Over the past three years, I’ve examined hundreds of hours of hidden camera footage from Australia’s nursing homes.
Some showed outright physical abuse, others revealed the so-called rough handling that comes from untrained, insensitive and overworked carers.
There was one video showing the physical assault of a frail woman with dementia that was so vicious that, by the end of production I had to avert my eyes and block my ears in the edit suite.
But there is one collection of footage that remains firmly in my mind, because instead of revealing an explosion of violence it shows a type of human rights abuse that is so common in aged care that it goes almost unremarked.
It creeps up over weeks, months and years, and yet is almost impossible to prove and is never investigated by the police.
It’s called neglect.
It’s also the title of the Royal Commission into Aged Care Quality and Safety’s interim report, because it is the overriding theme in the 10,000 submissions the inquiry received.
Luigi Cantali was 80, blind, and had dementia. Despite his disabilities, the video revealed Luigi also had a great attitude to life and a cheeky sense of humour, but none of those saved him from neglect.
At his Sydney nursing home, Luigi was only taken from his room to go to the bathroom or shower, and that wasn’t often.
Despite soiled incontinence pads leaking on to his clothes, his chair and the floor, he was rarely changed, nor was disinfectant consistently used to clean his room.
Footage showed one carer spraying his body and his clothes with deodorant.
When it came to meals, carers promised to feed him but left without returning.
On one day, the blind man managed to find a mango on his tray, which he peeled and devoured.
Another day, the tray is left out of his reach and 40 minutes later taken away by a carer, untouched.
On other occasions, Luigi was lifted naked in a hoist, taken out to the corridor for everyone to see, with no regard for his dignity.
But perhaps the most common image in the footage was Luigi alone, sitting in his chair or lying in his bed.
Occasionally he called out “hello?” in case someone should pass by his room.
His questions to carers about going out for a walk ignored, the cries for his wife plaintive, and his basic desire to connect with another human being quashed.
When the hidden camera was discovered by Carino Care, the private nursing home in Sydney where Luigi lived, management reported Luigi’s daughter to police, suggesting she was violating his privacy.
The police quickly dismissed that suggestion but didn’t investigate Carino Care about conditions for Luigi.
At the time of publishing Luigi’s story, Carino Care said it hadn’t viewed the footage because it was “a police matter” and that it had provided Luigi “with the best possible care.”
But when the regulator, the Aged Care Quality and Safety Commission, went and inspected the nursing home days after our story aired, it sanctioned Carino Care for putting residents at “serious risk”, finding it failed 24 out of 44 quality and safety standards.
Luigi’s family moved him to a new nursing home, but he died within six days.
Overwhelming evidence of aged care issues
Luigi’s hidden camera was put in place in December 2018, a few short months after Prime Minister Scott Morrison announced a royal commission into aged care.
That announcement came just the day before a special two-part investigation into aged care aired on Four Corners.
Who Cares? was the result of the ABC’s largest crowdsourced investigation at that time, which resulted in more than 4,000 families and staff from around Australia telling us their stories from inside nursing homes.
We heard of an overwhelming amount of work done by too few people with too little training; sexual and physical abuse swept under the carpet; $6 a day food bills; humiliations like continence pads restricted to three-per-day; a lack of transparency about how providers spend taxpayer dollars; and a broken regulatory and complaints system.
That evidence was repeated hundreds of times throughout two years of the royal commission’s hearings and now forms the final report, which was handed to the Governor-General on Friday.
It is expected the government will release that final report today, and we already have a good idea of what will be in it because counsel assisting laid out all 124 recommendations in the final hearings last October.
More surprising for this kind of inquiry is that we also know which changes the government is likely to reject — it’s all there in black and white on the royal commission’s website in a submission by the Commonwealth, namely the Department of Health and the federal aged care regulator.
For those who are cynical about the value of a royal commission, it makes grim reading.
Of the 124 recommendations, the joint submission supports just eight entirely.
They are completely opposed to six of them, while the vast majority — at least half — are referred to as being “supported in principle”.
They reject one of the royal commission’s key proposals to have an independent body separate from the government dictating the funding levels.
At the same time, the government submission questions introducing extra reporting requirements for aged care companies to publish how they spend the more than $20 billion in taxpayer money that goes to the sector.
Prime Minister Scott Morrison may try to argue that this submission from the department and the regulator doesn’t reflect the government view — an argument few would believe possible since ministers and the leadership direct their departments in policy.
Of the more than 100 recommendations, here are some of the responses.
Staffing mix agreed, but reporting shouldn’t be ‘overly burdensome’
Unlike in child care and hospitals, there are no staffing ratios in aged care.
There is not even a requirement to have a registered nurse on duty.
The staff in part one of Who Cares? talked about registered nurses being in charge of over 100 residents and skeleton staff on night duty.
Instead of suggesting minimum staffing numbers, the royal commission is recommending a “minimum staff time” for residents given by a “skills mix” of qualified nurses and personal care workers to do the hands-on work.
The aim is to ensure the average resident receives three hours of care per day plus another half an hour from a registered nurse.
That would be a vast improvement on what we have currently, with a royal commission study showing more than half of Australia’s facilities would rate just one or two stars in the US five-star rating system when it comes to staffing.
But while the government “supports the intent” of that change, it adds that the amount of time needed “varies significantly with the acuity of residents, and as a result the level and type of staff time appropriate for each facility will also vary”.
The suggestion — which echoes the industry line — is that some residents need less than three and a half hours of direct care per day.
That seems hard to believe considering most people entering aged care now do so as a last resort and are therefore older, more frail, sicker and require more assistance with bathing, dressing, eating, walking and attending to medical needs.
The Department of Health and the federal regulator also warn that reporting staff numbers on a quarterly basis as suggested shouldn’t be “overly burdensome” for aged care providers.
The government is more supportive of the need for having at least one registered nurse rostered on every shift.
Before the Aged Care Act of 1997 was introduced by then-prime minister John Howard, a registered nurse on duty 24/7 was a requirement in aged care.
Now the royal commission wants them back and, although the department and regulator say they “support the intent” of at least one registered nurse on-site at all times, they say exceptions would need to be made for rural and remote areas.
Advocates want the nurses back but are concerned with the long deadline the royal commission has given of 2024 to have the measure in place.
Mandatory qualifications ‘shouldn’t be a barrier’ for carers
In child care, staff need a Certificate III qualification to work.
However, in aged care there’s no minimum training requirement for personal care assistants who make up 70 per cent of all staff and who do the crucial work of showering, feeding and mobilising the elderly.
Training is so loosely defined in the sector: It can be one carer training another on the job over a period of days.
Throughout our many stories on aged care, the lack of training and knowledge of staff has been one of the consistent themes.
And it’s in hidden camera footage that it can be most clearly seen, such as the case of Ernie Poloni at Bupa Templestowe.
Ernie’s family installed the camera to find out why his pyjamas were consistently ripped and found the 85-year-old was handled roughly by a variety of staff.
But while the royal commission will recommend a Certificate III be the minimum training requirement in aged care, the federal regulator and the Department of Health say it “shouldn’t be a barrier to staff” who want to work in the sector and “who have the right attitude and aptitude to provide care”.
They say it should “take into account challenges posed by areas of low workforce supply such as rural and remote areas”, and that people should be able to gain the certificate while working on the job.
The peak industry groups share that view.
That’s probably because they are already struggling to attract workers and know that many people will not pay for a certificate for a job that often pays $21 an hour, just over a dollar per hour more than the minimum wage.
The government also takes exception to the royal commission’s recommendation staff should have mandatory dementia and palliative care training saying that may not be “practical or feasible” and instead should be considered part of “best practice guidance” rather than mandatory.
Considering half the residents in aged care have dementia and — realistically — almost all of them will die in there, this seems a shocking objection.
A lack of training in dementia is known to lead to the overuse of drugs and sedatives.
No support for plan to stop GPs prescribing antipsychotics
Chemical restraint, or the use of antipsychotics to control dementia behaviours, has been front and centre in our aged care stories.
The overuse of physical and chemical restraints has been described as a human rights abuse with the Australian Law Reform Commission making recommendations to stop it six years ago — reforms that were ignored by the government.
In January 2019, we broadcast pictures of Terry Reeves, who suffered after being physically and chemically restrained while on a respite stay in a Sydney nursing home.
That case was examined at the royal commission and showed that the GP who attended the nursing home increased the dosage of risperidone at the request of staff.
The royal commission wants changes made by November this year so that only a psychiatrist or geriatrician can authorise the initial prescription of antipsychotics.
But the federal regulator and the department oppose that change, saying it is not “feasible” as there are not enough specialists to do the job and that “improved clinician education” will stop the overuse of the drugs.
That will anger many, especially when it’s known that antipsychotics are not always effective, can cause death and that GPs can be coerced by overworked staff who don’t have the numbers or knowledge to deal with challenging behaviours.
On the other hand, others say the measure is short-sighted, as GPs will find other drugs to use if antipsychotics are restricted.
The answer, they say, is more trained qualified nursing and care staff who view psychotropic drugs as a last resort.
Home care waiting list
The royal commission wants the home care waiting list — at the moment topping 100,000 people — cleared by the end of the year.
We’ve interviewed families like those of Evelyn Micallef, who waited 18 months for the highest level package despite crippling dementia and her inability to walk.
The average wait for Level 4 packages is over two years, with estimates that 28,000 people died waiting between 2018 and 2020.
Clearing the waiting list is supported “in principle” by the Department of Health, which says it’s already doing that with the “progressive release of packages at a rate that the sector can implement”.
Although the federal government says it has now “funded” 50,000 home care packages, in reality, it has only “released” just over a third of those (or 17,000) which is why the waitlist remains so long.
What the government doesn’t say is that they’re holding back the packages because there is a massive shortage of home care workers.
The workforce shortage is a major problem in both residential and home care, which is why it’s puzzling that the regulator and department have rejected the recommendation that the government take charge of the Aged Care Workforce Council.
Once again, the government has a “hands off ” approach, leaving it to the industry to tackle a massive social issue as our population ages.
The federal regulator and department also warned that clearing the waiting list could put the elderly at risk because it will require more home care providers “who are inexpert” and the regulator will be busy monitoring them as they “will pose a significant regulatory uplift”.
It certainly will require an uplift.
Last year, the federal regulator did just 76 reviews of home care providers out of more than 900.
Split report expected
As for the future of funding and regulating the sector, this is the great sticking point that looks likely to split the commissioners.
During the final hearings in October last year, commissioner Lynelle Briggs voiced her opposition to a new statutory corporate body — away from Canberra — while fellow commissioner Tony Pagone QC was in favour of it.
It is clear the government supports Ms Briggs’ view, saying it would need to be convinced changing the regulatory body would improve the sector for the better.
The large cost of creating a new regulatory arm also seems to be on the government’s mind.
It seems likely the commissioners will disagree on other key recommendations too, judging by comments heard from Mr Pagone when speaking to the Governor-General, saying final proposals “have been difficult to reach” as the two have “different views on key measures”.
Overall, the Commonwealth submission gives a clear impression that the government is worried about the vast cost the reforms would entail.
If it is a split report, it’s easy to imagine the government implementing the least costly recommendation from either commissioner.
For example, the government opposes new Medicare benefit schedules for doctors to do three-monthly or six-monthly checks on aged care residents.
While it agrees on the need for an online rating system to allow families to compare nursing homes, it claims it already has a system in place on My Aged Care and the regulator’s website.
However, that’s not the case, with no publicly available information on staffing, complaints, assault or performance reports to assist someone in choosing the best aged care home.
It’s also opposed to extra measures to ensure increased governance by members of boards however the department has, once again, argued there should not be an extra burden on aged care providers.
The royal commission has heard from many traumatised families and staff throughout its hearings but there’s been little acknowledgement of that pain.
Dealing with literally hundreds of people myself, I can say that there are many damaged people who witnessed shocking neglect and abuse, who were further injured by providers who denied their stories and the final blow, saw no penalty meted out by the federal regulator — even when neglect and abuse were proven.
The Prime Minister’s oft-repeated claim that he called the royal commission because he wants the sector changed, rings hollow if the government is again going to ignore how to fix a broken system.
That has already happened with over 20 reports into problems in the sector gathering dust over the past decade.
The question is, will the government go so far as to ignore reforms recommended by the highest form of inquiry this country has to offer?
If the submission from its department and regulator is anything to go by, the answer is, unfortunately, yes.