The report features insights from SIRS “unreasonable use of force” notifications that make up almost two-thirds of all incidents notified to the Commission by residential aged care providers during that period.
The vast majority of these incidents involved interactions between residents and the report is focused on these types of cases. The report is intended to provide guidance and insights to help providers and their staff better understand the response, impact assessment and management of incidents. SIRS was introduced in April 2021 and requires aged care providers to notify the Commission of serious incidents impacting consumers.
The report highlights that reducing the chance of a serious incident requires providers to identify, manage and mitigate risks to consumers, learn from every incident, and introduce preventative measures to avoid recurrence. Janet Anderson, Aged Care Quality and Safety Commissioner, believes that SIRS notifications give the Commission another way to understand how effectively individual providers are managing risks in aged care. By using these notifications in combination with other Commission data, they can better identify and respond to provider and service level risk.
The number of serious incident notifications does not necessarily relate to the number of instances of harm to an aged care recipient. Reports can include multiple notifications about the same matter, suspected incidents, and situations where incidents occurred, but injuries were avoided. “In many cases where a serious incident is reported, the aged care provider has already dealt very effectively with the incident – taking all necessary steps to address any issues for the person concerned and making the changes required to prevent these incidents from happening again,” Anderson said.
However, the report’s case studies highlight aspects of managing incidents where some providers still need to improve at an operational and governance level. The Commission is concerned that 9 out of 10 providers assess incidents involving unreasonable use of force as having minor or no impact. This could be because they are not considering less obvious impacts that may be harder to identify where a resident isn’t able to reliably relate to what happened, or delayed impacts where physical injury becomes apparent later. The report emphasises the need for providers to identify and mitigate risks to consumers and to learn from every incident.
The SIRS data shows that aged care residents involved in incidents of unreasonable use of force are much more likely to have severe cognitive impairment than those involved in other serious incident types. However, these incidents should not be considered unavoidable. Providers who are genuinely interested in improving care for those in their care can deliver a better experience for every resident, regardless of their cognitive functioning.
“Staff who see things going wrong and who have clear processes to take action and/or escalate a response at their service can make a dramatic difference. Every person working to care for older people, at whatever level, has the potential,” said the Commission’s Chief Clinical Advisor Dr Melanie Wroth.
The Commission expects to see improvements in care and in the prevention of incidents, with the rate of incidents declining over time as providers’ ability to manage incidents improves.