ROYAL COMMISSION INTO AGED CARE QUALITY & SAFETY ... · 5 In summary, Bupa makes the following submissions in response to these propositions : (a) Bupa accepts that, with the benefit

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ROYAL COMMISSION INTO AGED CARE QUALITY & SAFETY

SUBMISSIONS FOR THE BUPA SOUTH HOBART CASE STUDY

I. INTRODUCTION

1 Bupa Aged Care Australia Pty Ltd (Bupa) makes these submissions in response to the

submissions from Counsel Assisting dated 2 December 2019 in relation to the Bupa

South Hobart Case Study (Counsel Assisting’s Submissions). The Bupa South

Hobart Case Study focused on matters relating to the quality and safety of care provided

at Bupa South Hobart from November 2014 to 18 September 2019 (Relevant Period).

2 Bupa has operated Bupa South Hobart (the care home) since June 2012. On 25 October

2018, the care home was sanctioned by the Department of Health after a site audit report

produced by the Australian Aged Care Quality Agency (October 2018 Site Report)

determined that it did not meet 32 of the 44 expected outcomes set out in the Quality of

Care Principles 2014 (Cth) (Accreditation Standards). The sanction was lifted on 23

July 2019 after Bupa conducted significant remediation at the care home and after the

Aged Care Quality and Safety Commission determined that the home was in full

compliance with Aged Care Quality Standards.

3 The Royal Commission heard evidence from former and current employees and from

family members of four residents at Bupa South Hobart: Mrs Berenice Eastman, Mr

Walter Eastman, Mrs Emily Flanagan and UR. The evidence of these family members

highlighted occasions where the level of care and quality of life provided was sub-

standard. Bupa accepts that it, and the leadership team at Bupa South Hobart, should

have done more for these families during what was, for them, a stressful and emotional

experience. Bupa is profoundly sorry for this and continues to work very hard to ensure

that this experience is not repeated.

II. EXECUTIVE SUMMARY

4 The following propositions are advanced in Counsel Assisting’s Submissions:

the implementation of Save a Shift and Project James at Bupa South Hobart (a)

was a misguided cost saving strategy (with the implication that Bupa was overly

focused on profitability);

there were shortcomings in the operation of Bupa’s clinical governance (b)

framework as relevant to the care home;

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there was a failure to adequately address comments and complaints at the care (c)

home; and

while Bupa has implemented a number of initiatives to address these concerns, (d)

there is a question as to whether Bupa has “learned the true lessons” from the

Relevant Period.

5 In summary, Bupa makes the following submissions in response to these propositions:

Bupa accepts that, with the benefit of hindsight, the implementation of Save a (a)

Shift and Project James at Bupa South Hobart was misguided. Bupa South

Hobart has historically been difficult to adequately resource due to its location

and competition with the public health system for quality clinical staff. The layout

of the home is also challenging. In light of these difficulties, Bupa accepts that

the Save a Shift and Project James strategies contributed to instances of sub-

standard care at Bupa South Hobart. However, although misguided, these

policies were implemented in good faith to manage the genuine financial

challenges that compromised the ongoing sustainability of the original Bupa

Model of Care and the intent of these strategies was to not compromise the

quality and safety of care of residents. Further details on this are set out at

section III below.

Bupa accepts that the clinical governance framework was not operating as it (b)

should have been at the care home prior to the October Site Audit Report. In

saying this, Bupa notes that the internal audits conducted at Bupa South Hobart

during the Relevant Period had correctly identified significant and recurrent

compliance issues, particularly in relation to Standard 2 of the Accreditation

Standards, but the measures put in place to address these issues were not

sustained. Bupa has since restructured its regional framework and its Clinical

Services Improvement (CSI) Team, as well as implementing changes to the

clinical governance framework, governance structure and compliance function

within the business. Further details on this are set out in section IV and

paragraphs 65-66 below.

Bupa accepts that feedback from residents and their families was not always (c)

acted upon appropriately at Bupa South Hobart and Bupa has taken steps to

address this issue at this care home and others. Further detail of steps taken to

enhance the mechanisms for addressing comments and complaints and

promote early resolution of complaints to the satisfaction of residents and their

families is outlined at paragraph 59-64 below.

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Bupa has learned many invaluable lessons from the Relevant Period, a number (d)

of which were identified by Ms Carolyn Cooper, the interim Chief Operating

Officer (interim COO) of the aged care business in Australia (BVAC Aus) from

19 November 2018 to 28 July 2019.1 Bupa adopts her observations. The

development and implementation of the 2019 Roster Proposal by Ms Cooper

and others is in fact evidence that Bupa has taken these lessons onboard

because the flexibility of the proposal provides for higher levels of staffing at

facilities such as Bupa South Hobart. In addition, the changes described in

further detail at paragraphs 47-48, 59-63 and 65-66 below evidence a number

of other measures Bupa has put in place in response to the experience at Bupa

South Hobart.

6 Bupa South Hobart has undergone significant remediation since late 2018 as

summarised in Annexure B to these submissions. As a result of this remediation and the

improvements to the clinical governance and compliance framework, Bupa is confident

that Bupa South Hobart is taking continuous actions to maintain the quality of care and

quality of life of its residents. In saying this, the constraints of the current funding model

that support Bupa South Hobart are part of the “ever present reality” placing significant

pressure on the operation of providers such as Bupa. Bupa welcomes recent

announcements of increased funding but notes that this will not substantially alleviate the

current financial strain across the aged care sector. Bupa hopes that the Commonwealth

Government, through the recommendations of this Royal Commission, addresses the

many challenges that are presented by the current funding arrangements.

III. THE BUPA MODEL OF CARE: 2016 TO 2018

7 In this section of the submissions, Bupa outlines changes to the Bupa Model of Care that

were implemented at Bupa South Hobart during the Relevant Period and provides

context to Counsel Assisting’s Submissions about these being “cost saving strategies.”2

8 Bupa accepts that some of these changes contributed to issues with the quality and

safety of care at Bupa South Hobart during the Relevant Period and it has undertaken a

number of remedial measures in response. However, Counsel Assisting’s Submissions

suggest that these changes were motivated by a desire for higher profits. This is

incorrect. The changes were motivated by genuine concerns about the sustainability of

the original Bupa Model of Care (BMOC 1) in light of the significant operational costs of

1 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [211]-[214].

2 Counsel Assisting’s Submissions at Section 2.1.

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BMOC 1 at a time when substantial reductions were introduced by the Commonwealth

Government to aged care funding.

BMOC 1

9 As set out in its Guiding Statement, the aim of the original Bupa Model of Care (BMOC 1)

was to improve the quality of health care through the reallocation of responsibilities

between various clinical roles and a re-organisation of reporting lines and functions.3

BMOC 1 was designed in the context of the funding model at the time before Government

reforms to funding were contemplated.

10 In summary, under BMOC 1:4

General Practitioners (GPs) were employed in the care homes. At Bupa South (a)

Hobart, from January 2016 Dr Libby Monks was employed as the GP in the

care home.5

Clinical Managers (who were Registered Nurses) were employed to work (b)

alongside the GPs to support the provision of health care within the care home

and provide a link with the rest of the home’s senior clinical management,

provide clinical analysis and facilitate case management.

Care Managers (who were also Registered Nurses) supervised care staff within (c)

the care home community and were allocated case management responsibility

for a specific portfolio of residents.

Rostered hours were prescribed by shift and staff category for each community (d)

within the care home.

For some forms of medications, the medication administration was done by the (e)

Enrolled Nurses and non-registered nursing staff under the direction and

supervision of Registered Nurses. This allowed the Registered Nurses to focus

on more complex aspects of care. The Registered Nurses retained

responsibility for medication management, pain management and clinical

oversight together with GPs according to the relevant regulations.

3 Exhibit 13-20, Bupa South Hobart Case Study Tender Bundle (Tender Bundle), Tab 176

[BPA.001.109.0015].


5 Exhibit 13-22 [WIT.0558.0001.0001], Statement of Dr Elizabeth Alice Monks dated 31 October 2019 at

.0006.

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11 BMOC 1 was implemented at Bupa South Hobart in or around January 2016.6 While

changes were made to it subsequently, elements of BMOC 1 continue to remain in place

at Bupa South Hobart today, particularly the presence of Dr Monks as the GP.

Increased financial pressure

12 Over the course of 2016 and 2017 it became apparent that aspects of BMOC 1 were

financially unsustainable. Further, each General Manager had been given significant

autonomy in the implementation of BMOC 1 having regard to the occupancy and acuity of

the care home. As Ms Cooper notes in her evidence, some General Managers exercised

that discretion to increase staffing and introduce new roles (beyond those contemplated

by BMOC 1), which significantly impacted the operating costs of BMOC 1 in a manner

that was not anticipated at the time of its implementation (although this did not occur at

Bupa South Hobart).7

13 These financial challenges were not assisted by funding reforms introduced by the

Commonwealth Government over the period from 2013 to 2017, which in composite had

the effect of significantly reducing the funds available to fund BMOC 1. These funding

reforms are summarised in the table below and have previously been referred to in

Bupa’s 8 February 2019 response to the Commission’s Provider Survey.8

Date Funding Announcement

2012-2013 budget Reduction of payments under Aged Care Funding Instrument (ACFI) by $1.6

billion over 5 years

20 March 2013 Resident Contribution Top-up Supplement ceased

1 July 2014 Commencement of the Living Longer Living Better Reforms

1 July 2014 Changes to accommodation supplement - new facilities or facilities that have

been the subject of “significant refurbishment”

6 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [53].

7 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [58(c)].

8 This table was included in Bupa’s 8 February 2019 response to the Commission’s Provider Survey dated 23

November 2018.

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Date Funding Announcement

31 July 2014 Dementia and Severe Behaviours Supplement ceased ($2 million impact per

annum to Bupa)

1 January 2015 Payroll Tax Supplement ceased ($20 million per annum impact to Bupa)

1 January 2015 Aged Care Workforce Supplement ceased

26 June 2015 Amendments to the Subsidy Principles 2014 to include matters on which

determination of accommodation supplement amount may be based.

2015-2016 Mid Year Economic and Fiscal Outlook (MYEFO) 2015-2016 announced

changes to the ACFI that would result in $1.2 billion saving over four years

1 July 2016 Indexation of the Complex Health Care (CHC) halved

1 July 2016 Amendments to the Classification Principles to reduce scores, and therefore

funding, in the CHC domain ($2 million in 2016, $4 million 2017, $6 million in

2018, $8 million in 2019 impact to Bupa)

December 2016 Modified set of 1 January 2017 changes regarding lower scores for some CHC

items, including medication administration, blood pressure measurement and

bandaging for arthritic joints

1 January 2017 Changes to ACFI Criteria from the 2016-17 Budget, including changes to the

eligibility criteria and overall increase to Viability Supplement

June 2017 Changes to indexation of ACFI subsidy rates and supplements ($1.3 million in

2017, $1.3 million in 2018 impact to Bupa)

14 These funding reforms compounded the already significant financial pressure (described

at paragraph 12 above on BMOC 1. In this context, Ms Jan Adams, Managing Director of

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BVAC Aus, reported to board of Bupa ANZ Healthcare Holdings Pty Ltd (the BAHH

Board) in August 2017 that for BVAC Aus:

the financial performance was very challenged for the first four months of the (a)

year;

over the period YTD EBIT was $10m against an expected result of $15m; and (b)

the cost of the reforms, if unmitigated, represent a $12.3m impact to BVAC Aus (c)

revenue in 2017, rising to $44.6m by 2019.9

15 The increased costs of BMOC 1 and the simultaneous decrease in funding ultimately led

to BMOC 1 being reviewed to ensure its ongoing financial viability.10

Dr Haertsch

acknowledged in her evidence that “when you look at aged care generally there is a really

serious issue around viability of aged care homes currently” and “Bupa is like other

homes, where they’ve got to be responsible around, you know, how they manage the

financial aspect to this”.11

16 The changes that eventuated in BMOC 2 were driven by acute and legitimate concerns

regarding the ongoing financial viability of BMOC 1 – in short, Bupa simply could not

afford to continue with BMOC 1 and it needed to take swift measures to address the very

real (and serious) financial pressures being faced by its aged care business to ensure the

ongoing viability of its operations. The changes to BMOC 1 need to be read in that

context, including statements such as those from Mr Burge extracted in Counsel

Assisting’s Submissions at [15].

17 The evidence also records a view within the Operations Teams that some positions that

formed a part of BMOC 1 needed to be reviewed. To that end, in May 2017, BVAC Aus

conducted a survey of General Managers, and some RMs and RSMs, in relation to

BMOC 1 (GM Survey).12

The purpose of the GM Survey was to assist an assessment of

what, if any, changes should be made to BMOC 1. The GM Survey records a series of

“common themes”, including that the responsibilities held by the Clinical Manager and

the Care Manager often overlapped, resulting in both roles performing the same task or

function, and an imprecise delineation and uncertainty for the proper role of those

9 Exhibit 13-20, Tender Bundle, Tab 296, Business Update – Aged Care Australia, [BPA.001.277.0334].

10 Transcript, Carolyn Cooper, 7135:29-46, 7136:01; Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms

Carolyn Cooper dated 22 October 2019 at [58]-[59].

11 Transcript, Maggie Haertsch, 7067:21-28.

12 Exhibit 13-20, Tender Bundle, Tab 211 [BPA.012.012.3443]; Transcript, Linda Hudec, 7028:20-24.

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members of staff.13

These issues were captured by the changes that eventuated in

BMOC 2, described below.

BMOC 2

18 The changes that eventuated into the revised model of BMOC 1 (BMOC 2) were

undertaken as part of a program called Back to Base. The Back to Base program was

designed to transition homes to a revised model that aimed to reduce the operating costs

of the relevant care home, and address the issues of role ambiguity and administrative

responsibilities, without compromising care standards.14

19 The changes contemplated by BMOC 2 were gradually implemented over two phases.

The first phase of BMOC 2 involved the following: the merger of the Clinical Manager and

Care Manager positions into a new role of Clinical Care Manager;15

Bupa stopped

recruiting for GPs; 16

and a policy called “Save a Shift” was introduced whereby the

number of shifts allocated to the staff in the home were reduced, or where a staff member

had taken leave, that shift would not be replaced.17

Save a Shift

20 Save a Shift was implemented at Bupa South Hobart.18

While the stated aim of Save a

Shift was to implement the policy without compromising the quality and safety of care to

Bupa South Hobart’s residents,19

each of Ms Cooper, Ms Hechenberger and Ms Wesols

accepted in their evidence that implementing Save a Shift could have had an impact on

the care provided to residents20

and, with the benefit of hindsight, Bupa accepts that its

application to Bupa South Hobart was misguided. This is particularly for the following

reasons:

13

Exhibit 13-20, Tender Bundle, Tab 211 [BPA.012.012.3443]; Transcript, Linda Hudec, 7028:24-29.


15 This occurred at Bupa South Hobart in October 2017 and one staff member was made redundant: Exhibit

13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [60(a)].

16 This did not affect Bupa South Hobart as Dr Monks was and remains employed in the home: Exhibit 13-38

[WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [60(b)].


18 Transcript, Stephanie Hechenberger, 6992:43-44.


See also Submissions of Ms Stephanie Hechenberger dated 15 December 2019 [RCD.0012.0047.0001] at

[4.15].

20 Transcript, Stephanie Hechenberger, 6992:20-24; Transcript, Carolyn Cooper, 7137:13.

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Bupa South Hobart has historically been difficult to resource adequately21

as the (a)

market for available potential experienced staff in South Hobart is limited. This

has resulted in recruiting staff in the care home who have not always had

suitable levels of clinical experience. It has consistently put pressure on the

home.22

The environment and physical layout of the care home (three separate buildings (b)

across multiple levels)23

creates unique challenges for ensuring appropriate

levels of staffing. This does not appear to have been appropriately understood

by the General Manager and those who had responsibility for making

operational decisions about Bupa South Hobart, as the roster did not appear to

sufficiently address the need to have appropriate levels of staff, with the

necessary skills, to manage the environment and acuity of the care home.24

Project James

21 The second phase of BMOC 2 was a reduction in the number of Registered Nurses and

Enrolled Nurses, and their hours, without compromising the care to residents. This was

known as Project James.

22 The process of implementing Project James at Bupa South Hobart commenced from April

2018 and was completed by around 30 July 2018.25

During the period that Project James

was in place at Bupa South Hobart, the care home rostered on an additional Clinical Care

Manager.26

This additional clinical staff member indicates that Bupa South Hobart was

operating on a roster model that was not consistent with that contemplated by Project

James. This was known as an “exemption” which had been granted by the Operations

Team in the support office to the then General Manager to include an additional clinical

staff member on its roster.27

It was Ms Cooper’s evidence that this indicates a recognition

that the combination of the unique layout, environment and acuity of the residents of

21

See also Submissions of Ms Stephanie Hechenberger dated 15 December 2019 [RCD.0012.0047.0001] at

2.4.


23 Exhibit 13-25 [WIT.0444.0001.0001], Statement of Ms Elizabeth Anne Wesols dated 22 October 2019 at

[16(a)]; Transcript, Elizabeth Monks 6924:6-11. See also the Submissions of Ms Stephanie Hechenberger dated 15 December 2019 [RCD.0012.0047.0001] at [2.5].

24 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [130(d)].

25 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [150];

[153].


27 Exhibit 13-20, Tender Bundle, Tab 181 [BPA.011.006.0438].

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Bupa South Hobart required additional staff to be rostered on in order to ensure that the

care needs of the residents were not being compromised.28

23 Nevertheless, with the benefit of hindsight, Bupa acknowledges that the development and

implementation of Project James, coupled with the environment, layout and acuity of the

residents of the care home, placed unnecessary pressure on the staff in the care home

and in doing so contributed to the instances of substandard care that were provided to

some residents and their families.29

The rostering policies under Project James or Save

a Shift are not policies that Bupa would endorse now, or in the future.30

Remediation at Bupa South Hobart

24 Bupa acknowledges that the roster implemented in any care home needs to provide an

appropriate skill mix, and the right number of staff rostered on, to meet the acuity,

environment and occupancy of the relevant care home. This ensures that residents

receive the quality of care and quality of life that they rightly deserve.

25 Bupa accepts that the policies of Save and Shift and Project James, as implemented at

Bupa South Hobart, did not appropriately take into account those matters and that it could

have contributed to incidents of substandard care at the care home.31

However, Bupa

rejects the assertion in Counsel Assisting’s Submissions at [79] that it may not have

“learned the true lessons of the 2016-2018 period” on the basis of its subsequent

approach to rostering.

2019 Roster Proposal

26 Counsel Assisting’s Submissions raise concerns with 2019 Roster that mischaracterise

its development, implementation and overall purpose. 32

The 2019 Roster Proposal

evidences that Bupa has taken steps to ensure the care home is appropriately and

adequately resourced to meet the needs of its residents and their families.

27 Counsel Assisting’s Submissions assert that the 2019 Roster was developed on the basis

of the 2018 StewartBrown Aged Care Performance Survey (2018 StewartBrown

Survey) with a view to achieving better financial performance as Bupa was

benchmarking itself against the ‘First 25%’ of financially performing homes. This is

incorrect.

28

Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [160].

29 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [163]-

[164].

30 Transcript, Carolyn Cooper, 7137:01-47.


32 In particular, Counsel Assisting’s Submissions at [71]-[79].

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28 Ms Cooper stated in her evidence33

that a roster should be developed so that it balances

a number of factors:

the acuity of the residents in the care home; (a)

the skill requirements within the available staff profile; (b)

annual leave and training requirements which will impact the availability of staff; (c)

the environment and layout of the home; and (d)

the full time equivalent budget. (e)

29 Each of the above factors informed Ms Cooper’s development of the 2019 Roster (and its

application to Bupa South Hobart) which was designed with Ms David Webb (Head of

Operations) and Ms Samantha Matheson (Head of Commercial Finance).34

Ms Cooper

was also informed in the development of the 2019 Roster by her 40 years of experience

in the health care industry across both Australia and New Zealand (with several of those

being in the aged care industry).35

30 In setting the 2019 Roster, the 2018 StewartBrown Survey was merely a reference tool to

determine what Bupa’s competitors were providing in terms of direct care hours. As

recognised in the background paper prepared by Professor Eager, among others, there is

presently no other objective mechanism to have regard to when considering the most

appropriate staffing levels in the aged care industry in Australia.36

In circumstances where

it was seen as becoming increasingly difficult to remain financially sustainable at the

Average facility level,37

and the sector is continuing to experience significant financial

pressure,38

the direct care hours of the ‘First 25%’ of homes (not providers) provide

relevant considerations as to the sustainability of any roster proposal.

31 Ms Cooper determined that the roster should set a minimum of 2.5 direct care hours

(being just above the ‘First 25%’ of facilities in the StewartBrown Survey). At Bupa South

Hobart, Ms Cooper approved a warranted variation to the 2019 Roster that would provide

33

Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [162].



36 Eagar, K et al, How Australian residential aged care staffing levels compare with international and national

benchmarks, October 2019 at 9.

37 Exhibit 2-86, Adelaide Hearing 2, StewartBrown ACFPS Sector June 2018 [GRA.0001.0001.0532] at .0546;

Exhibit 13-20, Tender Bundle, Tab 295 [RCD.9999.0273.0001] at .0006 and .0020.

38 Exhibit 2-86, Adelaide Hearing 2, StewartBrown ACFPS Sector June 2018 [GRA.0001.0001.0532] at .0539;

Exhibit 13-20, Tender Bundle, Tab 295 [RCD.9999.0273.0001] at .0005.

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3.0 direct care hours per resident per day. In addition, many of Bupa’s care homes have

been granted similar variations to the 2019 Roster (all in the nature of increases).39

32 Using the 2018 StewartBrown Survey as a reference tool demonstrates that Bupa’s

starting point was to provide more direct care hours than the First 25% of financially

performing homes surveyed in Australia, and in respect of Bupa South Hobart,

significantly more than that minimum.

33 Counsel Assisting’s suggestion that the implementation of the 2019 Roster at Bupa is

evidence of continuing desire to reduce staffing levels is incorrect. 40

It ignores several

aspects of the evidence presented to the Royal Commission:

First, the cogent evidence provided by Ms Cooper in relation to the factors she (a)

recognised through her 40 years of experience as important in the development

of the 2019 Roster. This did not relevantly include a desire to cut staff.

Secondly, the evidence provided to the Royal Commission by Ms Davida Webb (b)

— who in her former role as Head of Operations was involved in the

development of the 2019 Roster with Ms Cooper41

. Ms Webb rejected Counsel

Assisting’s suggestion that Bupa had a desire to reduce staffing levels in the

2019 Roster.42

Thirdly, that Bupa South Hobart continues to operate on the roster that was (c)

approved on 1 November 2018 (when an additional 33.5 direct care hours to

the roster) in response to the sanction.43

Even though the sanction has been

lifted, these hours have been kept on the roster to ensure that the remediation

of the care home and the measures put in place are sustained.

Fourthly, an additional Clinical Care Manager and additional nurse shift in the (d)

Court Community has been recently approved.44

34 The implementation of the current roster at Bupa South Hobart should be acknowledged

and recognised as a positive step by Bupa, particularly given the current financial strain

across the aged care sector that is part of the “ever present reality” facing providers such

39

Transcript, Carolyn Cooper, 7147:46-7148:26.

40 Counsel Assisting’s Submissions at [112].


42 Transcript, Ms Davida Webb, 7032:25-46.


44 Transcript, Elizabeth Monks, 6939:41-42.

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as Bupa. 45

Professor Eager acknowledges as much in her evidence in the Melbourne

Hearing observing that “[i]t is clear from the analysis and the evidence being presented

to the Commission that there is a need for additional investment in care funding, the

majority of which is required to improve the staffing mix and to increase staffing levels to

an acceptable standard”.46

35 Bupa hopes that the Commonwealth Government, through the recommendations of this

Royal Commission, addresses the many challenges that are presented by the current

funding arrangements.

IV. CLINICAL GOVERNANCE AND SOUTH HOBART

36 In this section of the submissions, Bupa outlines the clinical governance framework in

place during the implementation of BMOC 2 and responds to concerns raised in Counsel

Assisting’s Submissions regarding the application of that framework to Bupa South

Hobart.

37 During the hearing, the Royal Commission heard evidence from:

members of the Operations Team at the relevant time (Ms Webb, Ms (a)

Hechenberger, and Ms Wesols); and

members of the CSI Team at the relevant time (Ms Hudec and Ms Cooper).47

(b)

38 Each of the above had a role within the clinical governance framework at Bupa South

Hobart during the Relevant Period.

39 The General Manager of Bupa South Hobart during the BMOC 2, Project James, the

October Site Report and the sanction was called to give evidence but did not attend.48

The General Manager was supported by a leadership team of both clinical and non-

clinical staff, which included the GP (at all times Dr Libby Monks), the Clinical Care

Manager (or Care Managers and Clinical Managers), the Chef, the Maintenance Manager

and the Business Administrator (leadership team).49

The Royal Commission heard

evidence from Dr Monks.

45

Exhibit 2-86, Adelaide Hearing 2, StewartBrown ACFPS Sector June 2018 [GRA.0001.0001.0532] at .0536, 0539; Exhibit 13-20, Tender Bundle, Tab 295 [RCD.9999.0273.0001] at .0006.

46 Exhibit 11-2 [WIT.0459.0001.0001], Statement of Professor Kathleen Eagar dated 4 October 2019 at [53].

47 Ms Cooper was in the role of acting Head of CSI during February 2019 to April 2019 while a replacement

was recruited.

48 Mr Neal’s statement was tendered by Counsel Assisting: Exhibit 13-41 [WIT.0557.0001.0001], Statement of

David Ashley Neal dated 4 November 2019.


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40 The evidence of each of these witnesses related to the processes in place at Bupa South

Hobart to assess and monitor the quality and safety of care, implement measures in

response, and the extent to which these processes were followed during the BMOC 2

Period in particular.

Responsibilities of the Operations Team and CSI Team

41 Before addressing the submissions of Counsel Assisting on the Clinical Governance

Framework, the respective responsibilities of the CSI and Operations Teams are set out

below.

42 The CSI Team had responsibility for the following:

Conducting safety assurance, mock audits, clinical governance reviews and (a)

undertaking complaints management.50

Members of the CSI Team would assist

in remediating any clinical and compliance issues as promptly as possible

through assisting the care home with the creation of an action plan. However,

as described below, responsibility for implementation of that action plan sat with

the Operations Team.

Providing support to the care home staff in managing resident safety, quality (b)

assurance, (including the development of clinical policies and procedures),

clinical management, nurse education and professional development.51

Reviewing the processes and procedures set out in the clinical documentation (c)

governing the care homes to ensure these are appropriately implemented and

comply with the relevant standards. This was particularly the case in respect of

work instructions on the Bupa Management System.52

Providing reports to the Board of BACPL, the BVAC Aus Clinical Governance (d)

Committee and the BVAC Aus Risk & Governance Committee on the

performance and progress of Bupa’s care homes from a clinical and compliance

50

Transcript, Linda Hudec, 7015:05-23; Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [43(c)]; Exhibit 13-42 [WIT.0553.0001.0001], Statement of Ms Maureen

Berry dated 30 October 2019 at [17(b)].

51 Transcript, Linda Hudec, 7015:10-27; Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn

Cooper dated 22 October 2019 at [43(a)].

52 Transcript, Linda Hudec, 7015: 27; Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper

dated 22 October 2019 at [43(b)]; Exhibit 13-42 [WIT.0553.0001.0001], Statement of Ms Maureen Berry dated

30 October 2019 at [17(a)].

RCD.0012.0050.0014

page 15

perspective, including care homes undergoing remediation as a result of a

sanction issued by the Department of Health. 53

From time to time, providing updates and escalating issues to the COO during (e)

the period of the Combined BVAC Executive Leadership Team (ELT).54

Liaising with the Aged Care Quality and Safety Commission and the (f)

Department of Health in relation to any compliance issues at the care homes,

including care homes under sanction and those which have been deemed to

have not met certain accreditation standards.55

43 The Operations Team had responsibility for the following:

Monitoring and implementing remedial plans of action, in collaboration with the (a)

CSI Team, to address significant problems that had been identified by the CSI

Team in the course of an internal review of a care home.56

Ensuring compliance with the Accreditation Standards by providing oversight, (b)

leadership and support to the Regional Managers (RM) and Regional Support

Managers (RSM) who in turn supported and monitored the General Manager

and the leadership team in the care home.57

Conducting weekly meetings with the RMs to ensure that the relevant care (c)

homes in their region were conducting and responding to required audits such

as the BMS Self-Audits or the Clinical Care Audits and responding to the

internal reviews and mock audits carried out by the CSI Team.58

Managing responses to complaints that had been escalated to the Head of (d)

Operations or the CSI Team. The Head of Operations would meet directly with

the staff member, resident, or their representative to seek to listen to and

resolve their concerns.59

53

Transcript, Linda Hudec, 7015:18-19; Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn

Cooper dated 22 October 2019 at [43(d)(2)].

54 Transcript, Linda Hudec, 7015:10-12; Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn

Cooper dated 22 October 2019 at [43(d)(3)].

55 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [43(e)].

56 Exhibit 13-28 [WIT.0608.0001.0001], Statement of Ms Davida Webb dated 4 November 2019 at [50]; [93].

57 Exhibit 13-28 [WIT.0608.0001.0001], Statement of Ms Davida Webb dated 4 November 2019 at [53].

58 Exhibit 13-28 [WIT.0608.0001.0001], Statement of Ms Davida Webb dated 4 November 2019 at [91].

59 Exhibit 13-28 [WIT.0608.0001.0001], Statement of Ms Davida Webb dated 4 November 2019 at [66]-[67].

RCD.0012.0050.0015

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Mock Audits

44 The Royal Commission heard evidence regarding the four Care Home Clinical Mock

Audits (Mock Audits).60

These demonstrated that the CSI Team had assessed Bupa

South Hobart as having not met the relevant Accreditation Standards in various respects

at the relevant points in time. Dr Monks had also raised concerns (described below at

paragraphs 55-58), which were broadly consistent with some of the findings in the Mock

Audits.

45 Bupa acknowledges that the Mock Audits identify repeated internal assessments that

Bupa was not meeting the Accreditation Standards. A significant body of work,

summarised in Annexure C, was carried out at the time and in response to the issues

identified in each of the Mock Audits.61

However, the pattern of repeated poor results

suggests that whilst issues at the care home were identified, Bupa’s responses to those

issues were not sustained. In addition, as acknowledged by Ms Cooper, too much

reliance was placed upon the fact that in Bupa South Hobart was assessed to have met

the relevant Accreditation Standards in assessments undertaken by the Quality Agency

between the November 2014 Mock Audit and the July 2018 Mock Audit.62

46 Counsel Assisting submits that the evidence around the October 2016 Mock Audit

suggests that Ms Hechneberger and Ms Wesols did not fully understand the purpose of a

Clinical Governance Review (CGR) and how it was conducted.63

Bupa submits that this is

incorrect and makes the following submissions in response:

whilst a CGR was considered “deep dive” on issues of clinical governance, both (a)

Ms Wesols and Ms Hechenberger gave evidence of the benefits of the Mock

Audit as providing a more comprehensive review of the home64

which was

60

Exhibit 13-20, Tender Bundle, Tab 2 [BPA.001.197.0001]; Tab 6 [BPA.057.006.6321]; Tab 10 [BPA.019.004.2059]; Tab 69 [BPA.001.033.8415].

61 See also Exhibit 13-25 [WIT.0444.0001.0001], Statement of Ms Elizabeth Anne Wesols dated 22 October

2019 at [47]; [55]-[56]; [68]-[73].

62 20 May 2015: Exhibit 13-20, Tender Bundle, Tab 192 [BPA.001.240.0001]; Tab 193 [BPA.001.240.0024];

Exhibit 13-25, Statement of Ms Elizabeth Anne Wesols dated 9 October 2019 [WIT.0444.0001.0001] at [49]; 25 February 2016: Exhibit 13-20, Tender Bundle, Tab 195 [BPA.057.006.2073]; Exhibit 13-42, Statement of Ms Maureen Berry dated 30 October 2019 [WIT.0553.0001.0001] at [77]; 17 August 2016: Exhibit 13-20, Tender Bundle, Tab 8 [CTH.4018.2000.0312]; Exhibit 13-38, Statement of Ms Carolyn Cooper dated 22 October 2019 [WIT.0444.0002.0001] at [97]; Exhibit 13-25, Statement of Ms Elizabeth Anne Wesols dated 9 October 2019 [WIT.0444.0001.0001] at [57]. 29 August 2017: Exhibit 13-38, Statement of Ms Carolyn Cooper dated 22 October 2019 [WIT.0444.0002.0001] at [98]; Exhibit 13-25, Statement of Ms Elizabeth Anne Wesols [WIT.0444.0001.0001] dated 9 October 2019 at [74].

63 Counsel Assisting’s Submissions, [70].

64 Transcript, Elizabeth Wesols, 6987:44-47; Transcript, Stephanie Hechenberger, 6988:4-8. See also

Submissions of Stephanie Hechenberger dated 15 December 2019 [RCD.0012.0047.0001] at [5.6] and [5.7].

RCD.0012.0050.0016

page 17

necessary in circumstances where Ms Wesols had only recently been

appointed Acting General Manager;

as set out at paragraph 56 below, Dr Monks accepts that the concerns that (b)

contributed to the request for the Mock Audit in September 2016 were satisfied

by the significant body of work undertaken by Ms Wesols and Ms Hechenberger

around this time in response to issues identified in the home through the Mock

Audit process; and

Moreover, it is the responsibility of the RM (not the RSM) to request a CGR. Ms (c)

Hechenberger did request a CGR in response to concerns raised by Dr Monks

in 2017,65

but the request was declined because a mock audit was scheduled

for December 201766

which was then postponed until July 2018 as the home’s

accreditation period was extended by the Quality Agency as it had assessed

Bupa South Hobart as demonstrating consistent and sustained compliance with

the Accreditation Standards.67

Bupa accepts that it would have been

appropriate to reconsider whether a CGR or mock audit should have been

conducted at the end of 2017 given Dr Monks’ concerns and the care homes

historical issues identified in earlier Mock Audits, notwithstanding the extension

of the accreditation period by the Quality Agency.

47 Bupa accepts that the governance structure and the Clinical Governance Framework in

place to support Bupa South Hobart were deficient insofar as instances of substandard

care were able to manifest (and audit issues were able to repeat) over the Relevant

Period. Ms Cooper accepted this in her evidence.68

The effective communication of

information between each level of clinical governance – particularly between the General

Manager, the leadership team, the RSM, the RM, the CSI Team and the Operations

Team – is integral as the passage of that information ensures any issues identified in

the care home can be escalated appropriately, and any response sustained, so that the

quality and safety of care is not compromised. Bupa has learned a number of lessons

about this in the context of Bupa South Hobart:

65

Exhibit 13-20, Tender Bundle, Tab 37 [BPA.013.031.4294].


67 Exhibit 13-20, Tender Bundle, Tab 216 [BPA.001.202.0337]. The Quality Agency was seeking to

redistribute the dates for site audits for a number of services that have demonstrated consistent and sustained compliance with the Accreditation Standards to achieve a more level distribution of the timing of accreditation site audits over a three year period.

68 Transcript, Carolyn Cooper, 7142:04.

RCD.0012.0050.0017

page 18

The General Manager and the leadership team are central in providing (a)

appropriate leadership to the staff in the care home. On reflection, it does not

appear that the General Manager provided appropriate leadership in the care

home through implementing appropriate and safe systems and processes in

Bupa South Hobart that BVAC Aus had put in place through work instructions

and other measures of the CSI Team.69

The function of the CSI Team and Operations Team is also critical. The (b)

importance of strong lines of communication and clear lines of responsibility

between these teams can be seen from the respective responsibilities of each

team set out at paragraphs 42 and 43.70

It is clear that this did not exist in

respect of Bupa South Hobart at the time of, and prior to, the October 2018 Site

Report and the sanction.

The CSI Team and the Operations Team did not realise as quickly as they (c)

perhaps ought to have done that the processes and systems within Bupa South

Hobart were not aligned with those set by Bupa more generally, and that staff

appeared to have had limited knowledge or awareness of Bupa’s systems and

processes. These areas have been the subject of significant remediation since

the sanction was imposed on Bupa South Hobart, as described at paragraph 48

below.

Remediation of clinical governance issues

48 Since the sanction, Bupa has introduced a number of initiatives and changes relating to

clinical governance, including:

A revised Bupa ANZ Clinical Governance Framework, Clinical Governance (a)

Policy and Clinical Governance Committee terms of reference has been

adopted. Together they are designed to ensure that each care home, including

Bupa South Hobart, is compliant with the new Aged Care Quality Standards

(Quality Standards) that came into effect on 1 July 2019.71

A number of corporate governance arrangements have been implemented (b)

which aim to strengthen clinical governance:

69

Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [130(a)].

70 Transcript, Stephanie Hechenberger, 6969:04-30; Exhibit 13-26 [WIT.0607.0001.0001], Statement of Ms

Stephanie Hechenberger dated 3 November 2019 at [13].


RCD.0012.0050.0018

page 19

(1) the Head of CSI has been replaced by a more senior Clinical Service

Director role reporting directly to the Managing Director of BVAC

Aus.72

(2) Separate Executive Leadership Teams have been established or the

BVAC Aus business unit and the BVAC NZ business unit73

, however

the overarching ANZ ELT remains in place.74

(3) The creation of the new role of Resident Experience and Community

Engagement Director reporting to the Managing Director of BVAC

Aus.75

There has been a re-organisation and re-design of the CSI Team to provide (c)

increased clinical support for the homes. This includes the following changes:

(1) CSI is now known as the Clinical Services and Compliance Team

(CSC Team).

(2) An increase in:

(A) numbers of clinical quality partners from 8 to 13 to directly

support care homes in a partnership model rather than

support model as previously designed;76

and

(B) the number of educators from 4 to 7 to ensure sufficient

educator resources for all 13 regions.77

(3) The CSC Team provides updates to the Compliance Remediation

Committee and to the BVAC Aus ELT.78

(4) The establishment of the Quality and Safety Taskforce.79

72

Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [36(d)].

73 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [36(e)]

74 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [36(e) and

(h)].

75 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at

[187(a)(5)].

76 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [45(d)].

77 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [45(e)].

78 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [36(g)].

79 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [73]. This

team is referred to as the Quality and Safety Taskforce (QST) in Ms Cooper’s evidence but Bupa notes that

the name of the team fulfilling the role of this Taskforce will be amended going forward.

RCD.0012.0050.0019

page 20

The Operations Team has been re-organised to provide increased operational (d)

support. This includes the following changes:

(1) the roles of Chief Operating Officer and Head of Operations have

been removed and replaced by two Regional Directors.80

These

positions have been created to enable the direct partnership model

across the regions.81

(2) The regions for RMs and RSMs have been re-distributed to reduce

the number of homes for which they are individually responsible.82

The Transition Team83

has been further enhanced to monitor care homes after (e)

a sanction has been lifted for the purpose of maintaining a heightened level of

supervision and control over the care home. This is to ensure that the critical

elements which support the embedding of compliance, clinical safety, workforce

practice improvement and a culture of continuous improvement are maintained

post a sanction being lifted. The Transition Team is presently working with Bupa

South Hobart.84

V. ORGANISATIONAL CULTURE

49 Bupa recognises that the culture within a home (and within an organisation as a whole) is

in part shaped by way that comments and complaints are managed. This includes the

processes that are in place to invite, capture and respond to any such feedback. It is the

responsibility of the General Manager and the leadership team within the home, with the

assistance of the support office, to embed a culture that ensures residents, their families

and staff at Bupa South Hobart, are heard, and any comments or complaints they provide

are acted upon in a timely manner and resolved to their satisfaction and seen as

opportunities for continuous improvement.

50 Bupa accepts that in the past there have been instances at Bupa South Hobart where

concerns and complaints raised by residents, their families as well as staff members have

not been addressed, or have been addressed inadequately or inappropriately. Further, it

is accepted that there were times when the culture at the home was such that residents,

their families and staff members did not feel encouraged or supported to provide

80

Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [36(c)].


82 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [38(c)-(d)].



RCD.0012.0050.0020

page 21

comments and complaints. Bupa accepts that the failure to adequately address

comments and complaints is itself an instance of substandard care at Bupa South Hobart,

as well as a contributing factor to other observed areas of substandard care within the

home.85

Comments and complaints: residents

51 The Royal Commission heard evidence from family members of four residents who have

been cared for during the Relevant Period at Bupa South Hobart.86

On each occasion

when comments and complaints were raised by the families of the above residents, Bupa

acknowledges that the staff at Bupa South Hobart failed to address these matters

appropriately, or at times at all. Bupa acknowledges that the manner in which the

comments and complaints were responded to by the General Manager, the GP and other

members of the leadership team in Bupa South Hobart caused significant frustration and

undue stress to these families at what was a very difficult time. The documents before the

Commission87

indicate that on a number of occasions the issues raised by these families

were not dealt with appropriately by the General Manager, the GP, members of the

leadership team, or the support office. These documents indicate conduct that is wholly

inconsistent with Bupa’s expectations as to the manner in which comments and

complaints should be managed in a care home. It was and remains Bupa’s policy that

receiving and acting on feedback from residents and their families is central to ensuring

quality of care and safety in the home is maintained.88

52 Since Bupa South Hobart was sanctioned, significant remediation measures have been

implemented to ensure that residents and their families have appropriate and effective

methods to ensure that comments and complaints are managed appropriately and a

resolution is achieved their satisfaction. These measures are set out at paragraphs 59-

64 below.

85

Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [129(a)];

[130(f)].

86 Exhibit 13-35 [WIT.0584.0001.0001], Statement of UQ dated 29 October 2019; Exhibit 13-36

[WIT.0585.0001.0001], Statement of US dated 1 November 2019; Exhibit 13-24 [WIT.0582.0001.0001], Statement of Ms Merridy Eastman dated 31 October 2019; Exhibit 13-21 [WIT.0583.0001.0001], Statement of

Ms Diane Daniels dated 30 October 2019.

87 Exhibit 13-20, Tender Bundle, Tab 16 [BPA.055.005.2895]; Tab 49 [BPA.076.003.4112]; Tab 50

[BPA.055.003.6945]; Tab 53 [BPA.055.003.5499]; Tab 61 [BPA.055.006.6657]; Tab 62 [BPA.055.006.5759]; Tab 63 [BPA.055.003.0002].

88 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [212(f)].

RCD.0012.0050.0021

page 22

Comments and complaints: staff

53 The Commission heard evidence of Dr Monks in relation to concerns raised between

2016 and 2018 as to the quality and safety of care that was being implemented at Bupa

South Hobart.89

Dr Monks’ evidence was that these concerns were not appropriately

listened to and managed by members of the support office and the members of the BVAC

ELT.90

Bupa submits that whilst actions were taken in response to individual concerns

raised by Dr Monks, the pattern of concerns raised could have, and should have, been

addressed with sustained measures that were monitored and managed in a manner that

ensured they were being embedded in the care home. Bupa accepts that this was not

done and is a contributing factor to the consistency of the concerns raised by Dr Monks,

and other staff in the care home, as identified in the October 2018 Site Report.

54 At paragraph 59 to 64 below Bupa has summarised the remediation measures that have

been implemented to strengthen Bupa’s processes to manage staff feedback. Annexure

B also sets out the specific measures that have been implemented at Bupa South Hobart.

September 2016

55 On 15 September 2016, Dr Monks raised concerns about the care at Bupa South Hobart.

A review was undertaken by Ms Wesols as RSM.91

Shortly afterwards, Ms Wesols was

appointed Acting General Manager and:

took immediate steps92

to start to rectify a clinical roster that was in an (a)

“unsustainable state”;93

requested a mock audit be carried out by the CSI Team;94

and (b)

formulated an action plan following the release of the results of the Mock (c)

Audit.95

89

Exhibit 13-22 [WIT.0558.0001.0001], Statement of Dr Elizabeth Monks dated 31 October 2019.

90 Transcript, Elizabeth Monks, 6926:36.

91 Exhibit 13-25 [WIT.0444.0001.0001], Statement of Ms Elizabeth Wesols dated 9 October 2019 at [60]-[63];

Exhibit 13-20, Tender Bundle, Tab 9 [BPA.061.010.0150]; Tab 196 [BPA.001.246.0001].

92 Exhibit 13-20, Tender Bundle, Tab 197 [BPA.016.027.2783]; Exhibit 13-25 [WIT.0444.0001.0001],

Statement of Ms Elizabeth Wesols dated 9 October 2019 at [65]-[66]; Transcript, Stephanie Hechenberger, 6982:26-46.

93 Transcript, Stephanie Hechenberger, 6982:21. See also Submissions of Ms Stephanie Hechenberger dated

15 December 2019 [RCD.0012.0047.0001] at [2.2].

94 Transcript, Stephanie Hechenberger, 6928:20-24; Exhibit 13-25 [WIT.0444.0001.0001], Statement of Ms

Elizabeth Wesols dated 9 October 2019 at [66].

RCD.0012.0050.0022

page 23

56 The significant work undertaken by Ms Hechenberger and Ms Wesols at the home at this

time was accepted by Dr Monks as having resolved her concerns.96

November 2017

57 Dr Monks raised concerns about the care at Bupa South Hobart to her direct report, Dr

Tim Ross in November 2017.97

Ms Wesols, as RSM, undertook a review of care at the

home on the day the complaint was made.98

Based on her review Ms Wesols formulated

a series of recommendations to improve care within the home. 99

Dr Monks was also

asked for more detailed information on the residents Dr Monks had concerns about100

and it was concluded that Dr Monks’ concerns had been addressed.101

March 2018

58 Dr Monks raised further concerns in March 2018 following a GP Forum.102

These

concerns were raised directly with the Managing Director of BVAC Aus, Ms Jan Adams

and then following clarification from Dr Monks on 19 March 2018,103

escalated to the

then Chief Operations Officer, Ms Maureen Berry104

who requested a review. The

outcome of this review did not reveal any areas of concern,105

however, Bupa accepts

that the July 2018 Mock Audit results suggest that analysis of this data did not represent

a comprehensive review of the state of the home in response to Dr Monks concerns.

95

Exhibit 13-20, Tender Bundle, Tab 10 [BPA.019.004.2059]; Tab 13 [BPA.061.009.8218]; Tabs 198, 200-209 [BPA.001.197.0025] [BPA.001.197.0027] [BPA.001.197.0028] [BPA.001.197.0029] [BPA.001.197.0032] [BPA.001.197.0033] [BPA.001.197.0034] [BPA.001.197.0035] [BPA.001.197.0217] [BPA.001.197.0219].

96 Transcript, Elizabeth Monks, 6928:28-46; Exhibit 13-20, Tender Bundle, Tab 182 [BPA.019.004.0593].

97 Exhibit 13-22 [WIT.0558.0001.0001], Statement of Dr Elizabeth Monks dated 31 October 2019 at 0023-

0027; Exhibit 13-25 [WIT.0444.0001.0001], Statement of Ms Elizabeth Wesols dated 9 October 2019 at [76]; Exhibit 13-27 [WIT.0607.0002.0001], Statement of Ms Stephanie Hechenberger dated 12 November 2019 at

[12]-[25].

98 Exhibit 13-25 [WIT.0444.0001.0001], Statement of Ms Elizabeth Wesols dated 9 October 2019 at [77]-[78];

Exhibit 13-20, Tender Bundle,Tab 269 [BPA.001.245.0001].




102 Exhibit 13-22 [WIT.0558.0001.0001], Statement of Dr Elizabeth Monks dated 31 October 2019 at 0027-

0035; Exhibit 13-20, Tender Bundle, Tab 58 [BPA.010.013.6927].




RCD.0012.0050.0023

page 24

Remediation at Bupa South Hobart

59 Bupa acknowledges that the processes for inviting, capturing and responding to

comments and complaints from residents, their families and staff required

significant improvement, particularly in relation to the culture within Bupa South Hobart as

to the appropriate processes for listening to and managing comments and complaints.

Bupa recognises that any complaint should be seen as and therefore responded to as an

opportunity for continuous improvement.

60 Since the sanction, Bupa has implemented a number of steps to ensure that issues in

relation to culture, and the application of processes at Bupa South Hobart, are

addressed. These are:

Bupa retained Ms Wilson and Dr Webster to carry out a Consumer Engagement (a)

meeting at Bupa South Hobart.106

Ms Wilson and Dr Webster attended the site

for just over 2 hours in November 2018 to meet with residents and their

families.107

Following the visit, Ms Wilson and Dr Webster provided a report to

Bupa on their findings and recommendations.108

It was Ms Carolyn Cooper’s

evidence, interim COO during this period, that the report was integrated into the

remediation activities Bupa has developed to strengthen consumer engagement

across the business.109

A Resident Experience and Community Engagement Director has been (b)

employed in BVAC Aus.110

A Complaints Manager position was also created to

focus on complaints management.111

The role was filled by a former consumer-

adviser advocate.112

The advisors and administrators appointed under the sanction imposed on (c)

Bupa South Hobart assisted with the review of the complaints process at the

Bupa South Hobart both in relation to management of particular concerns

106

Exhibit 13-37 [WIT.0586.0001.0001], Statement of Ms Bethia Wilson dated 29 October 2019.

107 Transcript, Bethia Wilson and Dr Penny Webster, 7113:43-45.



110 Exhibit 13-20, Tender Bundle, Tab 266 [BPA.001.233.0006] at 0009; Exhibit 13-38 [WIT.0444.0002.0001],

Statement of Ms Carolyn Cooper dated 22 October 2019 at [187(a)(5)].



RCD.0012.0050.0024

page 25

raised113

and providing recommendations of how to improve engagement of

residents and their families at the home including for example the establishment

of a resident committee.114

Blackhall and Pearl was recruited to undertake a targeted review of complaints (d)

management within Bupa South Hobart. A report was prepared and provided to

Bupa on this that formed the basis of many of the measures that have since

been implemented.115

A new complaints management framework and policy was implemented in (e)

BVAC Aus that applies to Bupa South Hobart.116

61 As a result of the above, targeted measures have been implemented at Bupa South

Hobart as set out at Annexure B. These include:

education and training of staff in the use of the confidential log system for the (a)

recording of complaints and comments;

publication of newsletters for care recipients and families during the period for (b)

which the home was under sanction;

care recipient communique that addresses the processes of lodging a complaint (c)

and/or logging a maintenance request has been published;

a display folder has been placed at the sign-in desk at the entry to each of the (d)

towers which sets out the complaint process at the home;

staff, residents and their families can now use the Essendex messaging system (e)

to communicate any issues or concerns they have directly to the care home.

62 In addition, the measures described at paragraphs 48(c)-48(d) above to expand the size

of the CSC Team (including the introduction of quality partners) and redistribute and

reduce the number of regions for RMs or RSMs have increased the on-the-ground

support for homes, and will assist in both embedding the remediation processes

described above and providing oversight of the culture within Bupa South Hobart.

113

Exhibit 13-32 [WIT.0467.0001.0001], Statement of Ms Cynthia Payne dated 6 October 2019 at [45]; [51]-

[52] and [60].

114 Transcript, Cynthia Payne, John Engeler and Maggie Haertsch, 7058:5-7059:23.

115 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [192]-

[194]; Exhibit 13-20, Tender Bundle, Tab 155 [BPA.054.007.2374].

116 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [194];

Transcript, Carolyn Cooper, 7151:16-7152:3.

RCD.0012.0050.0025

page 26

63 As noted above, Bupa acknowledges that the culture within Bupa South Hobart

contributed to the manner that comments and complaints were handled by the General

Manager and the leadership team. It was the evidence of Ms Cooper that one of the

lessons Bupa has learnt from this is that it is essential that employees have both the

appropriate skills and the right attitude, such as empathy and integrity.117

This lesson has

resulted in Bupa implementing a system that tests the attitude of potential employees

during the recruitment process. It is known as of as Care Advantage118

and was a

process that was implemented by Ms Cooper in BVAC NZ and introduced to BVAC Aus

when Ms Cooper became interim COO. The Care Advantage system was used for

recruitment at Bupa South Hobart from January 2019. As this was a matter of interest to

the Commissioners, Bupa has prepared further details of this system in Annexure A to

these submissions.

64 Bupa submits that the change in approach to comments and complaints within the home

is evident from the July 2019 Site Audit Report.119

The Assessment Team recommended

that all four requirements of Standard 6120

had been met.121

65 Bupa acknowledges that in order to better support the operation of Bupa South Hobart,

and homes in similar circumstances, consequential changes were necessary to the

governance structure and compliance function. Bupa has implemented a redesigned

structure to the BACPL Board to strengthen these governance arrangements and, as

such, improve organisational culture in line with Standard 8 of the Quality Standards.

These include:

the adoption of a revised Fit and Proper Persons Policy and Fit and Proper (a)

Persons Framework to ensure that Directors of BACPL and senior managers of

BVAC Aus possess all of the requisite fitness and propriety required to manage

the responsibilities and duties of the key roles to which they are appointed;122

the Board of BACPL and the BVAC ELT have each undertaken specific (b)

education and training on clinical governance and the Aged Care Quality

117

Transcript, Carolyn Cooper, 7124:32-41.

118 Transcript, Carolyn Cooper, 7124:32-7125:37; 7126:22-29.

119 Exhibit 13-20, Tender Bundle, Tab 166 [CTH.4018.2100.0296].

120 Aged Care Quality Standards [CTH.0001.4000.8886] at 8888.

121 Exhibit 13-20, Tender Bundle, Tab 166 [CTH.4018.2100.0296] at 0305-0306.


RCD.0012.0050.0026

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Standards123

to provide a renewed emphasis on the promotion of a culture of

safe, inclusive and quality care for residents. The Board of Bupa’s parent

company has also undergone this training to introduce an additional layer of

scrutiny and oversight, particularly on compliance and clinical care, to the

benefit of residents;124

the creation of a new Head of Risk reporting to the Managing Director of BVAC (c)

Aus;125

the appointment to the BACPL Board of an Independent Non-Executive (d)

Chairman126

(who is also the Chairman of the BAHH Board127

) who has been

part of the BAHH Board for 3 years (and the former Chairman of the Bupa Care

Services New Zealand Limited Board, operating care homes in New Zealand)

with a further Independent Non-Executive Director with relevant expertise also

to be appointed in the new year;

the appointment of three members of the Bupa A&NZ Executive outside of (e)

BVAC Aus who together have significant experience in public and private sector

healthcare, clinical, regulated industries and the aged care sector;128

and

the adoption of a new Charter by the BACPL Board.129

(f)

66 The changes to the BACPL Board and terms of the Charter of the Board (extracts of

which are at Tab 264 of the Tender Bundle) demonstrates the commitment by the BACPL

Board to foster a culture that promotes the quality and safety of care to its residents

whilst at the same time allowing for the proper scrutiny of decisions made by

management that may affect the quality and safety of care.

123

Exhibit 13-20, Tender Bundle, Tabs [210], [261]-[263]. This measure was implemented to be consistent with the requirements of ongoing training and monitoring for Directors and Senior Management under the Fit and Proper Persons Policy [BPA.001.232.0001], the Fit and Proper Persons Framework [BPA.001.232.0026], the Clinical Governance Framework [BPA.001.258.0008] and the Clinical Governance Policy [BPA.001.258.0002].

124 Transcript, Carolyn Cooper, 7129:30-47. This training was undertaken by Cynthia Payne of Anchor

Excellence and aged care specialist, Julie McStay, of Thomson Geer.

125 Exhibit 13-38 [WIT.0444.0002.0001], Statement of Ms Carolyn Cooper dated 22 October 2019 at [35(g)]




129 Exhibit 13-20, Tender Bundle, Tab 264 [BPA.001.217.0003] including extracts at 0013.

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page 28

VI. CONCLUSION

67 Bupa acknowledges that the evidence heard by the Royal Commission demonstrated that

there were occasions on which the level of care and quality of life provided at Bupa South

Hobart was substandard. Bupa regrets that this occurred and has worked hard to ensure

that the home is back into full compliance and continues to provide the quality of life and

quality of care that its residents and their families are entitled to expect. Since 2018,

Bupa has not only identified a number of lessons it can learn from the experience at Bupa

South Hobart but has implemented significant remediation work both at the home itself

and across its 72 homes based on these lessons.

68 Consistent with its focus on continuous improvement, Bupa continues to review the

adequacy of the remediation work outlined above with a view to ensure that the focus

remains on the quality and safety of care provided to its residents and that improvements

in care homes are sustained. That said, without significant review of funding to the

residential aged care sector, the sustainability of provided such care will continue to be

challenging going forward.

Jane Needham SC

Jane Buncle

18 December 2019

RCD.0012.0050.0028

Annexure A

Overview

During the Hobart Hearing, Ms Cooper was asked a number of questions on the use of the ‘Care Advantage’ assessment tool.

For the purposes of assisting the Royal Commission, Bupa has provided further information in response to these questions.

Care Advantage

Introduction

A short summary of the kinds of services provided by Care Advantage and how those services have been implemented at Bupa is set out below.

Care Advantage

Care Advantage is a behavioural screening service that provides psychometric assessments for employees and potential employees of organisations operating within the care sector. The results of these assessments aim to provide organisations with a more complete picture of employees’ (or potential employees’) soft skills and their general suitability for employment that requires the provision of care.

There are four Care Advantage assessments that measure personality traits, cognitive ability, engagement and attitude to work:

Personality/Job Fit assessment – this assessment measures key personality traits and compares them against a benchmark of high performers in the same role. The assessment takes the form of a personality questionnaire comprised of 45 questions and tests the following core personality traits: conscientiousness; likeability; unconventionality (as opposed to rule-orientated); interpersonal skills; and resilience. Care Advantage have also developed two additional scales in response to market demands, being a ‘Good Impression’ (faking) scale, and a ‘Teamwork’ scale.

Attitudes assessment – this assessment comprises 27 questions that assesses whether a person is likely to engage in counter-productive work behaviours by assessing: hostility (aggression); conscientiousness (dependability); integrity (honesty); and a Good Impression scale. The resulting report summarises whether there are areas of ‘Low Concern’, ‘Some Concern’ or ‘Serious Concern’ with respect to those behaviours.

Cognitive assessment – this assessment comprises 30 questions and tests problem-solving and learning speed by assessing verbal, numerical and special reasoning.

Engagement Survey – this assessment comprises 30 questions and measures the level of commitment an applicant has towards their job and employer.

Following an assessment, different reports can be generated to assist employers in making informed hiring decisions and providing guidance to incumbent employees. For example, the Job Fit / Personality report summarises how well an applicant’s personality attributes, based on the outcome of their Personality / Job Fit assessment, match a particular position. The report compares the applicant’s scores relative to the general population, other successful incumbents for a particular job category, and the ‘best’ in a job category. The report can also provide a diagrammatic representation of whether a

RCD.0012.0050.0029

candidate’s score with respect to a personality dimension is ‘good’, ‘ok’ or ‘poor’ when compared to a chosen benchmark or against a basic job category report.

Care Advantage provides other tools to assist in assessing the appropriateness of an applicant’s role, such as an ‘Interview Faking Rating Scale’ which is a questionnaire that provides interviewers with a systematic approach to evaluating interviewee behaviour, particularly in respect of the degree to which the interviewee’s responses were lacking in candour, signifying that their presentation at interview was otherwise disingenuous.

The Care Advantage platform may be customised to suit the particular needs of an organisation in respect of recruitment or employee development. For example, at Bupa, additional matters are generated in reports such as additional interview questions that might be put to an applicant, an on-boarding report for a supervisor, and additional development reports.

Application of Care Advantage at Bupa

The Care Advantage platform is used by Bupa as a tool to influence the culture within the care homes. The platform allows Bupa to ensure that new employees or employees moving into new positions are aligned with Bupa values and particular behavioural traits required by a position. Bupa anticipates that use of the platform will have a positive impact on staff turnover by improving the ability to determine the suitability of a candidate to a particular role.

Bupa obtained unlimited annual licences for Care Advantage services for the Australian Aged Care Business, which commenced in January 2019. Bupa South Hobart commenced using Care Advantage at that time.

Bupa uses Care Advantage to supplement its other processes for the screening and selection of candidates for the following roles: Clinical Care Manager, Registered Nurse, all General Support Officers (including maintenance, the chef, and cooks), and all administrative staff.

When a candidate applies for a position at a Bupa care home, they are required to complete the Care Advantage assessments at an early stage in the process, following the confirmation of a candidate’s working rights, and prior to a telephone conversation with the candidate. In considering the results of the assessment, Bupa is particularly focused on an applicant’s integrity and engagement scores. These results are then used to provide a short list of candidates to be interviewed.

To that end, Bupa has identified certain results that will act as a red flag for potentially undesirable candidates. These results are summarised below:

where the Attitudes assessment indicates an applicant is of ‘Serious Concern’ in the domains of Integrity or Hostility, the applicant is deemed unsuitable and will not progress; and

where an applicant scores ‘Some Concern’ or ‘Serious Concern’ in the domains of Conscientiousness or Good Impression, or ‘Some Concern’ in Integrity or Hostility, the candidate may be progressed, but their results are noted to the hiring manager for further enquiry.

Following the selection of a short list of candidates, the results of the Care Advantage assessment are also used to inform the next steps of the recruitment process – such as the development of questions for face to face interviews.

Introduction of the Care Advantage Assessment tool into the Bupa recruitment process has a positive impact on the culture within a care home by facilitating the selection of the right people for the right jobs.

RCD.0012.0050.0030

Annexure B

Summary of remediation steps implemented at South Hobart1

Remediation step

Standard 1: Expected outcome 1.1: Continuous improvement

1. Implementation of daily management meetings and monthly general staff meetings is completed and

ongoing.

2. Implementation of monthly clinical management meetings as required.

3. Implementation of Registered Nurse meetings and bimonthly lifestyle staff meetings is complete.

4. Purchasing new notice boards. The new boards were placed at the entrance of each of the South Hobart

towers to disseminate information to staff.

5. Review and update of education calendars. Arrangement for these calendars to be implemented for each

month is complete.

Standard 1: Expected outcome 1.3: Education and staff development

6.

Implementation of the GROW education tracking system (GROW). The Business Administrator at Bupa

South Hobart extracts information from GROW and delivers a report to the General Manager (GM) to

identify staff who have overdue mandatory reporting education or training sessions. The GM is then charged

with following up those outstanding sessions with the relevant staff members. If staff do not attend, it

becomes a disciplinary issue managed by the GM.

7.

In or around January 2019, a staff meeting was held to update staff on outstanding mandatory training. A

text message was also issued to staff advising them that they had until 11 February 2019 to complete their

mandatory training or they had to meet with the GM. The training was completed by 11 February 2019.

8.

Implementation of the Bupa Training Matrix is complete. This is a spreadsheet outlining required training for

each staff member. The matrix is updated by the Business Administrator at Bupa South Hobart. A review

and update of education calendars is also implemented for each month.

9.

The Bupa orientation program (Bupa Ignite Induction) was revised and updated in or around April 2019. All

new staff have completed compulsory reporting training.

The Bupa Ignite Induction includes:

an orientation day, involving competency completion and mandatory manual handling, fire safety,

meeting the GM and orientation by relevant staff according to the relevant position; and

three buddy shifts, and more if required.

Standard 1: Expected outcome 1.4: Comments and complaints

10.

Complaints and comments are recorded and updated in a confidential log. Staff have received education

and training in the use of this process and have been instructed and reminded about this process regularly

at staff meetings.

11. Newsletters for care recipients and families are issued fortnightly. As the home is under transition these

were temporarily stopped but were reintroduced in November 2019 on a monthly basis.

1 While the actions summarised in this table were first implemented in response to the Accreditation Standards as they existed before 1 July

2019, these actions are ongoing and being implemented in a manner that is consistent with the new Quality Standards adopted on 1 July 2019.

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Remediation step

12.

The publication of a care recipient communique that addresses the process for lodging a complaint and for

logging a maintenance request is complete. Additionally, a display folder has been placed at the sign in

desk at the entry to each of the Bupa South Hobart towers which sets out the complaints process at South

Hobart.

13. Staff, residents and families can use the Essendex messaging system to communicate any issues or

concerns they have directly to the care home.

Standard 1: Expected outcome 1.6: Human resource management

14.

A review has been completed of all of the duty statements (referred to as "a day in the life of” documents)

for each role at South Hobart. These were updated and distributed to staff in December 2018 and posted on

the walls in the staff rooms of each building to ensure staff are aware of their roles and responsibilities.

15. From 1 November 2018, an additional 33.5 hours of staffing were added to the Bupa South Hobart roster.

This measure was applied to address the issues identified at the care home.

16. Bupa has employed two additional Registered Nurses. This is reflected in the Workforce Capacity

Improvement Project Plan at Bupa South Hobart.

17. The Performance Review database has been reviewed and a schedule was prepared for all appraisals.

These appraisals have been completed.

18.

New staff now complete a “buddy programme” for 3 days at the time of orientation. This involves the new

staff member shadowing a relevant staff member according to their work area, for example, a Registered

Nurse, a Carer or a member of catering staff.

19.

In November 2018 a review was conducted of absences resulting from a high rate of sick and unpaid leave

amongst staff during 2018. One-on-one meetings were conducted with the relevant staff members. As at

February 2019, sick and unpaid leave had trended down, with a 3% decrease from 9% to 6%. Absences

have not been requested since the review.

Standard 1: Expected outcome 1.7: Inventory and equipment

20. An audit, register and purchase of more slings was carried out.

21. Bed poles were removed from the facility.

22. The key pad on the door of the unsecured area was repaired.

23.

The following equipment was purchased:

air mattresses;

bins;

holders for sanitizers;

3 manual sphygmonometers;

3 stethoscopes; and

3 non touch thermometers.

24. An air conditioner was installed in the laundry.

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Remediation step

25. A wandering alarm system was installed within the facility.

26. An audit of all phones in the facility was carried out, and an additional phone was purchased.

27. Glove wall holders were purchased and installed.

Standard 1: Expected outcome: 1.8 Information systems

28. Email addresses and mobile telephone numbers for the next of kin of the residents were collected. These

have been entered into Essendex by the Business Administrator at Bupa South Hobart.

29. All care recipients’ clinical files were audited, to ensure they were up to date and in order with all the

applicable work instructions.

30.

A database for all the care recipients’ photographs was created and maintained. The photographs have

been provided to the pharmacy and are kept on the care recipients’ files and medication charts.

Photographs are updated annually.

31. All documentation that includes care recipients’ names has been moved to areas where it cannot be

inadvertently viewed. Clinical files are now also kept in locked nurses stations.

32. Dietary lists are kept separate in the kitchens and kitchenettes.

33.

Clinical handover sheets are kept at each nurse station, within a residents’ handover file. The 7 day clinical

handover process has also been updated to include more detail about the care recipient’s past history and

chronic medical issues.

34. A staff communication folder has been created and is kept in the staff room. Staff have been instructed to

review it regularly.

35. Implementation of a process for maintaining the resident location list is complete.


36.

The call bell system has been reviewed to identify errors in capturing data. Through that process, a number

of problems with the call bell data system were identified in that it was capturing active call bells and

cancelled call bells. Engineers have fixed the problems and all call bells are now captured. The GM and

Clinical Care Managers (CCM) receive daily call bell reports which are then reviewed with staff and

discussed at daily operation meetings. Daily call bell report investigation documents are filed in the GM’s

Office.

37.

All staff have been instructed to answer call bells within 12 minutes. Any failure to do will be escalated to

their supervisor. Call bells are directed immediately to Extended Care Assistants (AINs) and after 6 minutes

to a Registered Nurse and CCM and after 12 minutes to the GM.

38. DECT phones are carried by clinical and care staff to notify them of call bells or sensor alarms. DECT

phones are reviewed to ensure call bells are appropriately escalated.

39. One new DECT phone has been ordered.

40. Call bell training has been conducted with all staff. It is also now part of the orientation program for new

staff.

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Remediation step

41. It is mandatory for progress notes to be completed on a weekly basis. This process is managed through a

weekly schedule and pre-populated using weekly handover documents.

Standard 2: Expected outcome 2.2: Regulatory compliance

42. A medication competent carer is rostered on for every shift. This is reflected in the Medication Management

Improvement Project Plan.

43. Implementation of cleaning processes for individual medication cupboards is complete. Medication fridge

temperature and stock levels are also monitored daily.

44. Medication charts are stored centrally in medication trolleys rather than in care recipients’ rooms.


45.

Education needs analysis forms were distributed to identify, collate and evaluate staff’s perceived gaps in

their education. Training was then conducted to fill the gaps identified.

Education calendars have been maintained between December 2018 and December 2019. An education

calendar for 2019 was created and displayed in the staff room to enable appropriate training for staff.

46.

Monitoring and managing mandatory training through the GROW system is complete and ongoing. Non

mandatory training is monitored and managed through the Bupa Training Matrix to ensure that staff are up

to date.

Standard 2: Expected outcome 2.4: Clinical care

47. On 20 December 2018, a review of all respite admissions was undertaken to ensure all documentation

regarding care needs was up to date.

48. A staff review of care recipients with complex clinical care needs was completed on 22 January 2019.

49. Development and implementation of a medication management project plan to ensure all assessment and

care plans are up to date is complete.

50.

Implementation of Review Audit Reports and Serious Risk Reports which detail incidents of falls,

challenging behaviours, palliative care recipients, medication errors, comments and complaints is complete.

The reports are discussed at daily leadership meetings. In addition, weekly trend analyses of all incidents

are discussed at weekly clinical risk meetings and weekly leadership meetings. Trend reports are then

provided to staff in staff communication folders and addressed at all staff meetings.

51.

Commencement of a new monthly meeting between the CCM, the GM and Physiotherapist, focusing on

falls. Minutes of these meetings are taken and shared between staff at all staff meetings and placed in the

staff communication folder in each staff room.

52. Implementation of a new process to ensure medication incidents are investigated and resolved within 24

hours. In the event of non-compliance with this process, disciplinary action is taken as necessary.

53. Implementation of new 7 day handover forms, which are kept in nurses stations and updated by the CCMs.

54.

Implementation of a "Resident of the Day” process from 7 January 2019. This process involves staff

capturing daily changes to care recipients which allows staff to monitor any changes to their routines or

identify personal needs.This is subject to the Resident of the Day Guidance.

RCD.0012.0050.0034

Remediation step

55.

All nurses (including CCMs) were provided with access to online pathology results to give them greater

access to pathology information. All nurses were provided with training on how to access and use the online

pathology results in February 2019.

Standard 2: Expected Outcome 2.5: Specialised nursing care needs

56. Addition of 33.5 hours of staffing to the Bupa South Hobart roster from 1 November 2018 is complete and

ongoing.

57. Implementation of daily management meetings is complete.

58. Review of complex wounds by a wound specialist nurse practitioner and the development of care pathways

for ongoing treatment is complete and ongoing.

59. New directives were issued by the GP with respect to care recipients suffering from Type II diabetes.

60.

Catheter care plans were updated to include specific requirements for residents’ catheters and previous

experience in relation to removal and reinsertion. Individual catheter change boxes have also been provided

to all relevant care recipients.

61. Preparation and distribution of a clear flowchart for bowel management is complete.

62.

Establishment of a daily walk by the GM and the take 10 initiative, so that any observations and key

operational issues can be discussed. Care staff also attend daily clinical walk-arounds which are then

updated at daily operation meetings and weekly clinical risk meetings. The Clinical Risk Register is then

updated to reflect any identified clinical risk.

Standard 2: Expected outcome 2.6: Other health and related services

63.

A review of all care recipients’ charts was completed, to confirm that all care recipients who needed or

wanted to consult an allied health professional were doing so and that appropriate referrals were in place.

This review was completed by 31 December 2018.

Standard 2: Expected outcome 2.7: Medication management

64. An assessment of medication competencies of all staff and completion of a comprehensive medication audit

was completed.

65.

Mock scenario assessments were conducted with Cynthia Payne to identify staff members who were not

competent in medication management. Staff who were identified as not competent were not permitted to

administer medication until further education and assessments were conducted. All AINs have completed

medication competencies and continue to be monitored. Performance management strategies for staff with

repeated medication errors have been implemented.

66. Implementation of centralised medication management project plans and new schedule 8 books.

Standard 2: Expected outcome 2.8: Pain management

67. A Pain Management Improvement Project Plan has been created and was completed by Doctor Libby

Monks.

68. The admissions program has been updated so that information about care recipients’ pain is managed

during their time at South Hobart.

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Remediation step

Standard 2: Expected outcome 2.9: Nutrition and hydration

69.

All care recipients admitted as respite or general admissions are weighed on entry. All care recipients are

also weighed monthly, at a minimum, and more frequently at the direction of the GP. Results are tracked

and monitored so that appropriate changes to nutrition can be made, if necessary.

70. A comprehensive review of all care recipients’ charts that include information regarding nutrition and

hydration was completed by 20 December 2018.

71.

Implementation of the "Souped-Up” program. This is an electronic automated system to manage the

nutrition and hydration requirements of residents. On 30 January 2019, staff were provided online training

on how to use Souped-Up.

72. Mandatory nutrition and hydration training was provided in February 2019.

73. All medication supplements are now noted on medication charts.

74. Chefs were provided with best practice guides for food and nutrition. The chef from Bupa Ballina also

reviewed the systems and processes at Bupa South Hobart to provide guidance to the chefs at the facility.

Standard 2: Expected outcome 2.11: Skin Care

75. A full skin integrity audit was carried out.

76. Nurse practitioners with a specialty in wound care have provided training to the Registered Nurses.

77. A review of the appropriateness of skin care equipment, such as pressure mattresses, was completed.

78. All care recipients admitted with wounds and pressure injuries underwent a Braden Scale and Skin Integrity

Assessment on admission and the results have been noted in care plans.

79. Cameras were purchased for photographing wounds so that progress can be effectively tracked.

80. The weekly handover document has been amended so that it includes information about wound treatment.

Standard 2: Expected outcome 2.12: Continence management

81. Ongoing review of each care recipient’s room to identify and expel unwanted odour has been completed.

82.

Arrangements were made for Key2Care to provide additional continence training to carers. Training was

also conducted by Tena representatives on 12 February 2019 for all carers. During this training, there was

also a review of care recipients’ continence scripts with the Tena representatives.

Standard 2: Expected outcome 2.13: Behaviour management

83. Lifestyle staff have been allocated so that there is always a lifestyle staff member in the dementia unit.

84.

Individual cases of challenging behaviour are discussed with the GP. These cases are also discussed at

Daily Operations and Leadership meetings. Referrals are then made to geriatricians or Dementia Services

Australia as appropriate.

85. On 31 January 2019 a wandering alert system was installed at the main entry of the Court.

86. Dementia Services Australia have attended Bupa South Hobart on multiple occasions to provide advice and

directions for the care of specific care recipients. Additionally, between 7 and 18 January 2019, a skilled

RCD.0012.0050.0036

Remediation step

diversional therapist from Queensland (Bupa New Farm) attended the site to provide support and training.

87. The GP has increased referrals to Doctor Dunbabin, Geriatrician, for specific care recipient intervention.

88. Any incident of care recipient aggression is managed appropriately, including reporting to regulators.

Standard 2: Expected outcome 2.14: Mobility, dexterity and rehabilitation

89. A sling audit and update was completed by 26 October 2018.

90. Nurse practitioners conducted mandatory education sessions for all care and clinical staff on the clinical

management of falls. This was completed by January 2019.

91. A physiotherapist review was carried out to ensure documentation was up to date. A new physiotherapist

was hired in late January 2019.

92. Implementation of a quick reference guide to falls management is complete and ongoing. This guide has

been placed in the clinical handover file, and was also emailed to all relevant staff on 30 January 2019.


93. A review of the lifestyle program was completed by 20 December 2018.

94. Implementation of a “wish list box”, which is placed around the care home, to encourage care recipients to

voice their requests.

95. Members of staff attended LGBTI inclusiveness training in October and November 2019. Further training

was completed in October and November 2019.

96. Working It Out and Equality Tasmania provided training to staff in November 2018.

97. Mona Art Museum was engaged to conduct art projects with the care recipients at the care home.

98. A mobile kiosk trolley has been introduced into each unit which does fortnightly rounds.

99. The GM has held regular morning teas at each of the three towers on a monthly basis. The GM now also

chairs monthly Resident and Relative meetings.

Standard 3: Expected outcome 3.2: Regulatory

100. A LGBTIQ work instruction has been developed, and while it is in draft form, is being implemented at a

practice level.

101. LGBTIQ training was conducted on 7 December 2018.

102. Implementation of a mandatory folder where incident forms arising from physical aggression are placed.

103.

Implementation of a process whereby in the event of physical aggression, a care recipients’ care plan and

progress notes are updated and carried in the mandatory folder containing incident forms referred to

immediately above.

104. Mandatory reporting training was conducted and all staff have completed the training.

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Remediation step


105. The leisure and lifestyle coordinator of Bupa New Farm spent time with each of the staff members of the

lifestyle team and provided education on the work instructions.

106. A new activities list has been prepared which is reviewed and re-evaluated regularly by the lifestyle team.

Standard 3: Expected outcome 3.4: Emotional support

107. Completion of a “map of life” form for each resident was completed by 10 February 2019. A related work

instruction has also been prepared.

Standard 3: Expected outcome 3.6: Privacy and dignity

108. Education sessions were held on 29 January and 1 February 2019 with Key2Care regarding privacy and

dignity.

109. The doors have been fixed in the nurses stations to ensure they self-close.

Standard 3: Expected Outcome 3.7: Leisure Interests and Activities

110. Training was provided to the Recreational Activity Officers to improve communication and support

throughout the team.

111. Implementation of daily lifestyle team meetings is complete.

112. Training has been conducted around the Bupa work instruction "Life style - A working guide.”

113.

Update of the admission process to ensure the family and care recipient are issued with a "map of life” prior

to admission is complete. The details from the “map of life” are then included in the care recipient’s

Individual Activity Plan.

Standard 3: Expected outcome 3.9: Choice and decision making

114. Implementation of the Resident Meal Choice Feedback survey is complete.

115.

From January 2019, the practice of residents in Lodge eating dinner in their own rooms was replaced.

Residents at Lodge now have a choice of eating in a communal dining room, where residents can socialise,

or having dinner in their own room.

116. Implementation of the SoupedUp program.


117. Reorganisation of the Maintenance Management System.

118. Creation of a service reports folder where all hard copies of all service reports received from external

contractors following their works are kept.

119.

Implementation of monthly update emails from the maintenance manager to the Regional Asset Manager to

provide an update on the maintenance works in the care home. In addition, the GM conducts weekly

meetings with the Maintenance Officer to ensure that all maintenance logs and works throughout the facility

are up to date.

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Remediation step


120. Fire training sessions were conducted in December 2018 and January 2019.

Standard 4: Expected outcome 4.4: Living environment

121. An inspection of all slings at Bupa South Hobart was carried out by Aidacare on 5 November 2018.

122. On 14 December 2018, Nicola Smith, the external physiotherapist contracted for Bupa South Hobart,

conducted a sling audit in conjunction with Aidacare.

123. Reviews of the bin bays were conducted with Recycling & Recovery Australia (external waste managers)

and the Regional Asset Manager. New bins were subsequently purchased.

124. On 31 October 2018, a hole was repaired in room 22 and painted.

125. Installation of a wandering alert system is complete.

126. A walk around of the driveway and carpark was conducted as part of the ongoing review of the paths.

127.

From 28 January 2019, the pan room was added to South Hobart and full time cleaners at South Hobart are

required to clean the pan room four times a week. This is completed in accordance with the cleaners’

schedules.

128. A new spill kit was ordered and delivered on 13 September 2018.

Standard 4: Expected outcome 4.6: Fire, security and other emergencies

129. Fire safety training has been conducted.

130. Staff were required to complete an assessment "Action in the Event of a Fire – Assessment” as well as the

"Event of a Fire – Training Pre – Post Evaluation”.

131. On 9 November 2018, locking keypads were installed by Total Communications on the nine remaining

external doors to South Hobart that did not already have keypads fitted. All key pads are now working.

132. Implementation of access codes for the Memory Support Unit. All codes in the Memory Support Unit and

throughout the facility are updated every six months to provide additional safety.

133. Replacement of the emergency flip chart at the Lodge, which had been identified as missing.

134. A fire blanket has been placed at the barbeques located at the Court and the Lodge.

135. In October 2018, a sign was placed in each Nurses Station advising that oxygen must be secured.

Standard 4: Expected outcome 4.7: Infection control

136. Implementation of a weekly clinical handover process which incorporates a care recipient’s past medical

history including chronic infection.

137.

Implementation of the Yellow Butterfly system which is a visual aid to assist staff in identifying care

recipients with known chronic infections. Staff were notified of this system in a memo dated 9 December

2018.

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Remediation step

138. Infection control training was conducted on 6 December 2018 and in April 2019. Attendance at this training

was recorded.

139. Fourteen new trolleys were ordered for clean linen to be stored on.

140. Laundry staff conducted an audit of linen cupboards and linen. Anything frayed was disposed of.

141. The hole in the linoleum in the salon was repaired. It was rectified by placing a wash basin over the location

of the hole, which resulted in an improvement to the salon.

142. In November 2018, two locks were installed on storage cupboards to secure the chemicals used by

hairdressers.

143. All hairdressers tested and tagged relevant equipment by the end of October 2018.

144. E-Safe was used to test and tag every electronic item in the Facility.

145. Hairdressing salons at the care home have a cleaning roster to ensure that cleaners undertake a thorough

clean of these areas once each week.

RCD.0012.0050.0040

Annexure C

Expected outcome

Measure put in place

November 2014 Mock Audit

1.1 (Continuous improvement) – Partially compliant (PC)

On 2 December 2014, an action plan was prepared in response to the recommendations in the November 2014 Mock Audit (December Action Plan) ([BPA.001.228.0001]; Tab 3 Tender Bundle). The following steps were noted as

having been taken:

– develop meeting schedule for all committees and send outlook meeting appointments to attendees;

– display minutes as soon as possible ensure that meeting minutes have actions due date. Ensure that legislative changes a standing agenda item at CIC meeting; and

– analyse data collected to identify reason for incident or infection etc. occurring or increasing.

The December Action Plan also noted that work had commenced analysing, trending and taking appropriate actions (using improvement log system) for gaps identified in each audit and evaluating the actions taken to measure their effectiveness.

1.2 (Regulatory compliance) – PC

The December Action Plan records that a Registration Folder was created to monitor staff registration.

The December Action Plan also noted that work had commenced on the following steps:

– update the GP/Allied health/contractor folder to include relevant documentation;

– check that all staff handling food have current qualifications and documentation. An SMS had been sent to all staff with an address for online food handling training. As at the date of completing the December Action Plan, certificates of completion had been received from some staff. A further reminder was subsequently sent to staff. Further, a checklist was being used to identify gaps in documentation and staff had been contacted for supporting documents; and

– display WHS poster (responsibility of the WHS representative and Return to Work Coordinator (RTWC)). An email had been sent for WHS posters to be sent to

Bupa South Hobart.

1.3 (Education and staff development) – PC

The December Action Plan noted the following steps as having been taken:

– ensure training material and record of eLearning attendance in the education folder;

– ensure planned monthly calendars (at least 3 months in advance) in the education folders and monitor that they are congruent with the attendance sheet; and

– split the education folder into 2 copies: Jan to Jun and Jul to Dec.


– attend to Education Needs Analysis as soon as possible to assist in planning for 2015. An SMS invitation had been sent to all staff to complete relevant forms. Staff had returned completed forms and missing forms were being followed up;

– update spread sheets for training Needs Analysis, pre- and post-evaluation and

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education attendance on AWS. A spread sheet had been developed and missing forms were being followed up; and

– ensure that training matrix is up to date.

1.6 (Human resources) – PC

The December Action Plan recorded that a spread sheet had been created to monitor skill assessments and compulsory education attendance enable easier tracking in regards to staff compliance ([BPA.001.228.0001]; Tab 3 Tender Bundle at 0007).

The December Action Plan also noted that work had commenced on checking all staff files for relevant documentation ([BPA.001.228.0001]; Tab 3 Tender Bundle at 0006-

0007). Checking of staff members’ files had commenced in order to identify what was missing from each file.

1.8 (Information systems) – Non-compliant (NC)

The December Action Plan recorded that the home had received a quote to have a sliding lock door with partial wall at reception to stop public access.

2.4 (Clinical care) – NC

The December Action Plan records that a care plan schedule had been developed and that CMs and RNs understood its use. CMs were instructed to check that care plans had been completed at the end of each month and the instruction was added to the CM checklist.


– review all files to ensure full suites of assessments that are recent, completed and signed as being developed by the registered nurse. Reviews had commenced and were noted on the care plan review checklist. RNs were reminded about the process;

– information in assessments to be reflected in the care plans. RNs were reminded that a tool kit had been developed and delivered. This was added to the care plan review checklist;

– educate carers to document bowel charts each shift. A tool box had been developed for ECAs whereby ECAs would report to RN at the end of each shift and the RN would check that the documentation is completed. RNs were informed of this process. Spot checks were conducted;

– all new or respite residents must have an interim care plan. As part of the care plan review the CM was to check daily and a note had been added to the care plan review checklist; and

– care plans must direct care for special needs e.g. behaviour or complex. The CM was to check daily and a note had been added to the care plan review checklist.

2.5 (Specialised nursing care needs) – PC

The December Action Plan identified various steps to be taken to address this outcome. We have not been able to confirm whether these steps were taken.

2.7 (Medication The December Action Plan identified various steps to be taken to address this outcome.

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management) – NC

We have not been able to confirm whether these steps were taken.

2.8 (Pain management) – NC

The December Action Plan noted that work had commenced on instructing staff regarding pain management and pain assessments. This had been discussed at a nurse meeting and spot checks had been initiated.

2.9 (Palliative care) – PC

The December Action Plan noted that work had commenced reviewing palliative care at the home. A palliative care team had been established and was discussed at the January 2015 nurse meeting.

2.10 (Nutrition and hydration) – NC

The December Action Plan noted that work had commenced on the following steps:

– urgent need to have current and accurate drinks lists with diet types, supplements and thickened fluids on all tea trolleys. Educate staff. As at the date of completing the December Action Plan, diet analysis had been copied and placed in folder and on drinks trolley;

– review 100% of nutrition assessments, diet analysis, care plans, drinks lists and kitchen lists to ensure all matches. As at the date of completing the December Action Plan, information matches were being checked;

– assign key staff with responsibility of keeping information current in all wings. As at the date of completing the December Action Plan, the CMs were to complete diet analysis sheets and the kitchen information was to be updated by a separate individual;

– ensure GPs are alerted to their residents’ weight loss and convey if they have been referred to a dietician or speech pathologist. As at the date of completing the December Action Plan, it was noted that CMs when entering weights would notify the GP if their resident weight changes and they would have a dietician review;

– spot check that residents are given their supplements. As at the date of completing the December Action Plan, it was noted that CMs would spot check when checking medication charts; and

– spot check that staff are thickening fluids to the correct consistency. As at the date of completing the December Action Plan, training had been run by Nestle. CMs were to spot check.

2.11 (Skin care); 2.13 (Behaviour management) – NC


2.12 (Continence management); 2.15 (Oral and dental care); 2.16 (Sensory


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loss) – PC

3.7 (Leisure and lifestyle) – PC


– each section of the home to have individual activities calendar;

– residents who are unable to join in or have dementia to be occupied where possible; and

– some of the programs may not be adaptable to all areas therefore an individual plan may need to be developed for the different sections.


– all lifestyle staff to be educated and involved in writing individual care plans for their residents rather than relying on one person to write care plans. RAOs were writing their own care plans, but it was noted that the home would do a tool box to ensure it was satisfied with its ability to write care plans; and

– staff to follow focus group calendar and if there is a concern, a special focus group could be held but more importantly an improvement logs is to be filled out and brought to the attention of the GM so it can be tracked through the system. Focus meeting folders had been made up and given to each of the RAOs for their building and the process had been explained. Focus groups had already been held for January 2015.

4.5 (Occupational health and safety) – PC

The December Action Plan records that a different location had been found for storage of the lifting hoist in the Manor.


– update Hazardous Substance and Dangerous Goods Manifest in line with new chemicals on site and file a copy near the fire panel;

– update SDS master copy; and

– have SDS for ALL dept. to include not only Diversey products but also other products such as hand detergent, moisturising cream etc.

4.7 (Infection control) – PC


– have register in place for all staff and resident Flu and Pneumovax vaccination;

– clean and tidy the dirty utility rooms. Have a roster in place for general cleaning of the room including the floor. Ensure that skips are stowed appropriately;

– create an Outbreak kit to cover both gastro and flu outbreak;

– check compliant with daily fridge temperatures recording on medication fridge, fridges in common areas etc.; and

the December Action Plan noted that a review had commenced on ensuring that there were SDSs in each department for all chemicals used in that department.

4.8 (Catering, The December Action Plan records that training was completed by Nestle for carers

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cleaning and laundry) – PC

and kitchen staff in relation to food thickener preparation and colour-coded dots used.


– ensure that all diet analyses are updated and that meals and drinks requirement is delivered as per the diet analysis. A review had been commenced;

– ensure that tea lists are updated and are congruent with current diet analysis. A review had been commenced; and

– as per above ensure that all relevant staff have attended current food handler refresher course and food supervisor course. A food handling SMS had been sent to all staff with an online training address.

February 2016 Mock Audit

1.2; 2.2; 3.2; 4.2 (Regulatory compliance) – PC

Elizabeth Wesols created improvement log 385917 on 15 March 2016 ([BPA.001.227.0061]; Tab 287 Tender Bundle), which recorded that the following

steps had been taken:

– food handlers course delivered to catering staff;

– recruitment of two new catering staff;

– bell in freezer and cool room repaired; and

– head of kitchen was communicating to kitchen staff to ensure that WIs and FSP processes followed on an ongoing basis.

1.3; 2.2; 3.3; 4.3 (Education and staff development) – PC

Elizabeth Wesols created improvement log 385908 on 17 March 2016 ([BPA.001.227.0048]; Tab 282 Tender Bundle), which recorded that:

– she had followed up the education action items with the CMs, with sessions to be run by CMs on topics such as Parkinson’s disease and completing a care plan;

– an education folder had been set up in accordance with the work instruction;

– education plans had been shared with the GM and CMs;

– education schedule had been updated to April including eLearning and competencies;

– topics were added to the education calendar based on the training needs analysis, for example, infection control was added to the education calendar; and

– she had agreed to speak with all RNs continuing to use out-of-date Care Plan templates and educate on correct templates.

1.6 (Human resources) – PC

Elizabeth Wesols created improvement log 385907 on 17 March 2016 ([BPA.001.227.0046]; Tab 281 Tender Bundle), which recorded that there was now

ongoing maintenance of staff files, induction of new staff and staff appraisals.

1.8 (Information systems) – PC

Raylene Fresle created improvement log 385906 on 3 March 2016 ([BPA.001.227.0044]; Tab 280 Tender Bundle), which recorded the following as

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actions to be undertaken:

– put in place a system to remove all superseded material from the home;

– treat every admission as a new admission and comply with new admission documentation requirements; and

– advanced care plans must be completed correctly and ensure resident/power of attorney completes the appropriate section. Doctor to endorse the form.

Elizabeth Wesols created improvement log 385907 on 17 March 2016 ([BPA.001.227.0046]), which recorded that the RD, RSM and GM held a

teleconference regarding, among other things, confidentiality during handover and the support required to move this issue forward.

1.9 (External services) – PC

Elizabeth Wesols created improvement log 385909 on 17 March 2016 ([BPA.001.227.0050]; Tab 283 Tender Bundle), which recorded the following steps

taken by the Maintenance Officer:

– the contractor and allied health folders were combined into a single folder;

– the supplier list was reviewed and material for only current suppliers was kept; and

– it was ensured that the folder had all appropriate documentation.

2.4 (Clinical care); 2.5 (Specialised nursing care needs) – PC

Elizabeth Wesols created improvement log 385912 on 17 March 2016 ([BPA.001.227.0053]; Tab 284 Tender Bundle), which recorded that, following

discussions between the RD, RSM and GM, the following steps were completed:

– in respect of diabetic management, all residents were reviewed and CMs committed to getting the GPs to write reportable levels in the progress notes and remove non-BMS forms; and

– all pain assessments had been reviewed by the CMs.

Improvement log 385912 ([BPA.001.227.0053]; Tab 284 Tender Bundle) records that

the CMs reported on 18 April 2016 that all documentation was up to date.

In addition to the actions taken in accordance with the improvement log, various steps were noted in the action plan. We have not been able to confirm whether these steps were taken.

2.7 (Medication management) – PC

Elizabeth Wesols created improvement log 385913 on 17 March 2016 ([BPA.001.227.0055]; Tab 298 Tender Bundle) which recorded the following steps

had been taken:

– education added to calendar on processes around missing signatures, transcribing and effectiveness of PRN medications for May; and

– GM asked CMs to report on progress in reviewing medication charts with a view to move to MPS, checking that all charts have a current photograph and developing a plan to ensure annual photographs are taken.

2.8 (Pain management) –

As noted above, improvement log 385912 ([BPA.001.227.0053]; Tab 284 Tender

Bundle) recorded that all pain assessments were reviewed by the CMs.

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PC


See response to 4.8.

2.11 (Skin care) – PC


– she met with CMs in March and reviewed wound charts, CMs were instructed to rewrite wound charts; and

– she returned in April 2016 to review progress of CM completion of wound charts;

2.12 (Continence management) – NC


– the GM sent an email to CMs requesting an update on the status of various items listed, including that continence assessments and care plans be reviewed for accuracy and Tena education be organised for care staff; and

– the CMs were ensuring that all assessments and care plans for elimination are congruent and all residents have an individualised toileting schedule developed and bowel charts complete.

2.13 (Behaviour management); 2.17 (Sleep) – PC

We have not been able to identify what actions were taken.



4.4 (Living environment) – PC


4.7 (Infection control) – PC

Elizabeth Wesols created improvement log 385916 on 15 March 2016 ([BPA.001.227.0059]; Tab 286 Tender Bundle) which recorded that:

– she had a discussion with the RD and RSM; and

– infection control was included in the education calendar for the month of May.

4.8 (Catering / Cleaning /

Elizabeth Wesols created improvement log 385918 on 17 March 2016 ([BPA.001.227.0063]; Tab 288 Tender Bundle), which recorded:

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Laundry) – NC – the GM was meeting on regular basis with cleaning staff to ensure ability to get all areas of the home cleaned to standard;

– education arranged for cleaning staff and reminded today of need to audit equipment, education continues at regular catch ups on accountabilities and responsibilities and the need to escalate issues to the GM;

– cleaning logs were being brought to the GM for review at the end of each month; and

– regular spot checks of trolleys and cleaning processes were put in place.

October 2016 Mock Audit

1.1; 2.1; 3.1; 4.1 (Continuous Improvement Plan) – PC

Elizabeth Wesols created improvement log 409314 on 9 November 2016 ([BPA.001.197.0027]; Tab 200 Tender Bundle) reflected in the mock audit plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9019). The improvement log noted

that all outstanding audits were up to date and conducted according to standards.

1.2; 2.2; 3.2; 4.2 (Regulatory compliance) – PC

Elizabeth Wesols created improvement log 409314 on 9 November 2016 ([BPA.001.197.0027]; Tab 200 Tender Bundle) reflected in the mock audit plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9019). The checklist noted various

steps to be taken to address this outcome. We have not been able to confirm whether these steps were taken.


Elizabeth Wesols created improvement log 409314 on 9 November 2016 ([BPA.001.197.0027]; Tab 200 Tender Bundle) reflected in the mock audit plan (BPA.062.006.9019]; Tab 14 Tender Bundle at 9019). The improvement log noted

that the education plan for 2017 had been developed to ensure all the standards were covered.

1.6 (Human resource) – NC

Elizabeth Wesols created improvement log 409315 on 9 November 2016 ([BPA.001.197.0028]; Tab 201 Tender Bundle), reflected in the mock audit action plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9019-20). The following steps

were taken and are noted as completed in accordance with the improvement log:

– training material (‘Ignite’ induction books and supporting documentation) ordered for staff;

– training provided by a member from Payroll in the head office in relation to the completion of forms; and

– the new GM was provided with education on the need to sign all staff contracts.

In addition to the actions taken in accordance with the improvement log, the action plan noted that staff members who are on RTW duties were to be asked to set up new staff folders to include all documentation, as per the work instruction.

1.7 (Inventory) – We have not been able to identify what actions were taken.

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PC

1.8 (information systems) – PC

Elizabeth Wesols created an improvement log 409319 on 9 November 2016 ([BPA.001.197.0219]; Tab 209 Tender Bundle). The improvement log records that the

following changes were successfully implemented and used in all three buildings at Bupa South Hobart by the time the log was closed on 2 October 2017:

– process for delivering the clinical handover reviewed and a new process developed to ensure accurate handover of resident care changes and needs available to all staff;

– documentation developed including weekly handover sheet, in charge report, and education support for care staff;

– education provided to weekend Charge Nurse regarding the completion of In-charge report; and

– all RN staff informed of new system and tool box sessions held in each community on use of the new system.



2.4 (Clinical care) – Non-compliant;

2.5 (Specialised nursing care needs) – PC

Elizabeth Wesols created improvement log 409321 on 9 November 2016 ([BPA.001.197.0032]; Tab 203 Tender Bundle), reflected in the mock audit action plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9020). The following steps were

taken and are noted as completed in accordance with the improvement log:

– monthly restraint evaluations were diarised to remind staff to undertake those valuations;

– a new experienced Clinical Manager worked with the team to ensure compliance with documentation requirements and documentation requirements were overseen by the Clinical Manager and CLM;

– training provided to all staff on accurate completion of assessment and person first documentation of care plans and evaluations and RN accountability with work instructions;

– clinical education organised by the resident GP, Dr Monks and the CLM and the GP’s diary redesigned to ensure that documentation, observation and follow up was undertaken; and

– schedule was developed for each community for weekly documentation, annual appraisals and 3-monthly care plan reviews;

Elizabeth Wesols also managed and conducted a process for an internal and external recruitment drive to address the staffing issues that she had identified at Bupa South Hobart (see [71]-[72] of the Statement of Elizabeth Anne Wesols dated 9 October 2019).

2.7 (Medication management) – NC

Elizabeth Wesols created improvement log 409311 on 31 October 2016 ([BPA.001.197.0025]; Tab 198 Tender Bundle) and further action items were outlined in the mock audit action plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9020).

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The following steps were taken and are noted as completed in accordance with the improvement log:

– an audit of all medication charts conducted at all three communities;

– ensuring that all residents had photo identification on a medication plan if not already on their medication chart;

– education for all community nurses on the medication work instruction provided in November 2016;

– an audit was conducted on medication chart storage; and

– the clinical team designed a system to ensure signage of medication.

2.8 (Pain management); 2.9 (Palliative care) – PC

Elizabeth Wesols created improvement log 409322 on 9 November 2016 ([BPA.001.197.0033]; Tab 204 Tender Bundle), which was reflected in the mock audit action plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9022). The improvement

log and action plan note various steps to be taken to address this outcome. We have not been able to confirm whether these steps were taken.




– drinks list updated by kitchen staff, the necessity of maintaining the list discussed with catering staff, and task of updating the list given to a designated staff member; and

– CMs provided with authorisation to contact allied health professionals when resident needs review and to ensure all documentation complete.

2.11 (Skin care) – PC



– CMs reviewed all wound management plans and ensured they were accurately completed; and

– education was provided to staff, and the CMs checked that Community Nurses were accurately completing wound photos when new plan was written.

2.12 (Continence management) – NC



– continence education including in relation to completion of bowel charts for all care staff provided by representative from Tena; and

– CMs reviewed bowel charts and enforced requirement of care staff to complete chart each shift. Continence assessments reviewed for completion each day.

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2.13 (Behaviour management) – NC

Elizabeth Wesols created improvement log 409321 on 9 November 2016 ([BPA.001.197.0032]; Tab 203 Tender Bundle), reflected in the mock audit action plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9020). The action plan noted

that a review had been undertaken of all residents with bed rail documentation.

2.14 (Mobility, dexterity and rehabilitation) – PC

Elizabeth Wesols created improvement log 409317 on 9 November 2016 ([BPA.001.197.0217]; Tab 207 Tender Bundle), reflected in mock audit action plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9022). The following steps were


– incident forms provided to the care home and home implemented a system so that incident form packs could be ordered on a regular basis;

– in incident investigation, CLM to check that falls investigation tool completed as per work instruction;

– home ensured all night staff completed all outstanding falls investigation tools; and

– training provided to staff on post-fall assessment, and CM trained staff on how to use the infra-red bed alarm system to ensure correct positioning of residents.

2.15 (Oral and dental care); 2.17 (Sleep) – PC


3.4 (Emotional support); 3.5 (Independence); 3.6 (Privacy and dignity); 3.9 (Choice and decision making) – PC




4.5 (Occupational health and safety) – PC


4.6 (Fire, security and other emergencies) – PC


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4.7 (Infection control); 4.8 (Catering / cleaning / laundry) – PC

Elizabeth Wesols created improvement log 409318 on 9 November 2016 ([BPA.001.197.0218]; Tab 208 Tender Bundle), reflected in mock audit action plan ([BPA.062.006.9019]; Tab 14 Tender Bundle at 9022). The following steps were


– appointment of a new chef with support from experienced Bupa chef who provided guidance on FSP documentation and skills to lead the team in compliance. Cook was to ensure all decanted foods had labels;

– servery in the court was spring cleaned. Elizabeth Wesols reviewed the roster to compare staffing with other similar sized serveries, and hired additional staff to support in completion of duties. High cleaning contractor contacted to complete cleaning tasks;

– CLM discussed use of the vaccination tracker and vaccination tracker scheduled to commence in 2017 and

– process developed to de-clutter rooms.

July 2018 Mock Audit

1.1; 2.1; 3.1; 4.1; (Continuous improvement) – PC

A log was entered into Riskman (ID 88) as part of the home’s Plan for Continuous Improvement (PCI) by David Neal ([BPA.055.001.5793]; Tab 297 Tender Bundle at

5801), noting that an education session was scheduled for 17 September 2017 in relation to care plans/ assessments/ scheduling/ handover of duties.

The log records that the action was completed on 28 August 2018.

1.2; 2.2; 3.2; 4.2 (Regulatory compliance) – NC

See response to 1.1, 2.1, 3.1 and 4.1 above.


Two logs were entered into Riskman as part of the home’s PCI by David Neal (ID 48 and 328).

Log 48 noted that a mid-year Educational Needs Analysis assessment survey was distributed, the returns were monitored, and the results were assessed ([BPA.055.001.5793]; Tab 297 Tender Bundle at 5794). The log records that the

action was completed on 28 August 2018.

1.6 (Human resources) – NC

Two logs were entered into Riskman as part of the home’s PCI (ID 69 and 159).

Log 69 noted that administration audit on BMS was completed and an action plan developed by 20 August 2018. A meeting was held on 27 August 2018 and a further action plan was worked through and actions were assigned for completion by 7 September ([BPA.055.001.5793]; Tab 297 Tender Bundle at 5797-8).

1.8 (Information A log was entered into Riskman (ID 88) as part of the home’s PCI by David Neal ([BPA.055.001.5793]; Tab 297 Tender Bundle at 5801), noting that an education

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systems) – NC session was scheduled for 17 September 2018 in relation to care plans/ assessments/ scheduling/ handover of duties.

The log records that the action completed on 28 August 2018.



2.4 (Clinical care); 2.5 (Specialised nursing care needs) – NC


2.7 (Medication management) – NC

A log was entered into Riskman (ID 161) as part of the home’s PCI ([BPA.055.001.5793]; Tab 297 Tender Bundle at 5803), which noted the following

steps were completed:

– a medication audit on charts was conducted to fix errors, several missed signatures were located and the errors were fixed;

– education was provided to staff at handovers during the week; and

– managers were to do checks in different pen, and log the completion of items on a regular basis.

2.8 (Pain management) – NC


2.10 (Nutrition and hydration) – PC

A log was entered into Riskman (ID 162) as part of the home’s PCI by David Neal ([BPA.055.001.5793]; Tab 297 Tender Bundle at 5803-4), which identified certain steps

to be taken to address this outcome. We have not been able to confirm whether these steps were taken.

2.11 (Skin care) – NC


2.13 (Behaviour management) – NC

Two logs were entered into Riskman (ID 153 and 159) ([BPA.055.001.5793]; Tab 297

Tender Bundle) as part of the home’s PCI. These logs identified certain steps to be taken to address this outcome. We have not been able to confirm whether these steps were taken.

2.14 (Mobility, dexterity and rehabilitation);


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2.15 (Oral and dental care); 2.17 (Sleep) – PC


A log was entered into Riskman (ID 239) as part of the home’s PCI by David Neal ([BPA.055.001.5793]; Tab 297 Tender Bundle at 5805-6), noting that:

– appropriate training was provided and an action plan was put in place to ensure that evidence of map of life information was transferred to the activity plan and care plan. This action was completed on 28 August 2018; and

– staff updated activity plans to reflect residents’ Map of Life and preferred activities. It was noted that while ‘Court’ building was behind, it was up to date by the time the action was completed on 28 August 2018.

4.6 (Fire, security and other emergencies); 4.7 (Infection control); 4.8 (Catering / Cleaning / Laundry) – PC


Standard 1 Assessment August 2018

1.1 (Continuous Improvement Plan)

An Assessment was prepared by management at Bupa South Hobart in response to a letter from the Aged Care Quality Agency dated 9 August 2018 ([CTH.1006.1003.8052]; Tab 71 Tender Bundle), identifying certain items as being

outstanding in relation to Aged Care Quality Standard 1 after the July 2018 Mock Audit. A checklist was prepared in relation to the items identified in the Assessment ([BPA.055.005.8235]; Tender Bundle Tab 237 at 8235). The checklist identified a step

to be taken to address this outcome. We have not been able to confirm whether this step was taken.

1.4 (Comments and complaints)

The checklist noted that the following steps had been completed ([BPA.055.005.8235]; Tender Bundle Tab 237 at 8235):

– survey residents and representatives in relation to their understanding of the complaints management process (including process of external to home complaints);

– evidence of feedback discussed at leadership, staff and resident/relative meetings;

– evidence of all complaints logged, evaluated, closed and managed as per Bupa Complaints Management work instruction; and

– all complaints handling and advocacy brochures available, including ACCC.

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1.6 (Human resource)

The checklist noted that the following steps had been completed ([BPA.055.005.8235]; Tender Bundle Tab 237 at 8235-8236):

– all staff and regulated workers’ registrations current;

– all criminal history checks current;

– Education Needs Analysis sent out to all clinical and non-clinical staff today;

– daily nurse call response checks/audits by GM/delegate;

– no vacant shifts in home over last two weeks (with exception of managing occupancy);

– ongoing recruitment strategies in place i.e. regular assessment centres, advertising etc.;

– if utilising agency staff, all agency staff have evidence of induction and support to know residents and needs;

– all staff have annual competencies up to date; and

– all staff annual mandatory training completed and up to date.

1.7 (Inventory) We have not been able to identify what actions were taken.

1.8 (Information systems)


– meeting schedule including WHS, staff, R&R, catering, general, RN etc. Minutes to match schedule;

– meeting minutes table outcomes and actions of audits, themes, trends;

– BCP plan in place and staff understand use and location;

– if utilising agency staff, all agency staff have evidence of induction and support to know residents and needs;

– staff, residents/relatives feel medical attention is timely and appropriate and satisfied with communication between staff, GP and resident/NOK; and

– clinical handover occurring as per work instruction and in confidential location.


2.2 (Regulatory compliance)

An assessment was prepared by management at Bupa South Hobart in response to a letter from the Aged Care Quality Agency dated 9 August 2018 ([CTH.1006.1003.8052]; Tab 71 Tender Bundle), identifying certain items as being

outstanding in relation to Aged Care Quality Standard 2 after the July 2018 Mock Audit. A checklist was prepared in relation to the items identified in the Assessment ([BPA.055.005.8009]; Tender Bundle Tab 239 at 8009). The checklist noted that

incident/infection trending analysis had been used to improve outcomes for resident (with a direct link to CIPs).

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2.3 (Education and staff development)

The checklist identified various steps to be taken to address this outcome. We have not been able to confirm whether these steps were taken.

2.4 (Clinical care)


– ensure all assessments are within 12 months – or earlier if changes to resident needs;

– evidence resident review process – evidence of a schedule and ability to know when resident is due for review;

– care plan evaluations have occurred 3 monthly;

– exceptional report writing is evident; and

– clinical audits have been completed as per schedule.

2.7 (Medication management)

The checklist identified various steps to be taken to address this outcome. We have not been able to confirm whether these steps were taken.

2.10 (Nutrition and hydration)

The checklist noted that the following steps had been completed ([BPA.055.005.8009]; Tender Bundle Tab 239 at 8011):

– evidence the change of resident care needs process has been followed; and

– resident lists are up to date with the process in place when care needs change.

2.14 (Mobility, dexterity and rehabilitation)

The checklist noted that evidence of falls/found on floor are documented within timeframes. ([BPA.055.005.8009]; Tender Bundle Tab 239 at 8011-8012).


3.3 (Education and staff development)


outstanding in relation to Aged Care Quality Standard 3 after the July 2018 Mock Audit. A checklist was prepared in relation to the items identified in the Assessment ([BPA.061.005.0588]; Tender Bundle Tab 243 at 0588). The checklist identified a step

to be taken to address this outcome. We have not been able to confirm whether this step was taken.

3.4 (Emotional support)

The checklist notes that the following steps had been completed ([BPA.061.005.0588]; Tender Bundle Tab 243 at 0589):

– evidence staff are encouraging and relaxed; and

RCD.0012.0050.0056

Expected outcome


– evidence is focused on care and support.

3.6 (Privacy and dignity)

The checklist notes that there was evidence that confidentiality was being respected, as there were no lists around the nurses’ station with residents’ names on them, folders were placed back in cupboard after use ([BPA.061.005.0588]; Tender Bundle

Tab 243 at 0589).


4.4 (Living environment)


outstanding in relation to Aged Care Quality Standard 4 after the July 2018 Mock Audit. A checklist was prepared in relation to the items identified in the Assessment ([BPA.061.008.3300]; Tender Bundle Tab 250 at 3301). The checklist notes that the

following steps had been completed:

– living environment – easy to get around, nothing blocking doorways, hallways, etc.;

– fire exits are clearly marked;

– lighting is in good order;

– resident spaces are inviting and pleasant in lounge rooms;

– there is a comfortable atmosphere without lots of intrusive announcements or noise;

– resident’s private space/rooms look personal and are reflective of the individual; and

– evidence maintenance logs are being utilised.

RCD.0012.0050.0057

Documents

ROYAL COMMISSION INTO AGED CARE QUALITY & SAFETY ... · 5 In summary, Bupa makes the following submissions in response to these propositions : (a) Bupa accepts that, with the benefit