We would like to share the latest trend summary for the Sector Performance data for July – September 2023. Staying on top of trends is essential for both the Commission and your organisation. By employing a risk-based approach, the Commission assessors have been directed to focus on areas of non-compliance that are trending across the sector, in addition to the risk-based questions discussed in the entry meetings, including when assessors are not observing issues relating to your risk-based questions.
In both of the reports below it was noted that Governance requirements have seen a significant decline. With the introduction of the new Governance requirements as of December 2023, the Commission has commenced monitoring visits and it’s a significant area of risk that ALL providers both Residential and Home care need to consider.
To help you be prepared, CSS has outlined the top requirements where non-compliance was found in both the Residential and Home Care sectors during the specified period. These areas are likely to receive attention through unannounced visits and quality reviews in the future. CSS has also noted some commentary from the sector performance reports as well:
Home Care
| HOME CARE Top requirements where non-compliance were found. | Jul – sept 23 ( 10 noted) | April – Jun 23 (7 noted) | Jan – march 23 (9 noted) | Oct – Dec 22 (10 noted) | Jul – Sep 22 (10 noted) | Apr – Jun 22 (10 noted) | Jan – Mar 22 (12 noted) | Oct – Dec 21 (5 noted) | Jul – Sep 21 (11 noted) |
| 2 (3)(a) Assessment and planning informs safe and effective services | X | X | X | X | X | X | X | X | X |
| 8 (3)(c) Effective governance systems | X | X | X | X | X | X | X | X | X |
| 8 (3)(d) Risk management systems and practices | X | X | X | X | Twice | X | X | X | |
| 2 (3)(b) Assessment and planning identifies current needs | X | X | X | X | X | X | X | ||
| 2 (3)(d) Communication of assessment and planning outcomes | X | X | X | X | X | X | |||
| 2 (3)(e) Regular reviews of care and services | X | X | X | X | X | X | X | X | |
| 3 (3)(a) Safe and effective clinical care | X | X | X | X | |||||
| 8 (3)(e) Clinical Governance Framework | X | X | X | X | X | X | |||
| 7 (3)(c) The workforce is competent and effectively performing their roles | X | ||||||||
| 7 (3)(d) Recruitment. training and support for workforce | X | X | X | X | X | ||||
| 3 (3)(d) Recognition and response to deterioration | X | X | |||||||
| 8 (3)(b) Governing body promotes safety, inclusiveness and accountability | X | X | X | ||||||
| 6 (3)(d) Feedback and complaints used to improve services. | X | X | X | ||||||
| 6 (3)(c) Appropriate action is taken in response to complaints. | X | ||||||||
| 3 (3)(b) High-impact and high-prevalence risks managed effectively. | X | X | X | X | |||||
| 3 (3)(e) Sharing information to optimise care. | X | X | X | X | X | ||||
| 4 (3)(d) Communication of consumers’ conditions, needs and preferences | X | ||||||||
| 7 (3)(e) Regular performance assessment and monitoring of workforce | X |
From the performance sector report
- Across the 4 quarters from September 2022, compliance rates were lowest for Quality Standard 8 (Organisational governance). While we have seen an improving trend over the past 4 quarters, there is more work needed by home services providers to make sure that safe quality care is supported by good governance arrangements. Providers with poor governance receive more complaints, have more serious incidents, and worse clinical care.
- Lower overall compliance rates are also apparent for Quality Standards 7 (Human resources) and Quality Standard 2 (Ongoing assessment and planning with consumers). Further, in contrast to residential care, we are observing a decrease in the compliance rates for Quality Standard 3 (Personal care and clinical care). These trends will be closely monitored.
- Since Q3 2022–23, there has been a concerning drop in compliance rates for Quality Standard 2 (Ongoing assessment and planning with consumers).
- Issues associated with this standard are also increasingly showing up in complaints data. Complaints about case management, coordination and care planning account for 3 of the top 10 complaints received about home services this quarter (see page 39).
Residential
| RESIDENTIAL: Top ten requirements where non-compliance were found. | July – sept 23 | April – jun 23 | Jan – Mar 23 | Oct – Dec 22 | Jul – Sep 22 | Apr– Jun 22 | Jan – Mar 22 | Oct – Dec 21 | Jul – Sep 21 (11 noted) |
| 3 (3)(a) Safe and effective personal and clinical care | X | X | x | x | x | x | x | x | |
| 3 (3)(b) High impact or high prevalence risks managed effectively | X | x | x | x | x | x | x | x | |
| 8 (3)(d) Risk management systems and practices | X | X | x | x | x | x | x | x | x |
| 7 (3)(a) Number and mix of workforce | x | x | x | x | x | x | x | ||
| 2 (3)(a) Assessment and planning informs safe and effective services | X | X | x | x | x | x | x | x | x |
| 8 (3)(c) Effective governance systems | X | X | X | x | x | x | x | x | x |
| 2 (3)(e) Regular reviews of care and services | X | x | x | x | x | x | x | x | |
| 8 (3)(e) Clinical Governance Framework | X | X | x | x | x | x | x | x | x |
| 7 (3)(d) Recruitment. training and support for workforce | X | X | x | x | x | x | x | ||
| 3 (3)(g) Infection risk management and appropriate prescribing Ab’s | x | x | x | x | |||||
| 2 (3)(b) Assessment and planning identifies current needs | X | x | |||||||
| 3 (3)(d) Recognition and response to deterioration | x | ||||||||
| 5 (3)(b) Safe, clean and well maintained service environment | X | x | |||||||
| 6 (3)(d) Feedback and complaints used to improve services. | X | x | |||||||
| 7 (3)(e) Regular performance assessment and monitoring of workforce | X | x | |||||||
| 1 3(e) Information provided to each consumer is current | x | ||||||||
| 6 3 (c ) Open disclosure and complaints process | x | ||||||||
| 8 (3) (b) Governing body promotes a culture of safe, inclusive and quality care and services and is accountable for their delivery. | X | ||||||||
| 3 3 (e) Information about consumers condition is documented and communicated | X |
From the performance sector report
- Quality Standard 8 (Organisational governance) has the lowest rate of compliance in Q1 and fell this quarter after improving across the previous three quarters. This is concerning as we know that providers with poor governance often have more complaints made about them and more clinical and service delivery issues.
- Of the 10 Quality Standard requirements with lowest compliance, 4 of them relate to governance. These 4 requirements include culture, clinical governance and risk management, which are critical for safe and quality care.
- While Quality Standard 3 (Personal care and clinical care) had the lowest compliance rate (79%) of all Standards in Q2 2022–23, it has improved significantly in Q1 with a compliance rate of 90%. QI Program data (page 40) also shows improvements in: − medication management − physical restraint − unplanned weight loss − falls that resulted in major injury.
- However, we are continuing to see concerns about clinical and personal care in our complaints data (page 36). These issues account for half of the top 10 complaint issues. Medication management is the number one complaints issue and falls prevention and management the number 2 issue.
Sourced from reports at https://www.agedcarequality.gov.au/sector-performance
How prepared are you?
CSS has conducted many quality compliance audits during this 12 month period, a key outcome of our reviews is thorough identification of risk, enabling advanced preparation for Commission visits. Many of our clients having received 42/42 met outcomes during this period.
As we move closer to the strengthened standards, CSS has begun review of our Residential and Home Care audit programs based on new strengthening standards and Governance requirements, and we are excited to make the following available to you:
- Strengthened Standards Audit (Availability April 2024) for both residential and Home care
- Complete Current Standards Audit (Standard 1-8 – where applicable)
- NEW – Governance Dec 2022- 2023 Program Aduit (includes aspects of Standard 8 3 (b))
- Human Resources Audit (Standard 7, plus Std 8 (3 (c)(iv))
- Clinical Care Audit (Standard 2 and 3, plus Std 8 (3 (d) and (e))
- Complaints Management Audit (Standard 6 plus, Std 8 (3 (c))
- Risk Management Audit (Standard 1, 2, 3 and 8 relevant requirements)
- Risk Management Audit (Std 1, 2, 3 and 8 relevant requirements)
- Lifestyle Audit (residential care – Standard 1 and 4 relevant requirements)
- Consumer File Review (10% consumer care and services plan file review)
- The Usual Suspects (Std 3,7 and 8)
To schedule a quality review audit, or discuss how these CSS programs can add value to your organisation please contact fleur@cssconsulting.com.au / 0414 588 795.
