy services.
[9] Walton, Associate Professor Merrilyn, Review of the Aged Care Complaints Investigation Scheme, 2009. See <http://www.health.gov.au/Internet/main/publishing.nsf/Content/6E29D85E6… 257703000 36CB1/$File/ReviewCIS21009.pdf> [accessed 26 June 2012].
[10] According to DoHA’s Strategic Plan 2010–14: Aged Care Complaints Scheme, Phase 1 involved ‘getting the basics right and preparing for change’, while Phase 2 focused on ‘implementing and communicating change’. Phase 3 is ‘communicating outcomes and influencing industry’, while Phase 4 is to ‘lead good practice in complaints management’.
[11] In addition to investigation, complaint resolution methods now include service provider resolution, conciliation and mediation. The additional methods are intended to offer greater flexibility to resolve complaints and improved responsiveness for all parties. Methods can be selected with the agreement of all parties to allow the quickest resolution of complaints, and the protection of the relationship between the provider and the care recipient. Early resolution occurs during the Intake Phase and precludes cases from entering a formal resolution process.
[12] The average time taken to resolve or finalise complaints from the commencement of the Scheme on 1 September 2011 to 30 June 2012 was 48 days, with investigations averaging 90 days to resolve. While DoHA could not provide reliable timeliness data for complaints received under the previous Complaints Investigation Scheme, it advised that investigations, which were the focus of that scheme, had a similar duration to resolve of around 90 days.
[13] More than half of the Scheme performance measures are based on the survey, which had a response rate of only 34 per cent in 2011–12 and excludes complaints referred to early resolution and mediation.
[14] DoHA, 2012–13 Operational Plan, Aged Care Complaints Branch, p. 9.
[15] The main recent examples of the department identifying and addressing systemic issues are through the publication of a What can we learn report and Industry alerts. To date, the What can we learn report covered Residents who go missing, and Industry alerts have covered processes in relation to smoking and bed poles (both coronial findings) and call bells.
[16] Walton, op. cit., p. 28.
[17] The Scheme continues to be administered locally from offices across all states and the Northern Territory. The seven state and territory managers continue to report to four different Deputy Secretaries in DoHA, with only two reporting to the Deputy Secretary with overall responsibility for the Scheme.
[18] From 1 July 2012 the Australian Government assumed full funding, policy and operational responsibility for Home and Community Care services, covering over 450 000 clients in all states and territories (except Victoria and Western Australia).
[19] The highest risk cases are generally referred for investigation, and, depending on circumstances, reported to the: Aged Care Standards and Accreditation Agency for monitoring and investigation at a facility level if required; or DoHA’s aged care compliance area if the provider may not be meeting its legislated responsibilities.
[20] Conversely, a small number of individual complainants reported delays and poor outcomes under the Scheme, a lack of ongoing communication and little improvement following its implementation.
[21] The Aged Care Complaints Branch faces uncertainty about the future volume and nature of complaints following the transfer of responsibilities for the Commonwealth’s HACC Program (as discussed in paragraph 22) and the possible integration of complaints relating to a number of other aged care programs (such as the National Respite for Carers Program).
[22] Limitations of the existing electronic complaints management system extend to data integrity, functionality and analysis tools.
[23] In implementing NCCIMS, DoHA was required to pay for licences for staff to use the system. Despite internal advice to the contrary, the NCCIMS contract included the payment of initial licence fees and annual fees over three years before 30 June 2012 without any discount for prepayment, which imposed a cost on the Commonwealth. The amount paid by DoHA on signing the contract limits the options available to DoHA, such as holding back payments to manage the contract risks associated with delivery of required outcomes.