tag:theconversation.com,2011:/au/topics/residential-care-22298/articlesResidential care – The Conversation2021-03-17T17:22:31Ztag:theconversation.com,2011:article/1569212021-03-17T17:22:31Z2021-03-17T17:22:31ZSpecial guardianship helps thousands of children to leave care. It needs more support<figure><img src="https://images.theconversation.com/files/390125/original/file-20210317-19-82d63u.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C4924%2C3250&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/family-childhood-adoption-people-concept-sad-650287021">Syda Productions/Shutterstock</a></span></figcaption></figure><p>The pandemic has brought with it yet more hardship for families across the nation. But amid increases in <a href="https://theconversation.com/domestic-abuse-workers-reveal-the-trauma-of-trying-to-help-victims-during-lockdown-145273">domestic abuse</a>, parental and <a href="https://theconversation.com/10-parenting-strategies-to-reduce-your-kids-pandemic-stress-151419">child mental health difficulties</a> as well as deprivation and poverty, the impact on family courts has yet to be fully documented. </p>
<p>This is despite the integral role these courts play in intervening when it’s not safe for a child to remain at home. Without those opportunities to step in, more children could fall through the cracks, especially as the courts already expect an <a href="https://www.bbc.co.uk/news/uk-55682745">increase in child protection cases</a> when lockdown ends and schools have reopened (schools are one of the main referrers to children’s services).</p>
<p>The challenges over addressing and lessening the effects of the expected increase in demand for children’s services are enormous. Against this background, the work of the recently launched independent review of children’s social care is especially important. Described as a <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/952624/terms_of_reference_independent_childrens_social_care_review.pdf">“once in a generation opportunity to reform systems and services”</a>, the review is intended to be “bold” and “ambitious”.</p>
<p>The important role of adoption in providing children who can’t remain with their birth parents with a safe and permanent new home is singled out for special mention in the review. Boosting adoptions was a 2019 Conservative manifesto pledge which aimed to reduce the number of children in foster and residential care. Kinship care, which enables children to be brought up by family and friends, is also named as a priority for support. There are around 220,000 children currently living in these private family arrangements with their extended family or with friends.</p>
<p>But the review is silent on a less well-known legal order: special guardianship. The order gives carers – mostly relatives – the main parenting responsibilities and lasts until the child reaches the age of 18. Introduced into law in 2002, it was designed for children who, by virtue of their age, the strength of existing family ties, their culture, religion or their status as unaccompanied asylum seekers, needed an alternative to adoption.</p>
<h2>The benefits of special guardianship</h2>
<p>Special guardianship has struggled under a veil of invisibility since it was first introduced. Yet in recent years there’s been a remarkable transformation in its use. Family courts have placed more children with special guardians than with adopters in recent years, keeping children in their family networks and enabling them to stay in contact with their birth parents. In 2020, <a href="https://explore-education-statistics.service.gov.uk/find-statistics/children-looked-after-in-england-including-adoptions/2020">3,700 children were placed with special guardians</a> and 3,440 were adopted.</p>
<figure class="align-center ">
<img alt="little girl wearing a dress running to man with open arms in park" src="https://images.theconversation.com/files/390127/original/file-20210317-15-11vvmaa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/390127/original/file-20210317-15-11vvmaa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=385&fit=crop&dpr=1 600w, https://images.theconversation.com/files/390127/original/file-20210317-15-11vvmaa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=385&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/390127/original/file-20210317-15-11vvmaa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=385&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/390127/original/file-20210317-15-11vvmaa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=484&fit=crop&dpr=1 754w, https://images.theconversation.com/files/390127/original/file-20210317-15-11vvmaa.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=484&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/390127/original/file-20210317-15-11vvmaa.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=484&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Just 5% of children under special guardianship risk returning to court because of further harm.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/cute-asian-little-girl-playing-running-1259089474">Sukjai Photo/Shutterstock</a></span>
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</figure>
<p><a href="https://www.cfj-lancaster.org.uk/projects/supervision-orders-and-special-guardianship-a-national-study">National research led by Lancaster University</a> shows this is a clear pattern. More than <a href="https://www.cfj-lancaster.org.uk/app/nuffield/files-module/local/documents/HARWIN%20main%20report%20SO%20and%20SGOs%20_%204Mar2019.pdf">21,000 vulnerable children</a> now live with their extended family on a special guardianship order. The courts have played a part in this transformation by saying that adoption should only be used when “nothing else will do”. Put slightly differently, the message is that family ties matter and should be preserved and built on whenever possible, which was a principle of the Children Act 1989.</p>
<p>The research also shows that special guardianship brings many benefits to children. It gives children a stable and permanent home. Just <a href="https://www.cfj-lancaster.org.uk/app/nuffield/files-module/local/documents/HARWIN%20main%20report%20SO%20and%20SGOs%20_%204Mar2019.pdf">5% of children</a> under special guardianship return to court because of further harm within five years. Though the figure for adoption is lower <a href="https://www.nuffieldfjo.org.uk/app/nuffield/files-module/local/documents/making_special_guardianship_work_briefing_paper.pdf">(0.007%)</a>, 5% is still considered a small proportion. Children cared for by special guardians also have <a href="https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/884749/CLA_Outcomes_Additional_Tables_2019_Text.pdf">better results at school</a> than those who are looked after by children’s services (typically those in foster or residential care). For these children, belonging to a family and the anchor that it provides is highly valued. </p>
<p>But this isn’t the full picture. A powerful film made by Lancaster University with leading children’s charities Kinship and CoramBAAF, vividly illustrates the lack of support special guardians and their families receive and the struggles they face.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/pNO1sZb5mjc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
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<p>The decision to bring up a child in their wider family will change the lives of special guardians forever, yet they have no automatic entitlement to legal aid and don’t receive training. Special guardians aren’t a priority for rehousing either, and financial support from local authorities is patchy and variable. And, although guardians are entitled to therapeutic support from the Adoption Support Fund for the children in their care, <a href="https://questions-statements.parliament.uk/written-questions/detail/2020-02-10/14701">only 9% received help</a> in the past four years – the rest went to adopters. Unlike fostering and adoption, special guardians don’t get automatic employment leave when the child joins their family. The playing field is far from level.</p>
<h2>Fixing the issues ahead</h2>
<p>The <a href="https://www.judiciary.uk/wp-content/uploads/2020/06/PLWG-SGO-Final-Report-1.pdf">first steps</a> have been taken to address these serious issues and to improve practice by children’s services and the courts. But the agenda for change must go much further. A national coordinated strategy is needed, supported by key government departments that recognise the benefits special guardianship brings to children, their families and society. </p>
<p>On March 15, a <a href="https://www.lancaster.ac.uk/news/call-for-open-door-to-support-for-special-guardians-taking-on-life-changing-caring-role">landmark webinar</a> brought together sector leaders (including the chair of the independent review of children’s social care) and publicly acknowledged the need for change. The webinar, hosted by Lancaster University in partnership with Kinship and CoramBAAF, launched their <a href="https://youtu.be/euISHK0fbIs">new film</a> a second film which identifies top priorities for sector leaders.</p>
<p>But there’s still much more to do. If properly supported in law, policy and practice, special guardians can play a larger role in providing abused and neglected children with loving, safe and secure homes. Although it costs more to give special guardians the same range of support that adopters receive, in the long run, fewer children are likely to need foster care or residential care. Children flourish better when they <a href="https://www.nuffieldfjo.org.uk/resource/special-guardianship-a-review-of-the-evidence">remain with their relatives</a>.</p>
<p>The benefits of supporting and promoting special guardianship alongside adoption far outweigh the merits of the current situation. As Britain begins to open up again, providing as many avenues of support for children as possible will be a matter of urgency.</p><img src="https://counter.theconversation.com/content/156921/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Judith Harwin has received funding from The Nuffield Foundation and The Department for Education.
Grants from the Nuffield Foundation:
1. The contribution of supervision orders and special guardianship to family justice and children’s lives. Juth Harwin, principal investigator, 2015–2018
2. Evaluation research on the family drug and alcohol court in care proceedings - 2007–2011 and 2011–2013 - was funded by
the Nuffield Foundation.
3. Grant from Department for Education Children's Social Care Innovation Fund to carry out the studies: After
FDAC: outcomes 5 years later and problem-solving in court: current practice in FDACs in England</span></em></p>The legal order has struggled under a veil of invisibility for years. But research shows it provides better outcomes for many vulnerable childrenJudith Harwin, Professor in socio-legal studies and co-director of the Centre for Child and Family Justice Research, Lancaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1374782020-05-14T18:59:08Z2020-05-14T18:59:08ZCoronavirus crisis shows ableism shapes Canada’s long-term care for people with disabilities<figure><img src="https://images.theconversation.com/files/334502/original/file-20200512-82353-1wk8m7z.jpg?ixlib=rb-1.1.0&rect=91%2C37%2C3449%2C2295&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Staff members stand at a window as they watch a parade of well-wishers driving by Orchard Villa Care home, in Pickering, Ont., on April 25, 2020. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Chris Young</span></span></figcaption></figure><p>Nationwide, long-term care facilities, primarily occupied by residents who are elderly or live with disabilities, are in deteriorating condition. But little has been done to actually address the organizational decisions that lead to these dangerous conditions. COVID-19 has exposed many inequities within Canada’s care systems. </p>
<p>When we look at who is disproportionately affected by this pandemic, we can’t help but <a href="http://www.ohrc.on.ca/en/policy-ableism-and-discrimination-based-disability">ask how ableism shapes notions of whose lives are valued and whose are not</a>. As governments plan for a “return to normal” while serious systemic issues remain in long-term living facilities, is normal really what we want to return to? </p>
<p>Localized, facility-based outbreaks of the coronavirus have led to high numbers of residents and staff contracting COVID-19. More than 40 per cent of the residents of Pinecrest Nursing Home in Bobcaygeon, Ont., <a href="https://nationalpost.com/news/canada/covid-19-coronavirus-pinecrest-nursing-home-bobcaygeon">have lost their lives to COVID-19</a>. Similar patterns have surfaced <a href="https://globalnews.ca/news/6800965/bc-coronavirus-update-april-9/">in British Columbia</a>, other communities in <a href="https://ottawacitizen.com/news/ottawa-long-term-care-homes-bracing-after-outbreaks-in-almonte-carleton-place/">Ontario</a>, <a href="https://calgaryherald.com/news/local-news/live-at-330-p-m-dr-hinshaw-to-update-covid-19-response/">Alberta</a>, <a href="https://montreal.ctvnews.ca/quebec-takes-charge-of-seniors-home-after-reports-of-death-unhygienic-conditions-1.4891741">Québec</a> <a href="https://globalnews.ca/news/6807585/coronavirus-dorval-residence/">(most severely)</a> and <a href="https://www.cbc.ca/news/canada/nova-scotia/covid-19-update-nova-scotia-1.5545512">Nova Scotia</a>. </p>
<p>This is also true in facilities dedicated to people with disabilities. A Markham, Ont., facility reported that <a href="https://www.thestar.com/news/gta/2020/04/28/fifth-covid-19-resident-death-at-participation-house-in-markham.html">40 of 42 residents and 38 health-care workers tested positive for COVID-19</a> towards the end of April.</p>
<p>According to the <em>Toronto Star</em>, deaths of residents in long-term care facilities <a href="https://www.thestar.com/politics/federal/2020/05/07/82-of-canadas-covid-19-deaths-have-been-in-long-term-care.html">made up 82 per cent of the country’s total number of fatalities due to COVID-19</a> as of May 7, 2020. Despite the continuing threat of COVID-19 to residents in care facilities and warnings of a resurgence, many jurisdictions are now making plans to lighten travel and social restrictions.</p>
<h2>Long-term care, long-term problems</h2>
<p>Even before the pandemic, long-term care facilities had disturbing incidences of abuse, <a href="https://www.cbc.ca/news/business/elderly-care-violence-marketplace-investigates-1.4493215">neglect</a> and <a href="https://www.cbc.ca/news/canada/london/woodstock-ontario-elizabeth-wettlaufer-public-inquiry-report-1.5230181">even murder</a>. Yet the conditions that allow such atrocities to occur continue.</p>
<p>Long-term care facilities often experience <a href="https://www.unifor.org/sites/default/files/documents/document/final_psw_report.pdf">severe deficits in funding and staff.</a> Typically, there is far greater demand for beds than <a href="https://publications.virtualpaper.com/uploads/9b5ad0be6edd4b1d143d2ce54855c485/da758e87f7c273e9e3a4c31cd776beb2/pdf/annual_report_2019.pdf">there are beds available</a>, leaving no opportunity for choice of facility. </p>
<p>For many Canadians, the choice to move into residential care is not really a choice at all. There are limited options for many people who require around-the-clock care. Independent living centres are not broadly available and <a href="https://www.cbc.ca/news/canada/windsor/supportive-housing-delays-continue-1.5241574">many have extensive waiting lists</a>. Self-directed care options may be available, however, <a href="https://www.dfontario.ca/info/general-faqs.html">there are limitations for those who require full-time support</a>.</p>
<p>These services are also vulnerable to staffing shortages, lack of training and funding cuts. While personal support workers (PSWs) provide a critical service and support many personal care activities for daily living, their work is often undervalued. Many are overworked, underpaid and precariously employed. </p>
<p>In addition, care work is often fulfilled through the labour of poor, racialized and/or immigrant women who may face additional barriers in drawing attention to <a href="https://local4948.org/images/bibliography/articles/WorkingWomenMarch2014.pdf">exploitative working conditions</a>. During the pandemic, it has been revealed that PSWs are <a href="https://www.cbc.ca/news/canada/toronto/participation-house-critical-need-ppe-staff-1.5529384">not always provided with adequate personal protective equipment to keep themselves or the residents safe</a>. </p>
<p>But none of this is new or, at least, unexpected. For generations, the dangers that arise when we organize populations into institutional settings <a href="https://www.palgrave.com/gp/book/9781137393234">have been abundantly clear</a>. COVID-19 may have shone a spotlight on these issues, but the inequities were always there. </p>
<h2>An indifference towards people with disabilities</h2>
<p>At a March 23 news conference, Dr. Deborah Birx, the White House coronavirus response co-ordinator, spoke on the global mortality rates of COVID-19. She assured the public that the majority of people who do and will perish from the virus are largely elderly and those with pre-existing conditions. </p>
<blockquote>
<p>“Still 99 per cent of all the mortality coming out of Europe, in general, is over 50 and pre-existing conditions. The pre-existing condition piece still holds in Italy with the majority of the mortality having three or more pre-existing conditions. <a href="https://youtu.be/p4OKsUNRMzY?t=1401">I think this is reassuring to all of us, but it doesn’t change the need to continue to protect the elderly…</a>.”</p>
</blockquote>
<p>Birx’s statement echoes a dangerous discourse that <a href="https://www.thinkupstream.net/stop_dehumanizing/">people with disabilities as well as disability activists and allies have been challenging for some time</a> — an insidious indifference towards the lives of persons who are disabled or elderly. </p>
<p>To whom would this be reassuring? This casual and callous indifference has come further into focus as jurisdictions weigh the economic implications of returning to normal despite the continued, and possibly heightened, risk for persons in residential care. </p>
<p>Nirmala Erevelles, a critical disability studies scholar, explores the role capitalism and capitalist principles <a href="https://www.palgrave.com/gp/book/9780230100183">play in producing bodies that matter and bodies that do not</a>. Ableism is keenly expressed by attempting to justify human value through the lens of economic productivity and perceived expense. As disability justice activist Mia Mingus writes: “Ableism is connected to all of our struggles because <a href="https://leavingevidence.wordpress.com/2011/02/12/changing-the-framework-disability-justice/">it undergirds notions of whose bodies are considered valuable, desirable and disposable</a>.” </p>
<p>This crisis exposes how ableism has long shaped how we think about care and those who receive care. Ableism shapes how we organize long-term care funding, staffing and crisis management as well as day-to-day care. </p>
<p>As governments and organizations re-imagine how care can be more effectively delivered, there are lessons to be learned from people who have navigated care and service systems <a href="http://www.jeffpreston.ca/2020/05/05/opening-remarks-to-huma-committee/?fbclid=IwAR0hHeFJxTOi_GvaFGfRXzKs3BgzT5I56moMNAqTLLgxttjHcSF4oUl7tBQ">before the global crisis began</a>. People with disabilities and those who have experienced life in long-term care need to be at the forefront, leading and advising on systemic change.</p><img src="https://counter.theconversation.com/content/137478/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Gillian Parekh receives funding from the Social Science and Humanities Research Council. </span></em></p><p class="fine-print"><em><span>Kathryn Underwood receives funding from the Social Sciences and Humanities Research Council. </span></em></p>As governments start to return to a new normal, people with disabilities in care facilities are still in serious danger of being left behind during the coronavirus pandemic.Gillian Parekh, Canada Research Chair (Tier 2) in Inclusion, Disability and Education, York University, CanadaKathryn Underwood, Professor, Early Childhood Studies, Toronto Metropolitan UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1314492020-03-05T19:08:45Z2020-03-05T19:08:45ZWhich aged care services near you weren’t up to scratch in 2019?<figure><img src="https://images.theconversation.com/files/316569/original/file-20200221-92502-c83fkc.jpg?ixlib=rb-1.1.0&rect=34%2C0%2C5716%2C3828&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>In July 2019, the government introduced <a href="https://www.agedcarequality.gov.au/news-media/commission-media-release-new-aged-care-standards-commence">new aged care standards</a> to “raise the bar” in an aged care system where some nursing home residents have experienced care that is <a href="https://www.abc.net.au/news/2019-10-31/aged-care-royal-commission-report-finds-unsafe-industry/11658328">neglectful, depersonalised, uncaring, unsafe and of poor quality</a>.</p>
<p>We took a close look at <a href="https://www.myagedcare.gov.au/non-compliance-checker">breaches of aged care standards</a> from 2019 to see what effect the new aged care standards are having, and where aged care providers are falling short. </p>
<p>In the interactive map below you can see aged care providers that were non-compliant in 2019.</p>
<hr>
<p><iframe id="tc-infographic-461" class="tc-infographic" height="400px" src="https://cdn.theconversation.com/infographics/461/9157b3fe0de255f41d3f9b52ee6354ca7058d731/site/index.html" width="100%" style="border: none" frameborder="0"></iframe></p>
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<figcaption>Map created by data visualisation company <a href="https://smallmultiples.com.au/">Small Multiples</a></figcaption>
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<h2>What are aged care standards?</h2>
<p>Aged care standards are the minimum standard of care the government expects nursing homes to provide.</p>
<p>They are supposed to ensure people in aged care have access to quality care including competent staff who listen, best-practice clinical care and nutritious and tasty food.</p>
<p>Nursing homes that don’t meet standards are given a notice of non-compliance. If the provider doesn’t fix the problems that made it non-compliant, then it will be sanctioned. </p>
<p>If assessors decide there is an immediate and severe risk to residents, nursing homes can also be immediately <a href="https://theconversation.com/how-to-check-if-your-mum-or-dads-nursing-home-is-up-to-scratch-123449">sanctioned</a>. The nursing home provider must then bring the care up to standard before they can take new residents.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/nearly-2-out-of-3-nursing-homes-are-understaffed-these-10-charts-explain-why-aged-care-is-in-crisis-114182">Nearly 2 out of 3 nursing homes are understaffed. These 10 charts explain why aged care is in crisis</a>
</strong>
</em>
</p>
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<h2>The new aged care standards</h2>
<p>From 2014 until the new standards were introduced in July 2019, the number of non-compliance notices and sanctions increased steadily as can be seen in the chart below. </p>
<p>This was likely due to a combination of <a href="https://www.abc.net.au/news/2019-08-11/aged-care-commission-hears-recommendations-ignored/11400026">increasing scrutiny</a> of the quality of residential care as a result of the unsafe care revealed at Oakden in 2017, and the establishment of the <a href="https://agedcare.royalcommission.gov.au/Pages/default.aspx">aged care royal commission</a> in October 2018. A 2018 policy change meant providers <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/FlagPost/2018/February/nursing_home_quality_and_compliance_visits">were no longer warned</a> about upcoming accreditation visits. </p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/318042/original/file-20200302-18295-1fbu84s.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/318042/original/file-20200302-18295-1fbu84s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/318042/original/file-20200302-18295-1fbu84s.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=530&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318042/original/file-20200302-18295-1fbu84s.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=530&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318042/original/file-20200302-18295-1fbu84s.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=530&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318042/original/file-20200302-18295-1fbu84s.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=666&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318042/original/file-20200302-18295-1fbu84s.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=666&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318042/original/file-20200302-18295-1fbu84s.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=666&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Chart: Else Kennedy.</span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
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</figure>
<hr>
<p>The new standards, introduced in July 2019, <a href="https://www.agedcarequality.gov.au/news-media/commission-media-release-new-aged-care-standards-commence">focus</a> on “personal dignity and choice”. </p>
<p>They were designed to support the provision of care based on what residents want, rather than penalising providers when they let residents do something that could be considered “risky”, such as allowing someone with mild dementia to walk to the shops, or having a pet in the nursing home.</p>
<p>The number of non-compliance notices and sanctions in the first six months of the new standards decreased. This is likely because assessors visited fewer nursing homes in this period, and may still be learning how to interpret the new standards.</p>
<p>Aged care providers and industry bodies have <a href="https://www.australianageingagenda.com.au/2019/03/22/balancing-act-will-test-transition-to-new-quality-standards/">criticised</a> the new standards for being <a href="https://www.australianageingagenda.com.au/2019/03/01/objective-measures-needed-for-better-quality-regulation-rc-advised/">subjective and vague</a>. They do not measure objective resident outcomes like depression or number of infections.</p>
<h2>For-profit companies had a higher rate of non-compliance in 2019</h2>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/318047/original/file-20200302-18262-1vtgbvj.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/318047/original/file-20200302-18262-1vtgbvj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/318047/original/file-20200302-18262-1vtgbvj.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=497&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318047/original/file-20200302-18262-1vtgbvj.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=497&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318047/original/file-20200302-18262-1vtgbvj.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=497&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318047/original/file-20200302-18262-1vtgbvj.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=624&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318047/original/file-20200302-18262-1vtgbvj.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=624&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318047/original/file-20200302-18262-1vtgbvj.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=624&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Chart: Else Kennedy.</span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<hr>
<p>Some <a href="https://www.aihw.gov.au/getmedia/87fa8d3e-ca23-48e7-905f-57df367f8f14/aihw-age-101.pdf.aspx?inline=true">6% </a>of for-profit residential care facilities failed aged care standards in 2019, some of them multiple times. In comparison 5% of not-for-profit and 4% of government facilities failed standards. </p>
<p>The rate of non-compliance in for-profit facilities was 27% higher than not-for-profits, and 54% higher than government facilities.</p>
<p>This suggests for-profit providers in Australia are more likely to provide lower quality care. An <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2721035/">international review</a> has noted similar trends in other countries.</p>
<p>Profit margins are <a href="https://theconversation.com/its-hard-to-make-money-in-aged-care-and-thats-part-of-the-problem-103339">slim</a> in aged care, and for-profit providers are under pressure to make profits by cutting costs. This could lead to a lower standard of care compared with not-for-profit or government providers.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-is-nursing-home-food-so-bad-some-spend-just-6-08-per-person-a-day-thats-lower-than-prison-120421">Why is nursing home food so bad? Some spend just $6.08 per person a day – that's lower than prison</a>
</strong>
</em>
</p>
<hr>
<h2>Reasons for non-compliance in 2019</h2>
<p>The most common reasons for non-compliance in 2019 were in the area of personal and clinical care and the area of governance. </p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/318043/original/file-20200302-18291-1usnscx.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/318043/original/file-20200302-18291-1usnscx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/318043/original/file-20200302-18291-1usnscx.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=958&fit=crop&dpr=1 600w, https://images.theconversation.com/files/318043/original/file-20200302-18291-1usnscx.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=958&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/318043/original/file-20200302-18291-1usnscx.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=958&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/318043/original/file-20200302-18291-1usnscx.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1204&fit=crop&dpr=1 754w, https://images.theconversation.com/files/318043/original/file-20200302-18291-1usnscx.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1204&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/318043/original/file-20200302-18291-1usnscx.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1204&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Chart: Else Kennedy.</span>
<span class="attribution"><a class="license" href="http://creativecommons.org/licenses/by-nd/4.0/">CC BY-ND</a></span>
</figcaption>
</figure>
<hr>
<p>An example of a nursing home breaching the personal and clinical care standard could be if the home’s practices mean it isn’t giving medication correctly, isn’t managing wounds properly, or isn’t providing dignified help for residents using the toilet. </p>
<p>Homes might also breach the personal and clinical care standards if they don’t have sufficiently skilled staff such as registered nurses to care for residents with complex health needs.</p>
<p>A nursing home might be non-compliant in governance when it doesn’t have the right systems in place to monitor and improve its clinical care, for example in the areas of infection control or restraints. It might also be non-compliant if residents and families don’t have enough of a say in how the facility is run. </p>
<p>The new standards were supposed to place an <a href="https://www.agedcarequality.gov.au/news-media/commission-media-release-new-aged-care-standards-commence">increased focus</a> on dignity and choice, supporting the identity of a person, and increasing their say in the care they receive. This means catering for residents who want to have showers in the evening, stay up late, or make their own lunch. Previously there was much less emphasis on these aspects of aged care.</p>
<p>It is somewhat promising that more breaches of non-compliance in the “dignity and choice” standard have been picked up since the new standards came in. But given we know care is often poor in this area and there is an increased focus on this standard, we could have expected a more significant change.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-check-if-your-mum-or-dads-nursing-home-is-up-to-scratch-123449">How to check if your mum or dad's nursing home is up to scratch</a>
</strong>
</em>
</p>
<hr>
<p>Based on the first six months of non-compliance and sanctions data for the new aged care standards, we cannot be confident the new standards are ensuring nursing homes provide higher quality care. We await more data. </p>
<p>Until then, aged care residents and their families should monitor the quality of care they receive, know their aged care rights, and <a href="https://www.myagedcare.gov.au/contact-us/complaints">complain</a> if they think there is an issue.</p>
<p>If you or a family member are considering using an aged care provider, you can check whether the provider has breached standards via the <a href="https://www.myagedcare.gov.au/non-compliance-checker">My Aged Care non-compliance checker</a>.</p><img src="https://counter.theconversation.com/content/131449/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Lee-Fay Low currently receives funding from the NHMRC and Dementia Australia. She has previously received funding from aged care providers, and collaborates with several different aged care organisations. </span></em></p>We took a close look at breaches of aged care standards in 2019 to see what effect the new aged care standards are having, and where aged care providers are falling short.Lee-Fay Low, Associate Professor in Ageing and Health, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1141822019-05-05T20:17:02Z2019-05-05T20:17:02ZNearly 2 out of 3 nursing homes are understaffed. These 10 charts explain why aged care is in crisis<figure><img src="https://images.theconversation.com/files/272655/original/file-20190505-103053-jq7ic6.jpg?ixlib=rb-1.1.0&rect=2%2C2%2C1495%2C736&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Residential aged care is an immersive service for those with more complicated care needs.</span> <span class="attribution"><span class="source">The Conversation / Shutterstock</span></span></figcaption></figure><p>The <a href="https://agedcare.royalcommission.gov.au/Pages/default.aspx">Royal Commission into Aged Care Quality and Safety</a> begins hearings on residential aged care facilities, or nursing homes, in Sydney today.</p>
<p>The standards of nursing homes in Australia have been in the public eye since the <a href="https://www.abc.net.au/news/2017-09-22/oakden-closed-as-last-two-residents-moved-out/8974156">Oakden Aged Mental Health Care Service</a> in Adelaide became embroiled in an elder abuse and neglect scandal, sparking <a href="https://www.sahealth.sa.gov.au/wps/wcm/connect/Public+Content/SA+Health+Internet/About+us/Reviews+and+consultation/Review+of+the+Oakden+Older+Persons+Mental+Health+Service/">reviews</a>, <a href="https://www.abc.net.au/news/2017-11-21/oakden-senate-inquiry-begins/9172072">inquiries</a> and <a href="https://icac.sa.gov.au/system/files/ICAC_Report_Oakden.pdf">investigations</a> across the sector. This was the most prominent of a series of incidents of abuse and negligence that eventually led to the establishment of a royal commission.</p>
<p>So what are the challenges facing nursing homes and why are they under so much strain?</p>
<h2>How many Australians use aged care services?</h2>
<p>In the 2017-18 financial year, more than 1.2 million Australians accessed some form of aged care service:</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272440/original/file-20190503-103075-adfkb1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272440/original/file-20190503-103075-adfkb1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272440/original/file-20190503-103075-adfkb1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=649&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272440/original/file-20190503-103075-adfkb1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=649&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272440/original/file-20190503-103075-adfkb1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=649&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272440/original/file-20190503-103075-adfkb1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=816&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272440/original/file-20190503-103075-adfkb1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=816&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272440/original/file-20190503-103075-adfkb1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=816&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<p>Residential care is the most resource-intensive category of aged care, providing higher level care to older Australians with complicated medical needs, those in the last years of life, and people who can no longer live independently in their own homes.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/dont-wait-for-a-crisis-start-planning-your-aged-care-now-113572">Don't wait for a crisis – start planning your aged care now</a>
</strong>
</em>
</p>
<hr>
<h2>How old are residents?</h2>
<p>A large proportion of aged care residents are 90 and over. This reflects the increasing preference of older Australians to remain in their own homes longer, and only moving into residential care when home care is no longer adequate.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272397/original/file-20190503-103078-178htmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272397/original/file-20190503-103078-178htmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272397/original/file-20190503-103078-178htmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=659&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272397/original/file-20190503-103078-178htmp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=659&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272397/original/file-20190503-103078-178htmp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=659&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272397/original/file-20190503-103078-178htmp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=829&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272397/original/file-20190503-103078-178htmp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=829&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272397/original/file-20190503-103078-178htmp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=829&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
</figcaption>
</figure>
<hr>
<h2>Why aren’t you guaranteed a place?</h2>
<p>Australia has a relatively large proportion of older people, with <a href="http://www.abs.gov.au/ausstats/abs@.nsf/0/1CD2B1952AFC5E7ACA257298000F2E76?OpenDocument">more than 15%</a> of the population aged 65 years or over, which has resulted in strong demand for aged care places. </p>
<p>In 2017-18, almost a quarter of a million Australians (241,723) were approved for residential aged care, but just over 207,000 places were available. This left a shortfall of 34,581 places. </p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272242/original/file-20190502-103078-9k3gwn.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272242/original/file-20190502-103078-9k3gwn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272242/original/file-20190502-103078-9k3gwn.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=598&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272242/original/file-20190502-103078-9k3gwn.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=598&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272242/original/file-20190502-103078-9k3gwn.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=598&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272242/original/file-20190502-103078-9k3gwn.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=752&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272242/original/file-20190502-103078-9k3gwn.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=752&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272242/original/file-20190502-103078-9k3gwn.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=752&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<hr>
<h2>The aged care provision ratio</h2>
<p>The supply of home care packages and residential care places is determined using the <a href="https://www.gen-agedcaredata.gov.au/Topics/Services-and-places-in-aged-care/Explore-services-and-places-in-aged-care">aged care provision ratio</a>. The ratio will increase from its current target of 113 subsidised care places for every 1,000 people aged 70 and over to 125 places by 2021-22. </p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272418/original/file-20190503-103045-do1ysp.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272418/original/file-20190503-103045-do1ysp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272418/original/file-20190503-103045-do1ysp.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=846&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272418/original/file-20190503-103045-do1ysp.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=846&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272418/original/file-20190503-103045-do1ysp.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=846&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272418/original/file-20190503-103045-do1ysp.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1063&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272418/original/file-20190503-103045-do1ysp.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1063&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272418/original/file-20190503-103045-do1ysp.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1063&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<h2>Minimum staffing levels</h2>
<p>A <a href="https://www.smh.com.au/politics/federal/nursing-home-profits-soar-as-patient-care-declines-20151224-glupug.html">2015 survey</a> by Bentley’s Chartered Accountants estimated that residents received an average of 2 hours and 48 minutes of care per day. The Australian Nursing and Midwifery Federation <a href="http://anmf.org.au/campaign/entry/ratios-for-aged-care">recommends</a> residents receive 4 hours and 18 minutes of care per day.</p>
<p>The aged care industry does not currently have regulation related to <a href="https://theconversation.com/want-to-improve-care-in-nursing-homes-mandate-minimum-staffing-levels-104393">minimum staffing levels</a>, with the <a href="http://www8.austlii.edu.au/cgi-bin/viewdoc/au/legis/vic/num_act/spctpamtpra201551o2015643/s19.html">exception</a> of a small number of publicly owned aged care homes Victoria.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272420/original/file-20190503-103049-rnzh4k.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272420/original/file-20190503-103049-rnzh4k.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272420/original/file-20190503-103049-rnzh4k.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=677&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272420/original/file-20190503-103049-rnzh4k.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=677&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272420/original/file-20190503-103049-rnzh4k.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=677&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272420/original/file-20190503-103049-rnzh4k.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=851&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272420/original/file-20190503-103049-rnzh4k.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=851&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272420/original/file-20190503-103049-rnzh4k.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=851&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/want-to-improve-care-in-nursing-homes-mandate-minimum-staffing-levels-104393">Want to improve care in nursing homes? Mandate minimum staffing levels</a>
</strong>
</em>
</p>
<hr>
<h2>The workforce and skills shortage</h2>
<p>The Productivity Commission <a href="https://www.pc.gov.au/inquiries/completed/aged-care/report">estimated in 2011</a> the workforce will need to grow to about 980,000 by 2050 to meet the demand of aged care consumers. (And the population projections this estimate is based on have <a href="https://www.abs.gov.au/ausstats/abs@.nsf/0/5A9C0859C5F50C30CA25718C0015182F?Opendocument">increased substantially</a> since then, so this number may end up being significantly higher).</p>
<p>But providers are already finding it difficult to adequately staff nursing homes, with 64% of residential care facilities reporting shortages in 2016. And with employee costs representing 70% of the total expenses for residential care providers (an increase from 67% of total expenses in 2015-16), there is <a href="https://www.abc.net.au/news/2018-09-07/mandate-staff-resident-ratios-in-aged-care-nursing-homes/10210244">concern</a> that residents will not be given proper care.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272387/original/file-20190502-103078-5h2tp5.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272387/original/file-20190502-103078-5h2tp5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272387/original/file-20190502-103078-5h2tp5.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=631&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272387/original/file-20190502-103078-5h2tp5.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=631&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272387/original/file-20190502-103078-5h2tp5.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=631&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272387/original/file-20190502-103078-5h2tp5.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=793&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272387/original/file-20190502-103078-5h2tp5.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=793&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272387/original/file-20190502-103078-5h2tp5.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=793&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
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<hr>
<h2>Residential care providers and their financial viability</h2>
<p>There were <a href="https://www.gen-agedcaredata.gov.au/Resources/Access-data/2018/September/Stocktake-data-30-June-2018">210,815 operational residential care places</a> as at June 30 2018, an increase of about 24,500 places in the last five years. Over that time, the number of providers has decreased from 1,034 to 886, mainly due to consolidation.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272274/original/file-20190502-103045-1sigikt.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272274/original/file-20190502-103045-1sigikt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272274/original/file-20190502-103045-1sigikt.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=789&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272274/original/file-20190502-103045-1sigikt.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=789&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272274/original/file-20190502-103045-1sigikt.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=789&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272274/original/file-20190502-103045-1sigikt.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=992&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272274/original/file-20190502-103045-1sigikt.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=992&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272274/original/file-20190502-103045-1sigikt.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=992&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<hr>
<p>While profits (before tax) have almost doubled since 2012-13, only 68% of providers reported a net profit in 2016-17 (compared to 69% in 2015-16). A <a href="http://www.stewartbrown.com.au/news-articles/26-aged-care/166-june-2018-aged-care-sector-reports-released">survey</a> of more than 970 residential care facilities found 45% of facilities had negative earnings (before tax) in 2018, an increase from 33% in 2017.</p>
<hr>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272390/original/file-20190502-103068-1viyno8.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272390/original/file-20190502-103068-1viyno8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272390/original/file-20190502-103068-1viyno8.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=658&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272390/original/file-20190502-103068-1viyno8.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=658&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272390/original/file-20190502-103068-1viyno8.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=658&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272390/original/file-20190502-103068-1viyno8.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=827&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272390/original/file-20190502-103068-1viyno8.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=827&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272390/original/file-20190502-103068-1viyno8.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=827&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<hr>
<h2>Funding for residential aged care</h2>
<p>Residential aged care facilities require government funding as well as resident contributions to operate. </p>
<p>Government contributions accounted for <a href="https://www.pc.gov.au/research/ongoing/report-on-government-services/2019/community-services/aged-care-services">67.3% (A$12.4 billion)</a> of total provider funding in 2017-18, the majority (89%) of which is made up of the <a href="https://agedcare.health.gov.au/aged-care-funding/residential-care-subsidy/basic-subsidy-amount-aged-care-funding-instrument">basic care subsidy</a>.</p>
<p>The subsidy is calculated for each resident based on their needs using the <a href="https://agedcare.health.gov.au/funding/aged-care-subsidies-and-supplements/residential-care-subsidy/basic-subsidy-amount-aged-care-funding-instrument/aged-care-funding-instrument-acfi-user-guide">aged care funding instrument (ACFI)</a>. To care for a resident with high needs the provider will receive a <a href="https://agedcare.health.gov.au/sites/default/files/documents/03_2019/aged_care_subsidies_and_supplements_new_rates_of_payment_from_20_march_2019_-_schedule_of_fees_and_charges.pdf">larger subsidy</a>.</p>
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<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/272280/original/file-20190502-103071-110xs00.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/272280/original/file-20190502-103071-110xs00.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/272280/original/file-20190502-103071-110xs00.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=728&fit=crop&dpr=1 600w, https://images.theconversation.com/files/272280/original/file-20190502-103071-110xs00.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=728&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/272280/original/file-20190502-103071-110xs00.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=728&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/272280/original/file-20190502-103071-110xs00.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=915&fit=crop&dpr=1 754w, https://images.theconversation.com/files/272280/original/file-20190502-103071-110xs00.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=915&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/272280/original/file-20190502-103071-110xs00.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=915&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<hr><img src="https://counter.theconversation.com/content/114182/count.gif" alt="The Conversation" width="1" height="1" />
The aged care royal commission begins hearing evidence today about the quality of care in nursing homes. These 10 charts show how the current system works and the challenges it faces.Emil Jeyaratnam, Data + Interactives Editor, The ConversationAndrew Donegan, Data + Interactives Editorial Intern, The ConversationLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1048522018-10-23T19:15:52Z2018-10-23T19:15:52ZWhat is ‘quality’ in aged care? Here’s what studies (and our readers) say<figure><img src="https://images.theconversation.com/files/241748/original/file-20181022-105773-1214zei.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Social connections help retain a sense of purpose in older age.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>A challenge facing the recently announced <a href="https://agedcare.royalcommission.gov.au/Pages/default.aspx">Royal Commission into Aged Care Quality and Safety</a> will be to define “quality”. </p>
<p>Everyone has their own idea of what quality of care and quality of life in residential aged care may look like. The Conversation asked readers how they would want a loved one to be cared for in a residential aged care facility. What they said was similar to what surveys around the world have consistently found.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1050170868318392321"}"></div></p>
<p>Characteristics that often appear as the basis for good quality of life include living in a home-like rather than an institutionalised environment, social connection and access to the outdoors. Good quality of care tends to focus on providing assistance that is timely and appropriate to individual needs.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australias-residential-aged-care-facilities-are-getting-bigger-and-less-home-like-103521">Australia's residential aged care facilities are getting bigger and less home-like</a>
</strong>
</em>
</p>
<hr>
<h2>A bleak view of aged care</h2>
<p>A mature judgment to determine good quality requires us to recognise that many people have an instinctive and distressingly bleak view of ageing, disability, dementia and death. Some people express this as death being preferable to living in aged care, as the tweet below shows. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241384/original/file-20181019-67161-1v710ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241384/original/file-20181019-67161-1v710ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241384/original/file-20181019-67161-1v710ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=339&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241384/original/file-20181019-67161-1v710ct.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=339&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241384/original/file-20181019-67161-1v710ct.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=339&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241384/original/file-20181019-67161-1v710ct.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=426&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241384/original/file-20181019-67161-1v710ct.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=426&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241384/original/file-20181019-67161-1v710ct.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=426&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://twitter.com/47whitebuffalo/status/1050189788840521728">Twitter</a></span>
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</figure>
<p>This doesn’t necessarily reflect an objective assessment of the actual care being delivered in residential facilities, but it does speak to the fear of losing independence, autonomy and identity.</p>
<p>In a <a href="https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2540535">survey of patients</a> with serious illnesses hospitalised in the US, around 30% of respondents considered life in a nursing home to be a worse fate than death. Bowel and bladder incontinence and being confused all the time were two other states considered worse than death.</p>
<p>Aged care facilities will be the final residence for most before they die. This means the residents’ sense of futility and the notion one is simply waiting to die can and should be addressed. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-our-residential-aged-care-system-doesnt-care-about-older-peoples-emotional-needs-103336">How our residential aged-care system doesn't care about older people's emotional needs</a>
</strong>
</em>
</p>
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<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/241783/original/file-20181023-169819-12s8783.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241783/original/file-20181023-169819-12s8783.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/241783/original/file-20181023-169819-12s8783.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=568&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241783/original/file-20181023-169819-12s8783.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=568&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241783/original/file-20181023-169819-12s8783.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=568&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241783/original/file-20181023-169819-12s8783.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=714&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241783/original/file-20181023-169819-12s8783.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=714&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241783/original/file-20181023-169819-12s8783.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=714&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Loose-leaf tea can make someone feel at home.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/PVSCfkqcMP4">Matt Seymour/Unsplash</a></span>
</figcaption>
</figure>
<p>Our reason for being is usually expressed through social connections. This a recurring theme for residents who <a href="https://onlinelibrary.wiley.com/doi/abs/10.1111/jan.12332">define quality of care</a> as whether or not residents have friendships and are allowed reciprocity with their caregivers.</p>
<p>A <a href="https://www.ncbi.nlm.nih.gov/pubmed/22678747">systematic review</a> that drew together a number of studies of quality in aged care found residents were most concerned about the lack of individual autonomy and difficulty in forming relationships when in care.</p>
<h2>Good staff</h2>
<p>The need for positive social connections for residents extends to the relationships between staff and families. Achieving this requires <a href="http://journals.sagepub.com/doi/abs/10.1177/0733464812468503">staff with a positive attitude</a> who work to build trust and involve family in their loved one’s care. They must also engage on issues that have meaning to the individuals. </p>
<p>Good staff should be both technically proficient and, perhaps more importantly, good with people.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241758/original/file-20181023-169804-1u0t1cu.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241758/original/file-20181023-169804-1u0t1cu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241758/original/file-20181023-169804-1u0t1cu.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=197&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241758/original/file-20181023-169804-1u0t1cu.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=197&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241758/original/file-20181023-169804-1u0t1cu.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=197&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241758/original/file-20181023-169804-1u0t1cu.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=248&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241758/original/file-20181023-169804-1u0t1cu.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=248&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241758/original/file-20181023-169804-1u0t1cu.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=248&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Dianne Wintle comment.</span>
<span class="attribution"><span class="source">Facebook screenshot</span></span>
</figcaption>
</figure>
<h2>Idyllic, or the way it should be?</h2>
<p>A home-like setting – which may include having a pet and enjoying time in nature, as the Tweet below describes – may seem idyllic. However, more contemporary models of care are moving towards <a href="https://www.mja.com.au/journal/2018/208/10/clustered-domestic-residential-aged-care-australia-fewer-hospitalisations-and">smaller home-like environments</a> that accommodate fewer people and are more like a household than a large institution. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241361/original/file-20181019-67194-y0o4j1.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241361/original/file-20181019-67194-y0o4j1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241361/original/file-20181019-67194-y0o4j1.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=358&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241361/original/file-20181019-67194-y0o4j1.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=358&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241361/original/file-20181019-67194-y0o4j1.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=358&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241361/original/file-20181019-67194-y0o4j1.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=450&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241361/original/file-20181019-67194-y0o4j1.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=450&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241361/original/file-20181019-67194-y0o4j1.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=450&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="attribution"><a class="source" href="https://twitter.com/marymarjorie125/status/1050196591787659266">Twitter</a></span>
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</figure>
<p>The ability to relate and personalise care to a small group of 10-12 residents is surely easier than catering to 30-60 residents. Some studies in the US have shown residents in such smaller units have an enhanced quality of life that doesn’t compromise <a href="https://www.ncbi.nlm.nih.gov/pubmed/26743545">clinical care</a> or <a href="https://www.ncbi.nlm.nih.gov/pubmed/21158746">running costs</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/caring-for-elderly-australians-in-a-home-like-setting-can-reduce-hospital-visits-97451">Caring for elderly Australians in a home-like setting can reduce hospital visits</a>
</strong>
</em>
</p>
<hr>
<p>This cluster-style housing still has <a href="https://www.mja.com.au/journal/2018/208/10/residential-aged-care-there-no-single-optimal-model">limitations that need to be addressed</a>. These include selecting residents who are suitable together and catering for the changing clinical and care needs of each individual. </p>
<h2>Pets and the outdoors</h2>
<p>Research into the value of pets in aged care has <a href="https://www.ncbi.nlm.nih.gov/pubmed/29441797">largely focused</a> on the benefits to people living with dementia. Introducing domestic animals, typically dogs, has been shown to have positive effects on social behaviours, physical activity and overall quality of life for residents.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241756/original/file-20181023-169810-1gq5nii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241756/original/file-20181023-169810-1gq5nii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241756/original/file-20181023-169810-1gq5nii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241756/original/file-20181023-169810-1gq5nii.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241756/original/file-20181023-169810-1gq5nii.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241756/original/file-20181023-169810-1gq5nii.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241756/original/file-20181023-169810-1gq5nii.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241756/original/file-20181023-169810-1gq5nii.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Pets improve quality of life for people living with dementia.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Similarly, providing accommodation where the physical environment and building promote engagement in a range of indoor and outdoor activities, and allow for both private and community spaces, is <a href="https://www.ncbi.nlm.nih.gov/pubmed/24803645">associated with a better quality</a> of life.</p>
<h2>Good food</h2>
<p>Another major determinant of quality of life in residential aged care is the <a href="https://www.ncbi.nlm.nih.gov/pubmed/25373998">quality of food</a>. This becomes even more important as people age. Providing high-quality food and enriching meal times is more challenging as many diseases such as dementia and stroke affect older people’s dentition and swallowing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241382/original/file-20181019-67161-18sieq7.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241382/original/file-20181019-67161-18sieq7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241382/original/file-20181019-67161-18sieq7.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=428&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241382/original/file-20181019-67161-18sieq7.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=428&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241382/original/file-20181019-67161-18sieq7.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=428&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241382/original/file-20181019-67161-18sieq7.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=538&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241382/original/file-20181019-67161-18sieq7.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=538&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241382/original/file-20181019-67161-18sieq7.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=538&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://twitter.com/robyn1001/status/1050205639761223681">Twitter</a></span>
</figcaption>
</figure>
<p>Aged care services need proactive and innovative approaches to overcome these deficits and better promote general health. </p>
<p>A key feature often overlooked is the cultural significance of food. Providing <a href="https://www.ncbi.nlm.nih.gov/pubmed/26752100">traditional foods</a> to residents strengthens their feeling of belonging and identity, helping them hold on to their cultural roots and enhance their quality of life.</p>
<h2>Safety, dignity, respect and choice</h2>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241383/original/file-20181019-67182-1t25e5v.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241383/original/file-20181019-67182-1t25e5v.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241383/original/file-20181019-67182-1t25e5v.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=372&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241383/original/file-20181019-67182-1t25e5v.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=372&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241383/original/file-20181019-67182-1t25e5v.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=372&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241383/original/file-20181019-67182-1t25e5v.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=468&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241383/original/file-20181019-67182-1t25e5v.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=468&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241383/original/file-20181019-67182-1t25e5v.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=468&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://twitter.com/shinexox/status/1050191359846440961">Twitter</a></span>
</figcaption>
</figure>
<p>While the focus is often <a href="https://www.alrc.gov.au/publications/elder-abuse-report">on preventing abuse</a>, neglect and restrictive practices in aged care, the absence of these harmful events doesn’t equate to a positive culture. Residents want and have a right to feel safe, valued, respected and able to express and exercise choice. Positive observation of these rights is essential for quality of life.</p>
<h2>Clinical and personal care</h2>
<p>Time is a factor in aged care, as staff often don’t have enough time to spend with each resident. A recent <a href="https://www.abc.net.au/4corners/who-cares/10258290">ABC Four Corners investigation</a> into quality in aged care found personal care assistants had only six minutes to help residents shower and get dressed. No wonder, then, that staff often don’t have the personal time to be able to spend with residents who need life to be a little slower, as the Facebook comment below shows.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/241757/original/file-20181023-169822-mqj92i.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/241757/original/file-20181023-169822-mqj92i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/241757/original/file-20181023-169822-mqj92i.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=296&fit=crop&dpr=1 600w, https://images.theconversation.com/files/241757/original/file-20181023-169822-mqj92i.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=296&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/241757/original/file-20181023-169822-mqj92i.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=296&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/241757/original/file-20181023-169822-mqj92i.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=372&fit=crop&dpr=1 754w, https://images.theconversation.com/files/241757/original/file-20181023-169822-mqj92i.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=372&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/241757/original/file-20181023-169822-mqj92i.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=372&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Jo Art comment.</span>
<span class="attribution"><span class="source">Facebook</span></span>
</figcaption>
</figure>
<p>Clinical care is another important aspect of quality aged care. A resident cannot enjoy a good quality of life if their often multiple and chronic conditions such as diabetes, heart failure and arthritis are poorly managed by their doctors and nurses. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/australias-aged-care-residents-are-very-sick-yet-the-government-doesnt-prioritise-medical-care-88690">Australia's aged care residents are very sick, yet the government doesn't prioritise medical care</a>
</strong>
</em>
</p>
<hr>
<p>Residents in aged care are the same as those who live in the community. They are people with the same needs and wants. The only difference is they need the community to give the time, effort and thought to achieve a better life.</p><img src="https://counter.theconversation.com/content/104852/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Joseph Ibrahim has received funding in the past from State and Federal Government departments for research investigating premature and preventable deaths in nursing homes. </span></em></p>The Conversation asked readers how they would want a loved one to be cared for in a residential aged care facility. What they said was similar to what surveys around the world have consistently found.Joseph Ibrahim, Professor, Health Law and Ageing Research Unit, Department of Forensic Medicine, Monash UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1033232018-10-21T19:17:03Z2018-10-21T19:17:03ZFactCheck: is the Coalition spending ‘$1 billion extra, every year’ on aged care?<blockquote>
<p>In aged care in particular we’re spending A$1 billion extra, every year.</p>
<p><strong>– Prime Minister Scott Morrison, <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id:%22media/pressrel/6247445%22">doorstop interview</a>, Guildford, Western Australia, October 2, 2018</strong></p>
</blockquote>
<p>Preparations for the <a href="https://www.pm.gov.au/media/royal-commission-aged-care-quality-and-safety">Royal Commission into aged care</a> are <a href="https://agedcare.health.gov.au/royal-commission-into-aged-care-quality-and-safety">now underway</a>, with Prime Minister Scott Morrison having <a href="https://www.abc.net.au/news/2018-09-16/scott-morrison-announces-royal-commission-into-aged-care-sector/10252850">warned</a> Australians to brace themselves for “pretty bruising information” about the mistreatment of elderly people in the sector. </p>
<p>The Royal Commission <a href="https://agedcare.royalcommission.gov.au/Pages/Terms-of-reference.aspx">will examine</a> the quality and sufficiency of aged care services currently being provided – including a focus on <a href="https://www.abc.net.au/4corners/who-cares/10258290">evident</a> substandard treatment, mistreatment, abuse and systemic failures – and the challenges facing the sector more broadly as Australia’s baby boomer population begins to require its services. </p>
<p>Opposition leader Bill Shorten <a href="http://www.billshorten.com.au/abc_insiders_sunday_16_september_2018">said</a> it wasn’t possible to “repair the system whilst you’re cutting it at the same time”, with the Labor leader <a href="https://parlinfo.aph.gov.au/parlInfo/search/display/display.w3p;query=Id:%22media/pressrel/6217594%22;src1=sm1">and</a> <a href="https://twitter.com/SenatorWong/status/1041911109123358720">other</a> <a href="https://twitter.com/BOConnorMP/status/1041529828367687680">MPs</a> asserting the Coalition had made cuts of between A$1.2 billion and A$2 billion to aged care during Morrison’s time as Treasurer.</p>
<p>The Prime Minister rejected those accusations, saying the government was spending “A$1 billion extra, every year” on aged care.</p>
<p>Let’s look at the numbers. </p>
<h2>Checking the source</h2>
<p>The Conversation requested sources and comment from the Prime Minister’s office, but did not receive a response before publication. </p>
<hr>
<h2>Verdict</h2>
<p>Prime Minister Scott Morrison’s statement that the Coalition is “spending A$1 billion extra, every year” on aged care is correct when spending is calculated in nominal terms (not adjusted for inflation).</p>
<p>Budget papers show that estimated nominal spending on aged care has risen by more than A$1 billion per year since financial year 2014-15, following the Coalition’s first budget in May 2014. </p>
<p>In real terms – adjusted for inflation – estimated spending on aged care increased by between A$679 million and A$796 million per year between 2014-15 and 2017-18.</p>
<p>Spending on aged care is projected to continue to increase by more than A$1 billion per year (in nominal terms) from 2017-18 to 2021-22.</p>
<hr>
<h2>Coalition spending on aged care</h2>
<p>The Australian government is the primary <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp1617/Quick_Guides/Aged_Care_a_quick_guide">funder</a> and regulator of the <a href="https://www.aihw.gov.au/reports-statistics/health-welfare-services/aged-care/overview">aged care system</a>, with care provided by a <a href="https://www.myagedcare.gov.au/">range</a> of non-profit and private providers. </p>
<p>Budget papers show that estimated nominal spending on aged care (not adjusted for inflation) has risen by more than A$1 billion per year since financial year 2014-15, following the Coalition’s first budget in May 2014. </p>
<p>The table below shows estimates from each Budget of spending on aged care and services, including care and services for veterans, spending on nursing homes and other institutions, and community care services for older people, but excluding the aged pension and concessions.</p>
<p>In 2014-15, estimated spending was A$15.3 billion. This grew to an estimated A$18.4 billion in 2017-18.</p>
<iframe src="https://datawrapper.dwcdn.net/Floj5/6/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="400"></iframe>
<p>In real terms – adjusted for inflation – estimated spending on aged care increased by between A$679 million and A$796 million per year between 2014-15 and 2017-18.</p>
<iframe src="https://datawrapper.dwcdn.net/TZeEQ/5/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="420"></iframe>
<p>Here’s spending per person aged 85 and over:</p>
<iframe src="https://datawrapper.dwcdn.net/ZKTJz/4/" scrolling="no" frameborder="0" allowtransparency="true" width="100%" height="420"></iframe>
<h2>Have there been cuts to aged care funding, as Labor claimed?</h2>
<p>In the wake of the announcement of the Royal Commission into aged care, Opposition leader <a href="http://www.billshorten.com.au/abc_insiders_sunday_16_september_2018">Bill Shorten said</a> the current government had “cut A$2 billion, nearly, in aged care funding”. </p>
<p>Labor <a href="https://twitter.com/SenatorWong/status/1041911109123358720">Senator Penny Wong</a>, Shadow Minister for Employment and Workplace Relations <a href="https://twitter.com/BOConnorMP/status/1041529828367687680">Brendan O'Connor</a>, Greens Senator <a href="https://twitter.com/sarahinthesen8/status/1041182433775767553">Sarah Hanson-Young</a>, the <a href="https://twitter.com/unionsaustralia/status/1042270545474027520">Australian Council of Trade Unions</a> and its Secretary <a href="https://twitter.com/sallymcmanus/status/1041455196759445504">Sally McManus</a>, among others, pointed to a figure of A$1.2 billion in cuts from aged care during Scott Morrison’s time as Treasurer. </p>
<p>Shadow Minister for Ageing and Mental Health, Julie Collins, <a href="http://outagepi.aph.gov.au/">said</a> Morrison’s “$1.2 billion cut in the 2016 Budget came on top of the almost $500 million from aged care funding he cut in the 2015 MYEFO”.</p>
<h2>Funding changes outlined in 2015 MYEFO</h2>
<p>In its <a href="https://www.budget.gov.au/2015-16/content/myefo/html/index.htm">2015 Mid-Year Economic and Fiscal Outlook</a> (MYEFO), the government did <a href="https://www.budget.gov.au/2015-16/content/myefo/html/03_part_3-01.htm">outline</a> a range of policy decisions that had reduced spending.</p>
<p>One of these was changes to the <a href="https://agedcare.health.gov.au/tools-and-resources/aged-care-funding-instrument-acfi-reports">Aged Care Funding Instrument</a> – a measure used to assess the needs of aged care residents, and therefore how much funding the aged care providers receive as a result. </p>
<p>The government said it would refine the Aged Care Funding Instrument to “better align the funding claimed by providers to the level of care provided, through changes to the scoring matrix”. In other words, to make sure aged care providers weren’t receiving money for care that wasn’t required or being delivered. </p>
<p>The government said these changes were expected to reduce cash payments by A$472.4 million over three years to 2018‑19.</p>
<p>In addition, the 2015 MYEFO update <a href="https://www.budget.gov.au/2015-16/content/myefo/html/11_appendix_a_expense.htm">noted</a> that “improved compliance” around the provision of funding to residential aged care providers (including a focus on false claims) would lead to a net saving of A$61.9 million between 2015-16 and 2018-19.</p>
<p>The combination of the two initiatives were expected to lead to savings of A$534.3 million over four years.</p>
<p>But there were also <em>increases</em> in spending. </p>
<p>The 2015 MYEFO <a href="https://www.budget.gov.au/2015-16/content/myefo/html/03_part_3-01.htm">noted</a> that payments related to the Residential and Flexible Care program were rising, and were expected to:</p>
<blockquote>
<p>… increase by A$162 million in 2015-16 (A$943 million over the four years to 2018-19), largely reflecting a higher than expected growth in care subsidies provided to residential aged care facilities.</p>
</blockquote>
<p>Overall, the increase in payments to 2018-19 (A$943 million) was greater than the savings (A$534.3 million) over the same period. </p>
<h2>Funding changes outlined in the 2016-17 Federal Budget</h2>
<p>In the <a href="https://www.budget.gov.au/2016-17/content/bp2/html/bp2_expense-15.htm">2016-17 Budget</a>, the government said that by expanding on the refinements to the scoring matrix of the Aged Care Funding Instrument (outlined in 2015 MYEFO), it would achieve savings of A$1.2 billion over four years.</p>
<p>(That’s the A$1.2 billion federal Labor and other groups were referring to.)</p>
<p>In addition, the government said it would reduce indexation of the Complex Health Care component of the Aged Care Funding Instrument by 50% in 2016-17 (and establish a A$53.3 million transitional assistance fund to support providers).</p>
<p>The government said these measure were in response to continued higher than expected growth in spending on the Aged Care Funding Instrument, which had increased by a further A$2.5 billion over the forward estimates since the 2015 MYEFO.</p>
<p>The next item in the Budget papers outlined higher spending for regional aged care facilities. The government said it would provide A$102.3 million over four years from 2016-17 to target the viability supplement (which address cost pressures experienced by residential care providers) more effectively to areas of greatest need. </p>
<h2>The bottom line?</h2>
<p>The claims that the Coalition has cut aged care spending do refer to specific saving initiatives the government has made, but they do not include other policy changes that have <em>increased</em> spending and variations in <em>actual spending</em> due to higher costs.</p>
<p>So while there have been decreases in aged care spending in some areas, the MYEFO and Budget papers show that these were made, in part, to offset <em>increases</em> in spending in other areas of aged care. </p>
<p>And when we look at the final figure, it shows that estimated spending on aged care has risen by more than A$1 billion per year since 2014-15, and is projected to continue to increase by more than A$1 billion per year from 2017-18 to 2021-22. <strong>– Peter Whiteford</strong></p>
<hr>
<h2>Blind review</h2>
<p>Politicians love to claim credit for spending more on things such as health and aged care, and it would be a rare year if more money was not spent, given the underlying economic and demographic dynamics.</p>
<p>Governments like to focus on inputs – such as spending – preferably not adjusted for inflation or population growth, as it makes the numbers bigger. Oppositions also like to focus on numbers – and often reductions in promised future spending – suggesting governments are chiselling consumers or the industry. </p>
<p>The Government is indeed spending more on aged care, as shown in this FactCheck. But although aged care spending has increased, it would have increased more but for the Government’s actions, as Labor has asserted. <strong>– Stephen Duckett</strong></p>
<hr>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/162128/original/image-20170323-13486-72k52f.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Conversation FactCheck is accredited by the International Fact-Checking Network.</span>
</figcaption>
</figure>
<p><em>The Conversation’s FactCheck unit was the first fact-checking team in Australia and one of the first worldwide to be accredited by the International Fact-Checking Network, an alliance of fact-checkers hosted at the Poynter Institute in the US. <a href="https://theconversation.com/the-conversations-factcheck-granted-accreditation-by-international-fact-checking-network-at-poynter-74363">Read more here</a>.</em></p>
<p><em>Have you seen a “fact” worth checking? The Conversation’s FactCheck asks academic experts to test claims and see how true they are. We then ask a second academic to review an anonymous copy of the article. You can request a check at <a href="mailto:checkit@theconversation.edu.au">checkit@theconversation.edu.au</a>. Please include the statement you would like us to check, the date it was made, and a link if possible.</em></p><img src="https://counter.theconversation.com/content/103323/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Peter Whiteford has received funding from the Australian Research Council and the Department of Social Services. He is affiliated with the Centre for Policy Development. </span></em></p><p class="fine-print"><em><span>Stephen Duckett is a member of the Board of Directors of an aged care provider, the Brotherhood of St Laurence.</span></em></p>Prime Minister Scott Morrison has defended the Coalition’s spending on aged care as preparations for a Royal Commission into the sector get underway. We asked the experts to crunch the numbers.Peter Whiteford, Professor, Crawford School of Public Policy, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1007272018-08-14T22:25:27Z2018-08-14T22:25:27ZWhen choosing a nursing home, check the clothing and laundry<figure><img src="https://images.theconversation.com/files/231384/original/file-20180809-30446-zw0yyt.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Clothes are central to our personal identity and our dignity. Their condition reveals the care work that has gone into their selection and maintenance. </span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Last year, Elizabeth Wettlaufer pleaded guilty to killing eight nursing home residents while working as a nurse in southern Ontario between 2007 and 2016. The inquiry into this case has once again <a href="https://www.cbc.ca/news/canada/london/risk-level-long-term-care-homes-wettlaufer-inquiry-1.4776033">raised debate about how nursing homes are inspected and how the health and safety of residents can be ensured</a>. </p>
<p>Not surprisingly, when I tell my friends that I am researching nursing homes to find good ideas worth sharing, they cannot imagine my interest. Their first response is: “I’ll never go there.” Yet any one of us could end our days in a care home, whatever our current health or income.</p>
<p>When I tell my friends that I am writing about <a href="http://www.mqup.ca/wash--wear--and-care-products-9780773549234.php?page_id=73&">clothes and laundry in nursing homes</a>, they are even more surprised. But when I say this to anyone who lives in, works in or visits a nursing home, they understand how clothes and laundry are in fact critical to health.</p>
<p>Clothes are about gender, class, culture and care. Indeed, clothes <a href="https://doi.org/10.1017/S0144686X06005794">are central to our personal identity and our dignity</a>. Their condition reveals the care work that has gone into their selection and maintenance. </p>
<p>Clothes have a particular significance in the communal setting that is a nursing home, where so many other aspects of identity may be under threat. Clothes are a way to establish individuality, helping residents and their families control how they are perceived by others. Clothes also indicate how much and what kind of work went into their presentation and care.</p>
<p>Our <a href="http://reltc.apps01.yorku.ca/our-team">research team</a> has searched in Norway, Sweden, Germany, the United Kingdom, the United States and Canada for ideas worth sharing on how to make nursing homes as good as they can be — for those who live and work in them. </p>
<p>Everywhere, we heard about clothes and laundry. </p>
<h2>Sagging, urine-stained pants</h2>
<p>On admission to a nursing home, residents are often told to bring only three changes of clothes (and we saw closets so small that they could not hold more). </p>
<p>Many homes require that clothes be labelled, machine washable and able to withstand the high temperatures used to destroy germs that may be a threat to seniors. So forget about that cashmere sweater your daughter gave you! </p>
<p>The labelling is not surprising. In one home, clothes were returned from an outside laundry on racks that were left in the hallway. One daughter told us that residents treated the racks like those in Walmart, taking their pick. We saw signs saying: “Has anyone one seen this sweater?” and heard lots of complaints about ruined clothing.</p>
<p>We also witnessed residents in mismatched clothing, in sagging urine-stained pants and with blouses undone. </p>
<p>In some places, this reflected the regulation that requires staff to have everyone up, dressed and at breakfast by 8 a.m. The rush was complicated by staffing numbers too small to deal with both the high needs and significant variation among residents.</p>
<h2>Well-dressed residents, well-staffed homes</h2>
<p>But we also observed places where residents were well-dressed in ways that established their identity. A number of practices and structures contributed. The most common was daughters taking their mothers’ clothes home to be cleaned. Decent-sized closets also helped ensure a range of choices. </p>
<p>In Sweden, we studied a home that had a small bench at the entry way, where bulky outdoor clothes were hung. Their presence suggested at least the promise of a walk outside. </p>
<p>The Swedish home also had a small washer/dryer in each resident’s bathroom. When the care worker came to help the resident get up and dressed, she put the clothes in the washing machine and adjusted it for delicate wash when necessary. </p>
<p>The practice also kept any germs in the room and prevented clothes from being lost, and at the same time it relieved the worker from having to lift heavy laundry loads. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/231392/original/file-20180809-30452-l9kv0p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/231392/original/file-20180809-30452-l9kv0p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/231392/original/file-20180809-30452-l9kv0p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/231392/original/file-20180809-30452-l9kv0p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/231392/original/file-20180809-30452-l9kv0p.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/231392/original/file-20180809-30452-l9kv0p.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/231392/original/file-20180809-30452-l9kv0p.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Strategies such as in-room laundry facilities or allowing breakfast in pyjamas can help nursing home residents maintain their dignity and identity.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Washer/dryers in each room may be out of reach for many homes, but other homes have adjustable machines in each small section of the home, offering more control over clothes and their care compared to commercial laundry services.</p>
<p>The homes where we saw better-dressed residents tended to have lots of staff, like one German home that had 66 nursing staff supplemented by 110 apprentices. Some Norwegian homes had nearly one staff member per resident. </p>
<p>But other strategies can also help. In one Nova Scotia home, the residents can get up when they want and eat in their pyjamas if they wish. This gives workers the time to pay attention to each resident’s dress. Indeed, we observed staff consulting with residents about whether they thought the green sweater matched the blue blouse.</p>
<p>We have other examples of promising practices and these are detailed in an <em>Ideas Worth Sharing</em> <a href="http://reltc.apps01.yorku.ca/books">series of books and e-books we have produced</a>. </p>
<p>Above all, when designing, managing and choosing nursing homes, we need to pay attention to clothes. This means attending to how residents are helped to dress and how clothes are worn, cleaned and stored. This means attending to workers, families, residents and physical environments.</p><img src="https://counter.theconversation.com/content/100727/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Pat Armstrong receives funding from Social Science and Humanities Research Foundation; Canadian Institutes for Health Research. </span></em></p>As the Wettlaufer inquiry wraps up for the summer, an international research team offers suggestions on how to make nursing homes as good as they can possibly be.Pat Armstrong, Distinguished Research Professor of Sociology, York University, CanadaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/943972018-05-31T19:52:11Z2018-05-31T19:52:11ZChildren with severe trauma can be fostered, and recover with the right treatment and care<figure><img src="https://images.theconversation.com/files/219898/original/file-20180522-51141-gndcxm.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Traumatised children can go on to lead better lives.</span> <span class="attribution"><a class="source" href="https://unsplash.com/photos/eo11MS0FSnk">Photo by Bruno Nascimento/Unsplash</a></span></figcaption></figure><p>Being a foster carer for <a href="https://www.dcp.wa.gov.au/ChildProtection/ChildAbuseAndNeglect/Documents/ChildDevelopmentAndTraumaGuide.pdf">children who have experienced early life trauma</a> – such as emotional and physical violence – can be challenging, complex and confusing. For children, experiencing severe early trauma can manifest in <a href="http://oohctoolbox.org.au/trauma-and-behaviour">difficult behaviours</a>, resulting in <a href="http://journals.sagepub.com/doi/abs/10.1177/1473325012474017">unsuccessful foster care placements</a>.</p>
<p>We were commissioned to evaluate the effectiveness of a Victorian, home-based therapeutic program that only accepts children who aren’t suitable for traditional foster care because their needs are deemed too complex. These children are either already in residential care – a system of care that involves rostered staff as carers, and group living – or are eligible for it.</p>
<p>In residential care, a child may be exposed to other young people with high-risk behaviours and can be disconnected from family, culture, school and community supports. This delays their recovery and puts them at risk of further trauma.</p>
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<strong>
Read more:
<a href="https://theconversation.com/nothing-to-see-here-the-abuse-and-neglect-of-children-in-care-is-a-century-old-story-in-australia-68743">Nothing to see here? The abuse and neglect of children in care is a century-old story in Australia</a>
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<p>The Treatment and Care for Kids (<a href="https://professionals.childhood.org.au/our-specialist-therapeutic-services">TrACK</a>) program was developed as an alternative to residential care for children with complex needs. Some children in the program have experienced severe trauma including witnessing murder by their parents and being subjected to chronic sexual assault (with some being involved in paedophile rings organised by their parents).</p>
<p>Among the 48 children who have been fostered through the program, 19 had come from residential care where they had multiple placements. Fifteen of these children had lived in more than six placements before TrACK and seven had experienced more than ten placements. One child had experienced 18 and another 30 placements within five-and-a-half years. </p>
<p>A review of their case files identified a shift from placement instability to long-term placement stability after joining TrACK. The program showed encouraging results in other domains too, including education, forming peer relationships and emotional regulation. </p>
<p>These results show complex trauma can be healed.</p>
<h2>Children in care and TrACK</h2>
<p>In Australia, one in every 32 children has <a href="https://www.aihw.gov.au/getmedia/66c7c364-592a-458c-9ab0-f90022e25368/aihw-cws-63.pdf.aspx?inline=true">received child protection services</a>. By the time they are in residential care, they have often experienced <a href="http://developingchild.harvard.edu/wp-content/uploads/2012/05/The-Science-of-Neglect-The-Persistent-Absence-of-Responsive-Care-Disrupts-the-Developing-Brain.pdf">physical, sexual and emotional violence</a> in early childhood, as well as <a href="https://www.ncbi.nlm.nih.gov/books/NBK195987/">severe neglect from their caregivers</a>. </p>
<p>After ageing out of care at 18 years, many of these young people are <a href="https://www.legalaid.vic.gov.au/sites/www.legalaid.vic.gov.au/files/vla-care-not-custody-report.pdf">over-represented</a> in the criminal justice system. They experience <a href="https://www.aihw.gov.au/reports/homelessness-services/vulnerable-young-people-interactions-across-homel/contents/table-of-contents">homelessness</a>, unemployment, mental illness and poor social relationships at greater rates than the rest of the population.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-faulty-child-welfare-system-is-the-real-issue-behind-our-youth-justice-crisis-72217">The faulty child welfare system is the real issue behind our youth justice crisis</a>
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<p>Due to the complexity of their trauma, every child in TrACK has a therapeutic plan tailored to their needs and a team of specialists who support them and their family. For children who are placed in care, <a href="https://nursebuddha.files.wordpress.com/2011/12/complex-trauma-in-children.pdf">complex trauma</a> has mostly been acquired through repeated traumatic experiences in the context of a relationship that’s meant to be secure and trustworthy.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/219910/original/file-20180522-51141-gqsdgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/219910/original/file-20180522-51141-gqsdgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/219910/original/file-20180522-51141-gqsdgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/219910/original/file-20180522-51141-gqsdgs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/219910/original/file-20180522-51141-gqsdgs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/219910/original/file-20180522-51141-gqsdgs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/219910/original/file-20180522-51141-gqsdgs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/219910/original/file-20180522-51141-gqsdgs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">Children need loving relationships to heal from a history of complex trauma.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/DIZBFTl7c-A">Kevin Gent/Unsplash</a></span>
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<p>TrACK’s approach to treating complex trauma is informed by the <a href="http://psycnet.apa.org/record/2004-10639-003">science of neurobiology</a>, which suggests trauma develops in a relationship and can also be healed in a relationship. This is also referred to as the <a href="https://books.google.com.au/books?hl=en&lr=&id=ATUpDwAAQBAJ&oi=fnd&pg=PR3&dq=trauma+within+a+loving+relationship+for+children&ots=7QiVr14Ekx&sig=Uhdh4U0W_Y1NM9O6MfKFuCcHeCc#v=onepage&q=trauma%20within%20a%20loving%20relationship%20for%20children&f=false">neurobiology of love</a>, where love isn’t just a simple emotion but a deep sense of care, concern and connectedness to the child. </p>
<p>We are all wired for connection. However, most children in care have been denied this opportunity. The neurobiology of love, in this case, is about accepting their complexities and vulnerabilities, providing comfort and constantly nurturing the relationship between the carer and the traumatised child.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/complex-trauma-how-abuse-and-neglect-can-have-life-long-effects-32329">Complex trauma: how abuse and neglect can have life-long effects</a>
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<p>The success of a placement is mainly based on the carer’s capacity to respond to the complexity of the child. TrACK carers are trained in several key areas. This involves knowing ways to counter some of the negative self-perceptions the child may have; having appropriate expectations of the child and showing them love and acceptance even if their behaviour isn’t changing; avoiding escalation; and noticing and responding to the child’s emotional needs.</p>
<p>TrACK only recruits carers who are prepared to commit to the long-term care of children with significant adversity. In return, they are offered “round the clock” support. This includes specialist training on parenting children with complex needs and individualised coaching. </p>
<h2>What we found</h2>
<p>Our key finding was a considerable reduction in the number of placements children experienced after joining TrACK. It fell from a median of 6.1 to 1.9 (remember seven children had over ten placements before joining the program). </p>
<p>We also found all children in TrACK at the time of the evaluation were attending school full-time. A 2012 <a href="https://www.audit.vic.gov.au/sites/default/files/20140326-Residential-Care.pdf">Victorian report</a> showed 49% of children in residential care, and 88% in other home-based care programs, were going to school every day.</p>
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<strong>
Read more:
<a href="https://theconversation.com/foster-parents-need-more-support-to-care-for-vulnerable-children-32680">Foster parents need more support to care for vulnerable children</a>
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<p>All children in TrACK experienced enhanced emotional stability and capacity to regulate their own emotions. Although this was hard to measure, carers reported their children were less volatile than when they first arrived in their care.</p>
<p>Stability of relationship with carers was another key outcome. All the children in a TrACK placement at the time of the evaluation were able to develop trusting relationships with their carers. This result is encouraging because many of these children had previously been identified as being too complex, volatile and aggressive for a home-based care placement. </p>
<p>One young person in TrACK, Daren, said: </p>
<blockquote>
<p>I definitely think I am part of the family, from the first time I walked in, they were welcoming […] had a joke which was amusing and funny […] and not leaving me out of anything pretty much […] they let me know everything that involves me and [even] when it does not involve me, [they tell me] what they are doing in their lives […] there are no secrets.</p>
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<p>Daren now continues to live with his foster parents despite his foster care arrangement ending at the age of 18. </p>
<p>One of the carers said his strategy for reassuring his foster sons that he will never leave them is by speaking to them in future tense. </p>
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<p>I talked to [our foster son] when he was 14 about how I’m going to teach him how to drive [when he is older] and he knows he is welcome to stay here for the rest of his life. </p>
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<p>Our interviews with young people and reports from their carers showed recovery started when the young people felt the foster family would never abandon them, reject them, retraumatise them, hurt them or withdraw their affection, regardless of how slow or complex their healing journey was. </p>
<p>It’s critical that locally grown programs do not fall off the agenda as viable and cost-effective <a href="https://www.communities.qld.gov.au/resources/childsafety/foster-care/sfc-literature-review-australian-programs-description.pdf">strategies for reform</a>. Often, our systems are criticised for what they do not achieve for children; they also need to be acknowledged when they do something well.</p>
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<p><em>TrACK is funded by the Victorian Department of Health and Human Services and run by the <a href="https://www.childhood.org.au/">Australian Childhood Foundation (ACF)</a> and <a href="https://www.anglicarevic.org.au/">Anglicare-Victoria</a>.</em></p><img src="https://counter.theconversation.com/content/94397/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kathomi Gatwiri received funding from the Australian Childhood Foundation to Conduct an Evaluation of the TrACK program. </span></em></p><p class="fine-print"><em><span><a href="mailto:lynne.mcpherson@scu.edu.au">lynne.mcpherson@scu.edu.au</a> has received funding from the Australian Childhood Foundation to conduct this research. </span></em></p>An evaluation of a therapeutic foster care program has shown significant improvements in children previously thought too complex and challenging for foster care.Kathomi Gatwiri PhD, Lecturer, Southern Cross UniversityLynne McPherson, Senior lecturer, Southern Cross UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/819902017-08-13T21:11:14Z2017-08-13T21:11:14ZThe bad buildings scream – lessons from Don Dale and other failed institutions<p>It’s just over a year since the <a href="https://theconversation.com/rethinking-youth-justice-there-are-alternatives-to-juvenile-detention-63329">Don Dale scandal</a> became public. A youth was <a href="http://www.abc.net.au/4corners/stories/2016/07/25/4504895.htm">shown on ABC Four Corners</a> bound and in a spit mask. Within a few hours, a <a href="https://childdetentionnt.royalcommission.gov.au/Pages/default.aspx">royal commission</a> was initiated, and within days the Northern Territory centre was to be condemned. </p>
<p>Now the brief is out for a new centre – but word is, <a href="http://architectureau.com/articles/design-brief-for-new-darwin-youth-detention-centre-slammed/?utm_source=ArchitectureAU&utm_campaign=ec0c99a5cc-AAU_2017_07_12&utm_medium=email&utm_term=0_e3604e2a4a-ec0c99a5cc-41314117&mc_cid=ec0c99a5cc&mc_eid=00d901f802">it’s “a disgrace”</a>.</p>
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<figcaption><span class="caption">An excerpt from the Four Corners report, Australia’s Shame, on July 26 2016.</span></figcaption>
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<p>An obsession with “function” – the patterns and protocols of management and care – dominates the designs of residential institutions that serve unwilling guests, such as prisons, detention centres and mental health facilities. The functional spaces assume people’s behaviour will remain the same regardless of the architecture. And so residential institutions end up as places where the business of managing people should be easy.</p>
<p>But people aren’t easy. When forced into an institutional residential setting, they come with baggage that can’t be checked in at the sally port (the gate). </p>
<p>The clients are products of diverse cultures, they have kin, they may have addictions and special needs. Some will be prone to <a href="http://strona.app.nazwa.pl/uploads/images/2014_16_4/5Golembiewski_ArchivesPP_4_2014.pdf">aggression or at risk of suicide</a> (or both). In Australia, about half have <a href="http://www.aihw.gov.au/prisoner-health/mental-health/">mental illness</a>.</p>
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<p><em><strong>Further reading:</strong> <a href="https://theconversation.com/good-mental-health-care-in-prisons-must-begin-and-end-in-the-community-40011">Good mental health care in prisons must begin and end in the community</a></em></p>
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<p>Much of the functional planning is designed to control this diversity and unruliness. But people generally don’t like to be controlled, especially if it means they can’t be with the people they love or contribute meaningfully to society. It’s hardly a surprise that facilities see bursts of violence.</p>
<h2>Tougher controls add to pressures</h2>
<p>If ever there’s an unplanned event with lasting consequences, the architecture is usually patched to prevent another similar event. This is usually very literal, such as putting in a layer of vandal-proof glass, CCTV, or some other invasive security measure. </p>
<p>These modifications rarely help, because they only intensify resentments and feelings of being controlled. Before too long, another incident is inevitable. </p>
<p>The final blow for a facility is usually when the public hears of an incident – <a href="http://www.abc.net.au/news/2014-08-25/don-dale-detainees-to-be-housed-at-mental-health-facility/5694616">the Don Dale Youth Detention Centre</a> and <a href="http://www.theage.com.au/victoria/half-of-parkville-youth-detention-centre-closed-because-of-rioting-20170109-gtobl4.html">Parkville Youth Justice Centre</a> in Victoria are recent cases in point. Remember, these are places that <em>unnecessarily</em> separate people from their loved ones and everything of importance – is an angry response really a surprise?</p>
<p>When a centre is being shut down, administrators frequently blame architecture: they say “it wasn’t fit for purpose”. Suddenly it’s the building that’s done wrong, not the people or protocols that gradually developed in it.</p>
<p>But the administrators may be right. <a href="https://theconversation.com/building-a-better-world-can-architecture-shape-behaviour-21541">Architecture can be very manipulative</a>; it can affect our behaviour and the choices we make. So why don’t designers anticipate behavioural problems when they’re designing a facility?</p>
<p>These problems arise because <em>as vulnerability increases, choice decreases</em>. When people are mentally ill, feel they’re oppressed, are emotionally overwrought or physically ill, their <a href="https://www.ncbi.nlm.nih.gov/pubmed/26597102">brains begin to function differently</a>. Their capacity to choose how to react to any given circumstances is reduced to a set of learned and instinctive behaviours, however inappropriate these are to those circumstances. </p>
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<figcaption><span class="caption">In oppressive conditions, peope’s capacity to choose how to react to any given circumstances is greatly reduced, however inappropriate their behaviour might be.</span></figcaption>
</figure>
<p>Importantly, this same effect reduces the possibility of behavioural change and reform, which is meant to be the focus of the <em>corrections</em> system. And only this past week, this was revealed to be a <a href="https://ipa.org.au/publications-ipa/research-papers/ipa-research-finds-australia-falling-behind-world-criminal-justice-costs-results-2">serious and costly problem</a> for criminal justice in Australia.</p>
<hr>
<p><em><strong>Further reading:</strong> <a href="https://theconversation.com/the-state-of-imprisonment-in-australia-its-time-to-take-stock-38902">The state of imprisonment in Australia: it’s time to take stock</a></em></p>
<hr>
<p>What’s worse is that <a href="http://www.urbandesignmentalhealth.com/journal2-psychosis.html">people with mental illness can become symptomatic</a> in bad environments. Only when people are in a state of robust mental health can they develop new, nuanced responses and adapt well to circumstances.</p>
<h2>There is a better way</h2>
<p>People who have studied this problem talk about congruency. It’s about “the good fit” between the person, their culture and the place: the physical layout, the things there are to do, the attitudes of staff, etc. </p>
<p>If the clients were all healthy, this wouldn’t be so important, because people can then adapt easily. But in mental health facilities all the clients have mental problems, and a high number in prisons too – whether diagnosed or not.</p>
<p>To provide for clients in residential institutional care, administrators first have to understand that all clients are vulnerable. Even if they’re tattooed and tough and might carry a shank knife; if they’re in a residential institution, they’re vulnerable.</p>
<p>It’s essential to treat humans with dignity. First up, that means that prison should never primarily be a punishment (it’s not meant to be under <a href="https://www.unodc.org/documents/justice-and-prison-reform/GA-RESOLUTION/E_ebook.pdf">current United Nations rules</a> either). </p>
<hr>
<p><em><strong>Further reading:</strong> <a href="https://theconversation.com/prisons-policy-is-turning-australia-into-the-second-nation-of-captives-38842">Prisons policy is turning Australia into the second nation of captives</a></em></p>
<hr>
<p>But beyond just abiding by the rules, it’s essential to provide for a meaningful existence. Different people and different cultures find meaning in different places, and it can be hard to provide for everyone. But that’s no excuse not to try.</p>
<p>Some universal values provide meaning for just about everyone. These can be expressed by making provision for family and for meaningful activity such as gardening, art, music, sport and religious expression. </p>
<p>Other provisions must be geared to local cultures. <a href="http://www.waikatodhb.health.nz/assets/news/Improving-mental-health-in-prisons.pdf">Te Kauwhata</a>, a secure mental health facility in New Zealand, has places for Maori clients to carve wood, based on the understanding that this cultural activity is important enough that they are equipped with dangerous carving tools.</p>
<p><a href="http://architectureau.com/articles/west-kimberley-regional-prison/">A prison in the Kimberley</a> provides wide, open spaces that are close to kin, and prisoners have opportunities to personalise their spaces.</p>
<p>Very few clients will be there for life. To maintain the competencies needed in the real world, it’s essential to shift the locus of control from staff to the clients. For this reason, the institution should promote trade in wholesome goods.</p>
<p>People should be encouraged to cook for each other and themselves, to do their own cleaning and to develop workplace and cultural skills such as sports development or learning musical instruments.</p>
<p>Until these basic concepts are routine and the reflexes of management are to look at opportunities to improve wellbeing, rather than making facilities harder and more segregated, social problems will remain at the heart of one scandal after another.</p>
<p>Remember, all buildings speak to us on a psychological level – but the bad ones scream.</p>
<hr>
<p><em><strong>Further reading:</strong> <a href="https://theconversation.com/from-expected-reoffender-to-trusted-neighbour-why-we-should-rethink-our-prisons-60114">From expected reoffender to trusted neighbour: why we should rethink our prisons</a></em></p><img src="https://counter.theconversation.com/content/81990/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jan Golembiewski does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Architecture can affect behaviour and the choices we make. The brief is out for a centre to replace the Don Dale facility, but word is, it’s ‘a disgrace’. We can do much better.Jan Golembiewski, Researcher, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/788902017-07-04T23:23:24Z2017-07-04T23:23:24ZA new way to think about dementia and sex<figure><img src="https://images.theconversation.com/files/174091/original/file-20170615-24991-1rcxsfq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">There's an urgent need for a new ethic of dementia care that supports the facilitation of sexual expression.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>Persons living with dementia don’t have sex. Or they have weird sex. Or they have dangerous sex, in need of containment. </p>
<p>When it comes to dementia and sexuality, negative language and apocalyptic warnings abound. The aging population has been described in the media as a “<a href="http://www.dailymail.co.uk/news/article-2374771/Sex-dementia-Aging-population-set-rape-case-timebomb-nursing-homes-Alzheimer-rates-rise.html">rape case time-bomb</a>.”
Health practitioners often respond in punishing ways to sexual activity in residential care. And the sexual rights of persons living with dementia are largely ignored within residential care policy, professional training and clinical guidelines. </p>
<p>As critical social researchers, we argue that <a href="https://doi.org/10.1093/geront/gnw137">a new ethic of dementia care</a> is urgently needed, one that <a href="https://doi.org/10.1177/1471301216636258">supports the facilitation of sexual expression</a>. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/173053/original/file-20170609-25091-17038yy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/173053/original/file-20170609-25091-17038yy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/173053/original/file-20170609-25091-17038yy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/173053/original/file-20170609-25091-17038yy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/173053/original/file-20170609-25091-17038yy.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/173053/original/file-20170609-25091-17038yy.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/173053/original/file-20170609-25091-17038yy.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/download/success?src=7slevk0NfV6-f-pxjyQM2Q-1-1">Practitioners and administrators often hold negative and judgmental attitudes about dementia and aged sexuality (Shutterstock)</a></span>
</figcaption>
</figure>
<p>Our research at the University of Toronto and the Toronto Rehabilitation Institute-University Health Network investigates embodiment, relationality, ethics and dementia. We are motivated by a shared concern about the reductive focus of dementia care on basic physical needs, and our desire to foster a more humane and life-enriching culture of care. We have explored how the sexualities of persons living with dementia are poorly supported in long-term residential care settings such as nursing homes. </p>
<h2>Sex and dementia in the media</h2>
<p>When we see persons living with dementia and sex linked in the media, it tends to be in high profile cases of alleged abuse. One example is the <a href="http://www.cbc.ca/news/world/henry-rayhons-acquitted-of-sexual-abuse-of-wife-an-alzheimer-s-patient-1.3045185">legal trial of Henry Rayhons</a>, an Iowa lawmaker found not guilty of sexually abusing his wife who at the time was living with dementia in a nursing home. Another example is the wider <a href="http://www.ctvnews.ca/w5/w5-investigates-cases-of-sexual-assault-in-ontario-nursing-homes-1.2849923">investigation into sexual assaults in nursing homes</a> in Ontario. </p>
<p>Vital as such investigations are to the safety of residents in long-term care, we rarely see sexual expression valued or as <a href="http://www.dx.doi.org/10.1111/j.1467-9973.2009.01591.x">fundamental to human flourishing</a>.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/173051/original/file-20170609-32402-1ompjme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/173051/original/file-20170609-32402-1ompjme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/173051/original/file-20170609-32402-1ompjme.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/173051/original/file-20170609-32402-1ompjme.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/173051/original/file-20170609-32402-1ompjme.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/173051/original/file-20170609-32402-1ompjme.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/173051/original/file-20170609-32402-1ompjme.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Institutional policies, structures and practices must support sexual expression.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Our research has explored how these negative representations of the sexualities of persons living with dementia are also found within long-term residential care settings such as nursing homes. </p>
<p>Practitioners and administrators often hold negative and judgmental attitudes about dementia and aged sexuality. When faced with sexual activity, they can intervene in threatening and punishing ways. And long-term care policies, professional training and clinical guidelines tend to ignore the sexual rights of persons with dementia. </p>
<h2>The problem with biomedical ethics</h2>
<p>The sexualities of persons living with dementia are considered troubling partly because long-term care polices are shaped by biomedical ethics. This ethical approach relies on four core principles: autonomy, beneficence, non-maleficence and justice. These principles support intervening in residents’ sexual expression if it will cause harm to themselves or cause harm or offence to others. </p>
<p>However, this approach sets the bar for practitioners’ interference excessively high. It can restrict voluntary sexual expression by residents living with dementia in nursing homes. </p>
<p>Biomedical ethics also ignore the performative, embodied and relational aspects of ethical reasoning. It assumes that people are rational autonomous beings. It also assumes that self-expression, including sexuality, results only from cognitive and reflective decision making. Given that dementia involves progressive cognitive impairment, persons living with dementia may be unfairly discriminated against by this approach to sexual decision making. </p>
<h2>A duty to support sexual expression</h2>
<p>We use a model of relational citizenship to create an alternative ethic in which sexuality is seen as embodied self-expression. It is an ethic that recognizes human beings as embodied and embedded in a lifeworld. And one that views sexuality as an important part of being human.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/173643/original/file-20170613-30107-101n81v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/173643/original/file-20170613-30107-101n81v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/173643/original/file-20170613-30107-101n81v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/173643/original/file-20170613-30107-101n81v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/173643/original/file-20170613-30107-101n81v.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/173643/original/file-20170613-30107-101n81v.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/173643/original/file-20170613-30107-101n81v.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Social and leisure activities supportive of the development of intimate relationships are essential within nursing homes.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>This new ethic broadens the goals of dementia care. No longer do health professionals just have the duty to protect persons with dementia from harm. There is also a duty to support their right to sexual expression. </p>
<p>We argue that institutional policies, structures and practices must also support sexual expression. These should facilitate sexual rights. We must also introduce education for health professionals and the broader public — and policy initiatives to counteract the stigma associated with sexuality and dementia. </p>
<p>Social and leisure activities that are supportive of sexual expression and the development of intimate relationships are also essential within nursing homes. </p>
<p>Of course, protection from unwanted contact or sexual harm is still important. However, freedom of sexual expression should only be restricted when necessary to protect the health and safety of the individuals involved.</p><img src="https://counter.theconversation.com/content/78890/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Alisa Grigorovich holds a Postdoctoral Ontario Women’s Health Scholars Award, funded by the Ontario Ministry of Health and Long-Term Care, Ontario, Canada. </span></em></p><p class="fine-print"><em><span>Pia Kontos does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>The sexuality of persons living with dementia is demonized by media and ignored by clinical guidelines. But sexuality is fundamental to being human and vital to a humane culture of residential care.Alisa Grigorovich, Postdoctoral Fellow, Dalla Lana School of Public Health, University of TorontoPia Kontos, Senior Scientist,Toronto Rehabilitation Institute - University Health Network and Associate Professor, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/757402017-04-26T13:09:12Z2017-04-26T13:09:12ZIt’s time to end the taboo of sex and intimacy in care homes<figure><img src="https://images.theconversation.com/files/166601/original/file-20170425-12645-1yjb4j1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption"></span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/older-couple-cuddling-together-when-man-530269198?src=M6U5Kun5Tj3KRBzNmWIlcA-1-54"> Photographee.eu/shutterstock</a></span></figcaption></figure><p>Imagine living in an aged care home. Now imagine your needs for touch and intimacy being overlooked. More than <a href="http://webarchive.nationalarchives.gov.uk/20160105160709/http://www.ons.gov.uk/ons/dcp171776_373040.pdf">500,000 individuals aged 65+</a> (double the population of Cardiff) live in care homes in Britain. Many could be missing out on needs and rights concerning intimacy and sexual activity because they appear to be “designed out” of policy and practice. The situation can be doubly complicated for lesbian, gay, bisexual or trans individuals who can feel obliged to go “back into the closet” and hide their identity when they enter care.</p>
<p>Little is known about intimacy and sexuality in this sub-sector of care. Residents are often assumed to be prudish and “past it”. Yet neglecting such needs can <a href="https://www2.rcn.org.uk/__data/assets/pdf_file/0011/399323/004136.pdf">affect self-esteem</a> and mental health. </p>
<p>A <a href="http://onlinelibrary.wiley.com/doi/10.1111/jan.13080/full">study</a> by a research team for Older People’s Understandings of Sexuality (OPUS), based in Northwest England, involved residents, non-resident female spouses of residents with a dementia and 16 care staff. The study found individuals’ accounts more diverse and complicated than stereotypes of older people as asexual. Some study participants denied their sexuality. Others expressed nostalgia for something they considered as belonging in the past. Yet others still expressed an openness to sex and intimacy given the right conditions. </p>
<h2>Insights</h2>
<p>The most common story among study participants reflected the idea that older residents have moved past a life that features or is deserving of sex and intimacy. One male resident, aged 79, declared: “Nobody talks about it”. However, an 80-year-old female resident considered that some women residents might wish to continue sexual activity with the right person. </p>
<p>For spouses, cuddling and affection figured as basic human needs and could eclipse needs for sex. One spouse spoke about the importance of touch and holding hands to remind her partner that he was still loved and valued. Such gestures were vital in sustaining a relationship with a partner who had changed because of a dementia. </p>
<p>Care staff underlined the need for training to help them to assist residents meet their sexual and intimacy needs. Staff highlighted grey areas of consent within long-term relationships where one or both partners showed declining capacity. They also spoke about how expressions of sexuality posed ethical and legal dilemmas. For example, individuals affected by a dementia can project feelings towards another or receive such attention inappropriately. The challenge was to balance safeguarding welfare with individual needs and desires. </p>
<p>Some problems were literally built into care home environments and delivery of care. Most care homes consist of single rooms and provide few opportunities for people to sit together. A “no locked door” policy in one home caused one spouse to describe the situation as, “like living in a goldfish bowl”. </p>
<p>But not all accounts were problematic. Care staff wished to support the expression of sex, sexuality and intimacy needs but felt constrained by the need to safeguard. One manager described how their home managed this issue by placing curtains behind the frosted glass window in one room. This enabled a couple to enjoy each other’s company with privacy. Such simple changes suggest a more measured approach to safeguarding (not driven by anxiety over residents’ sexuality), which could ensure the privacy needed for intimacy. </p>
<h2>Conclusions</h2>
<p>Our study revealed a lack of awareness by staff of the need to meet sexuality and intimacy needs. Service providers need guidance on such needs and should provide it to staff. The information is out there and they can get the advice they need from the Care Quality Commission, Independent Longevity Centre, Local Government Association and the Royal College of Nursing. </p>
<p>Policies and practices should recognise resident diversity and avoid treating everyone the same. This approach risks reinforcing inequality and doesn’t meet the range of needs of very different residents. The views of black, working-class and LGBT individuals are commonly absent from research on ageing sexuality and service provision. One care worker spoke of how her home’s sexuality policy (a rare occurrence anyway) was effectively a “heterosexuality policy”. It may be harder for an older, working-class, black, female or trans-identified individual to express their sexuality needs compared to an older white, middle-class, heterosexual male. </p>
<p>Care homes need to provide awareness-raising events for staff and service users on this topic. These events should address stereotyping and ways of achieving a balance between enabling choices, desires, rights and safeguarding. There is also a need for nationally recognised training resources on these issues. </p>
<p>Older people should not be denied basic human rights. This policy vacuum could be so easily addressed over time and with appropriate training. What we need now is a bigger conversation about sex and intimacy in later life and what we can do to help bring about some simple changes in the care home system.</p><img src="https://counter.theconversation.com/content/75740/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Paul Simpson receives funding from Economic and Social Research Council UK, Transformative Research initiative (2014) but this article reflects the author's personal views.
The OPUS research initiative involves academics from Sociology, Psychology and Nursing and Public Health.
This article was written with: Laura Brown (University of Manchester), Christine Brown Wilson (University of Queensland), Maria Horne (University of Leeds), Tommy Dickinson (Kings College, London University) and Stuart Smith (Age Concern Manchester). </span></em></p>The intimate needs of elderly people living in cares homes are being ignored – the system needs to change.Paul Simpson, Lecturer in Applied Health & Social Care, Edge Hill UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/752862017-03-29T00:13:11Z2017-03-29T00:13:11ZFour Corners: can the NDIS prevent abuse of people with disability?<figure><img src="https://images.theconversation.com/files/162899/original/image-20170328-30807-1v58hwv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Will abusers still be able to move to a new service and continue abusing under the NDIS?</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>Monday’s Four Corners program, <a href="http://www.abc.net.au/4corners/stories/2017/03/27/4641276.htm">Fighting the System</a>, was deeply disturbing viewing. It detailed shocking sexual abuse allegations of two residents at a group home for people with disabilities.</p>
<p>One of the most intolerable elements of the program was the revelation that the abuse was allegedly flagged with authorities, but nothing was done. Family members felt powerless to control what happened to their loved ones.</p>
<p>Anne Mallia, the mother of a young man with intellectual disability who had allegedly been abused, said she would sometimes park her car outside the residential facility her son was in and watch.</p>
<blockquote>
<p>… because I wasn’t permitted to go in […] I felt close to my son so that if he did need something I’d be there, but the reality is, I couldn’t protect him at that point.</p>
</blockquote>
<p>The program raised many issues needing urgent attention. They include whether the police listen to people with cognitive impairment when they report abuse. Whether the recently enacted <a href="https://www.legislation.sa.gov.au/LZ/B/CURRENT/STATUTES%20AMENDMENT%20(VULNERABLE%20WITNESSES)%20BILL%202015.aspx">South Australian Vulnerable Witnesses Bill</a>, which allows people with cognitive impairment to give evidence to courts in more supportive ways, will result in more convictions of abusers. And if such laws should be adopted nationally.</p>
<p>Another issue is how people with disability who don’t have family or friends to advocate for them can be heard, including those unable to communicate verbally.</p>
<p>Once the National Disability Insurance Scheme (NDIS) comes into full effect, there is the question of whether abusers will be able to move to a new service and continue abusing. And if the NDIS will have the necessary structures and procedures to stop the abuse of people with disabilities.</p>
<p>If the NDIS is implemented in accordance <a href="https://www.legislation.gov.au/Details/C2013A00020">with its legislation</a>, it could mitigate some of the abuse and the distress experienced by people with disability. But it won’t be able to address all the other issues raised by Four Corners.</p>
<h2>Choice and control</h2>
<p>We know from numerous inquiries that vulnerable people are targeted by those with a proclivity to abuse. Victoria’s 2013 <a href="https://www.parliament.vic.gov.au/fcdc/article/1788">inquiry into the abuse of children</a> in religious and other non-government institutions concluded that there will always be the risk of employees and others abusing the vulnerable.</p>
<p>Part of the trauma of the stories told in the Four Corners program was that the people being abused and their families were powerless to have the person moved away from the abuse. Their requests to service providers and government for alternative accommodation were not met. </p>
<p>The NDIS’s principles of choice and control give people with disabilities the right to choose what services they will purchase, with the assistance of family and loved ones when appropriate. This was one of the main features of the <a href="http://www.pc.gov.au/inquiries/completed/disability-support/report">Productivity Commission’s</a> recommendation for a national disability scheme in 2011, which led to the introduction of the NDIS. The expectation was that the choice of provider would motivate the provision of high quality services in a competitive market. </p>
<p>When the scheme becomes fully operational and it applies to residential services, people should be able to give notice and move to another service, as occurs with other commercial contracts. </p>
<h2>National watchdog</h2>
<p>Social Services Minister Christian Porter has said the federal government would <a href="http://www.abc.net.au/news/2017-03-28/disability-service-autism-plus-faces-sexual-assault-claim-review/8393132">establish a new watchdog</a> as disability services moved to a national model under the National Disability Insurance Scheme (NDIS). He told Four Corners there would be an “ongoing system of registration for service providers in disability accommodation that will ensure that standards are regularly reported on, regularly investigated and regularly enforced”.</p>
<p>This oversight will <a href="https://probonoaustralia.com.au/news/2017/03/disability-groups-renew-call-abuse-royal-commission/">presumably be based</a> on the <a href="https://www.dss.gov.au/sites/default/files/documents/02_2017/ndis_quality_and_safeguarding_framework_final.pdf">NDIS Quality and Safeguarding Framework</a>, which outlines a strategy to protect people with disabilities. It has plans to build capability and support systems, prevent harm and promote quality, and respond if things go wrong. However, there are flaws with this plan that undermine confidence in the NDIS. </p>
<p>A central feature of the quality framework is “having formal safeguards in the NDIS planning, implementation and review processes”. Planning and reviews supposedly give people with disabilities the opportunity to consider what services and supports they want to support their lifestyle. </p>
<p>But my discussions with planners and other staff involved have revealed that the National Disability Insurance Agency (NDIA), which runs the NDIS, has contracted planning conversations with NDIS participants to be had by phone. Draft plans are negotiated and agreed to, and later go to senior staff for approval. </p>
<p>Anecdotal reports from outside the NDIS suggest that people are not being supported during these phone calls to consider their options and opportunities. The plan is returned to them with changes they don’t want, and they have difficulties getting a review meeting. </p>
<p>This process flies in the face of the NDIS principles of choice and control, and raises serious doubts about the planning and review mechanisms to ensure safety.</p>
<p>The complaints procedures outlined in the safety framework are necessary but not sufficient to stop the abuse that we know occurs. Ensuring all registered providers have an internal complaints system will not stop abuse, nor will links to universal protections outside the NDIS, such as police, other regulatory and complaints systems.</p>
<h2>A royal commission</h2>
<p>In light of the Four Corners program and other abuse inquiry reports, the NDIS quality framework does not go far enough. The <a href="https://www.dss.gov.au/sites/default/files/documents/02_2017/ndis_quality_and_safeguarding_framework_final.pdf">framework states</a> it will continue the community visitor scheme for the time being. This is where trained volunteers inspect residential facilities without prior notice. </p>
<p>But the framework also states that there is no commitment to this continuing beyond the transition stage of the NDIS rollout, and indicates no other monitoring system.</p>
<p>The 2015 <a href="http://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Community_Affairs/Violence_abuse_neglect/Report">Commonwealth Senate inquiry’s</a> report into abuse and neglect of people with a disability in institutional settings stated the committee was:</p>
<blockquote>
<p>very disturbed by the significant body of evidence it has received which details the cruel, inappropriate and, in many cases, unlawful treatment of Australians with disability.</p>
</blockquote>
<p>The committee mentioned the largely inadequate responses from authorities and people in positions of responsibility when abuse was reported. The first of 30 recommendations was for a royal commission to be held into the mistreatment of people with disabilities in group homes. The second recommendation was for a national, independent, statutory protection watchdog.</p>
<p>The royal commission was recommended because because the committee suspects that we have only seen the tip of the iceberg, and a national system for reporting and investigating abuse is needed. </p>
<p>The federal government’s <a href="http://www.abc.net.au/news/2017-03-03/royal-commission-into-abuse-of-disabled-people-ditched/8320364">recent rejection</a> of a royal commission on the basis that the NDIS will protect people with disability is fallacious. The NDIS does not have rigorous mechanisms for protecting its participants, let alone the many vulnerable people with disability who will not be eligible for the NDIS. </p>
<p>Australia needs new mechanisms to stop the abuse of people with disabilities. The NDIS has the potential to assist. An important way it can help is by listening to people in planning and review meetings, and following up any concerns. To date, the NDIS is proving to be a missed opportunity. We need a royal commission to put pressure on the NDIS to live up to the principles in its legislation.</p><img src="https://counter.theconversation.com/content/75286/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Carmel Laragy has received national and state research grants. </span></em></p>We know predators will continue to target the vulnerable, including children and people with disability. The NDIS will mitigate some of the issues in this space, but we need a royal commission too.Carmel Laragy, Senior Research Fellow, RMIT UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/726602017-03-06T03:10:06Z2017-03-06T03:10:06ZContested spaces: who belongs on the street where you live?<figure><img src="https://images.theconversation.com/files/158849/original/image-20170301-29933-e33puo.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">It turns out cul-de-sacs may be better than we realised for creating a safe and inclusive community within a community.</span> <span class="attribution"><a class="source" href="https://en.wikipedia.org/wiki/File:Cul-De-Sac_Northwest_Pakuranga.jpg">Wikipedia</a></span></figcaption></figure><p><em>This is the second article in our <a href="https://theconversation.com/au/topics/contested-spaces-36316">Contested Spaces</a> series. These pieces look at the conflicting uses, expectations and norms that people bring to public spaces, the clashes that result and how we can resolve these.</em></p>
<hr>
<p>Our neighbourhoods need to be safe and inclusive places – safe for even the most vulnerable in our community. This includes the <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/4433.0.55.003main+features102012">668,100 Australians</a> living with intellectual disability. </p>
<p>With the right support, these adults, who account for 2.9% of the population (up from 2.6% in 2009), can have independent and meaningful lives in a regular house or apartment. The main issue is not the type of accommodation, but its location. The neighbourhood, its design, and the community of people who live there are all significant factors for supporting safety and inclusion. </p>
<p>Yet neighbourhoods are complex and contested spaces. Communities and individuals assemble sets of <a href="http://search.proquest.com/docview/1460136424?pq-origsite=gscholar">exclusionary values</a> and expectations of the kinds of people and behaviours within them. Our perceptions of desirable streets are now so intertwined with property values and social status that we have very little tolerance of change. </p>
<p>This <a href="https://pdfs.semanticscholar.org/7f5a/56e4a5bc19adbdd116ba78a704c3f4a43df8.pdf">collective socialisation</a> and the strength or relative weakness of a neighbourhood’s social networks all influence the environment and outcomes for existing and new residents. </p>
<p>Expectations of the physical and social desirability of a street include perceived qualities such as privacy, parking, like-mindedness, spacious, healthy, clean and so on. These expectations can have a significant impact on who is welcome. </p>
<p>Without a tolerance of difference and a diversity of demographics, ages, cultures and housing type, neighbourhoods will always struggle to be welcoming and safe.</p>
<p>A neighbourhood that is stigmatised as poor or rough is as likely as one deemed well-off to subject susceptible people to ongoing disadvantage. <a href="http://www.emeraldinsight.com/doi/pdfplus/10.1108/14608790200500031">Research</a> shows that people with disabilities are at greater risk of bullying when living in economically disadvantaged or socially similar communities. </p>
<p>We need new understandings of what makes a neighbourhood a safe and inclusive place. We cannot ignore this issue. As medical and social care advances, adults with intellectual disability are <a href="http://www.tandfonline.com/doi/abs/10.1080/02673030903086790">outliving their parents</a>. </p>
<p>This is wonderful news. But it is creates a concern for their families and support services. Where will these adults live independent and productive lives beyond the care of their parents?</p>
<h2>What is the ideal neighbourhood?</h2>
<p>Our research seeks to explore and describe the complexity of establishing the ideal neighbourhood <a href="https://hf-sts.com/">“system”</a> that will provide safe, inclusive and accessible places for adults with intellectual disability. We focused on adults aged between 18 and 40 who have <a href="https://www.qld.gov.au/disability/community/intellectual-disability/">mild and moderate intellectual disability</a> as the primary disability. That’s upwards of 172,500 Australians. </p>
<p>We asked intellectually impaired adults, their parents and carers, as well as urban development and disability sector decision-makers, about the “ideal” neighbourhood. </p>
<p>Our outcomes consider the planning, design and engineering requirements of neighbourhoods. We also look at how to draw on the <a href="http://link.springer.com/chapter/10.1007/978-1-349-62397-6_12">social capital</a> of a community to make a local neighbourhood safer and more inclusive. </p>
<p>Our approach includes ideas of a <a href="http://www.cornellpress.cornell.edu/book/?GCOI=80140100737740">“Just City”</a>. This is about delivering places that are socially inclusive. By this we mean difference is not just tolerated, but treated with recognition and respect. </p>
<h2>What has our research found?</h2>
<p>Preliminary results indicate that three crucial high-level functions need to be established when designing or refurbishing a neighbourhood: </p>
<ul>
<li><p>actual and perceived safety within the street and neighbourhood</p></li>
<li><p>access to services and amenities via walking, cycling or public transport </p></li>
<li><p>inclusion in community life and local neighbourhood activity. </p></li>
</ul>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/158852/original/image-20170301-19806-l72fu6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/158852/original/image-20170301-19806-l72fu6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/158852/original/image-20170301-19806-l72fu6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=672&fit=crop&dpr=1 600w, https://images.theconversation.com/files/158852/original/image-20170301-19806-l72fu6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=672&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/158852/original/image-20170301-19806-l72fu6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=672&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/158852/original/image-20170301-19806-l72fu6.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=845&fit=crop&dpr=1 754w, https://images.theconversation.com/files/158852/original/image-20170301-19806-l72fu6.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=845&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/158852/original/image-20170301-19806-l72fu6.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=845&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">An ‘exclusive neighbourhood’ has become a selling point, but may actually be less
safe and supportive because of its lack of diversity.</span>
<span class="attribution"><a class="source" href="https://commons.wikimedia.org/wiki/File:Montalke-cut-3919.jpg">Vmenkov/Wikimedia</a>, <a class="license" href="http://creativecommons.org/licenses/by-sa/4.0/">CC BY-SA</a></span>
</figcaption>
</figure>
<p>A safe neighbourhood has a mix of residents who “keep an eye” on each other. Diversity in a neighbourhood can help minimise the <a href="http://www98.griffith.edu.au/dspace/bitstream/handle/10072/47425/80101_1.pdf?sequence=1">vulnerability</a> of adults with intellectual disability to abuse, or to their corruption and exploitation to behave illegally.</p>
<p>Neighbourhood diversity includes the types, scale and intensity of buildings, ensuring a variety of residential accommodation and commercial uses. This mix is important: it enables a range of activity and people across the neighbourhood day and night. </p>
<p>The challenge of accessibility is recognised from two aspects. The first involves access to health, employment and community services – or accessible transport to those services. The second issue is how close the independent living is to family and friends. </p>
<p>Inclusive locations have opportunities for recreation and social activities that all residents value. In some existing neighbourhoods, community education and introduction to diversity may be needed to enhance inclusiveness. </p>
<p><a href="http://journals.sagepub.com/doi/abs/10.1177/0013916585175001">Cul-de-sacs</a>, long considered by planners as inhibitors of (auto) connectivity, are emerging as preferred solutions for many families. A cul-de-sac offers residents a community within a community. Calmed traffic and greater opportunities for knowing your neighbours happen in cul-de-sacs.</p>
<h2>So how do we assess ‘ideal’ neighbourhoods?</h2>
<p>We are identifying the key features of neighbourhoods that offer community life, work and recreational opportunities for residents and visitors. We are taking a human factors and ergonomics <a href="https://en.wikipedia.org/wiki/Sociotechnical_system%E2%80%8Bhttp://www.tandfonline.com/doi/full/10.1080/1463922X.2016.1143988">sociotechnical systems perspective</a>. </p>
<p>We look at the roles that, for instance, streets, trees, recreational opportunities, employment, transport, diversity and tolerance play as part of an entire neighbourhood “system”.</p>
<p>This allows us to develop a framework that shows the relationships between the features of a neighbourhood and safe, accessible and inclusive outcomes for residents. The framework helps planning and social housing decision-makers to identify and explore potential locations for independent living. </p>
<p>Importantly, we recognise that the values used in this approach to designing community neighbourhoods match the values we seek for equitable, ecological and economically viable built environments.</p>
<p>With this human factors approach we consider: </p>
<ul>
<li><p>people as assets in the system</p></li>
<li><p>technology as a tool to assist people</p></li>
<li><p>promotion of quality of life</p></li>
<li><p>respect for individual differences</p></li>
<li><p>responsibility of all stakeholders.</p></li>
</ul>
<p>These considerations underpin what makes neighbourhoods safe, accessible and inclusive. And understanding the requirements of a neighbourhood that is good for adults with intellectual disability helps create places that are good for everyone.</p>
<hr>
<p><em>You can read other pieces in the series as they are published <a href="https://theconversation.com/au/topics/contested-spaces-36316">here</a>.</em></p><img src="https://counter.theconversation.com/content/72660/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Cate MacMillan is affiliated with The Compass Institute Palmwoods as an honorary general Board Member.</span></em></p><p class="fine-print"><em><span>Nicholas Stevens is affiliated with the Planning Institute of Australia. </span></em></p>Understanding what makes a neighbourhood street a good place to live for adults with intellectual disability can help create places that are good for everyone.Cate MacMillan, PhD Candidate, University of the Sunshine CoastNicholas Stevens, Senior Lecturer and Researcher, Land Use Planning & Urban Design, University of the Sunshine CoastLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/722172017-02-12T19:10:44Z2017-02-12T19:10:44ZThe faulty child welfare system is the real issue behind our youth justice crisis<p>Somewhere along the way, many vulnerable children in state care turn to crime. How this happens and what can be done about it are two of the most important crime-prevention questions facing society. Evidence indicates that, if the care-to-crime pathway is <a href="https://theconversation.com/why-have-so-many-people-in-prison-spent-time-in-care-as-children-66941">not acknowledged and addressed</a>, today’s vulnerable kids will become tomorrow’s criminals.</p>
<p>There have recently been a <a href="http://www.theage.com.au/victoria/malmsbury-riot-youth-justice-is-out-of-control-pressure-mounts-on-premier-daniel-andrews-20170125-gtypkd.html">series of riots</a>, escapes and assaults in youth detention centres across the country, most notably in Victoria. Victims of such assaults, as well as commentators, immediately called for <a href="http://www.theage.com.au/victoria/woe-is-me-20170126-gtz8se.html">tougher sentencing</a> and harsher treatment of detainees.</p>
<p>Critics have cast a wide net of blame for Victoria’s woes. <a href="http://www.smh.com.au/comment/victorias-youth-justice-crisis-has-been-building-for-decades-20170130-gu1bwa.html">Paul McDonald</a>, the CEO of Anglicare Victoria, the state’s largest provider of out-of-home care services, blamed the changing demographics of young offenders – their age, ethnic origin and circumstance. He said the youth justice system had failed because the state’s justice program had “for too long … been the poor cousin to child protection issues”. </p>
<p>McDonald is a former government official responsible for both Victoria’s juvenile justice and child protection systems. Yet in all his criticism, he has been silent about one fact: children in our juvenile jails were failed by child protection systems like the one he used to run. He is not alone in ignoring this link.</p>
<p>Policymakers are reluctant to acknowledge the care system is producing criminals. This is despite abundant research showing children <a href="http://unsworks.unsw.edu.au/fapi/datastream/unsworks:38185/SOURCE02?view=true">become involved</a> in crime through the processes of the care environment itself. </p>
<h2>Residential care</h2>
<p>Last year, ABC’s <a href="http://www.abc.net.au/4corners/stories/2016/07/25/4504895.htm">Four Corners</a> highlighted the brutality in the Northern Territory’s Don Dale youth detention facility. Footage of Aboriginal boys teargassed, taunted and abused by guards led the prime minister to institute a <a href="https://www.ag.gov.au/About/RoyalCommissions/Pages/Royal-Commission-into-the-Detention-of-Children-in-the-Northern-Territory.aspx">royal commission</a> into how the NT treats juvenile offenders.</p>
<p>A few weeks later, <a href="http://www.abc.net.au/4corners/stories/2016/11/14/4572365.htm">Four Corners</a> focused on the Australian child welfare sector’s failure to protect children placed in state care. One form of care in particular, residential care – where children live with paid workers in small group-based facilities – has been linked to <a href="http://www.abc.net.au/news/2015-08-19/substantial-changes-for-state-care-system-abuse-cases-report/6707986">sexual exploitation</a> of children by adults, <a href="http://www.abc.net.au/news/2016-08-08/child-protection-systems-royal-commission-findings/7699900">recruitment into prostitution</a>, <a href="http://www.abc.net.au/lateline/content/2012/s3514803.htm">violence and crime</a>. </p>
<p>State governments have tried to address some of the issues. The Tasmanian government recently <a href="http://www.abc.net.au/news/2016-12-02/children-removed-from-safe-pathways-care/8086738">closed one of its residential facilities</a> after allegations of neglect. The NSW government <a href="https://www.facs.nsw.gov.au/about_us/media_releases/media_release_archive/nsw-residential-care-gets-multi-million-dollar-overhaul">began an overhaul</a> of its residential care system, while the Victorian government <a href="http://www.premier.vic.gov.au/fixing-victorias-residential-care/">announced the imminent transfer</a> of hundreds of so-called “resi kids” to other, purportedly safer forms of care.</p>
<p>At the same time, agencies such as UnitingCare, whose staff were recently embroiled in the <a href="http://www.dailytelegraph.com.au/news/nsw/girl-x-uniting-care-in-new-abuse-case-after-earlier-debacle/news-story/f990efb06a2b9e0b5aa2c8bffd6a147e">alleged sexual assault</a> and death of NSW resi-care teen “Girl X”, announced it <a href="http://www.abc.net.au/news/2016-12-19/uniting-church-residential-care-homes-close-nsw-after-review/8130558">would no longer provide</a> residential care services. The agency also <a href="https://probonoaustralia.com.au/news/2015/11/uniting-a-new-nfp-name-for-advocacy/">launched a “rebrand”</a> of its tarnished image.</p>
<h2>Towards criminality</h2>
<p>Few are talking about how children in residential care and those in juvenile jail are essentially the same people. Yet the evidence is everywhere. </p>
<p>Several of the Don Dale kids had come through the NT’s out-of-home care system. Half of all children in Victoria’s youth detention centres <a href="http://www.dhs.vic.gov.au/__data/assets/pdf_file/0004/890932/Youth-Parole-Board-and-Youth-Residential-Board-Annual-Report-2013-14.pdf">have come from</a> the child protection system. And last week, <a href="http://www.legalaid.vic.gov.au/sites/www.legalaid.vic.gov.au/files/vla-care-not-custody-report.pdf">Victoria Legal Aid announced</a> children in residential care were much more likely to be charged with a criminal offence than those who stay with their families. </p>
<p>Studies from the <a href="http://archive.vera.org/sites/default/files/resources/downloads/Foster_care_bias.pdf">United States</a>, <a href="https://www.rcybc.ca/sites/default/files/documents/pdf/reports_publications/kids_crime_and_care.pdf">Canada</a>, the <a href="https://www.education.gov.uk/consultations/downloadableDocs/6781-DfES-CM%20Summary.pdf">United Kingdom</a> and <a href="http://www.legalaid.vic.gov.au/sites/www.legalaid.vic.gov.au/files/vla-care-not-custody-report.pdf">Victoria</a> have shown few of these children engaged in criminal behaviour before coming into care. </p>
<p>In other words, we are making criminals. Residential care in particular is criminogenic. Badly trained and poorly supported staff, inadequate matching of children of different ages, experiences and background (offenders and victims of abuse are often placed together), and a readiness to call police to manage children’s behaviour are all <a href="http://howardleague.org/wp-content/uploads/2016/02/Criminal-Care.pdf">factors</a> contributing to <a href="http://www.prisonreformtrust.org.uk/Portals/0/Documents/care%20review%20full%20report.pdf">children being turned</a> from child-in-need to child offender.</p>
<p>My <a href="http://unsworks.unsw.edu.au/fapi/datastream/unsworks:38185/SOURCE02?view=true">research shows</a> that children in care make up less than 1% of the NSW child population but comprise half of all cases before the NSW Children’s Court. I found children in care are arrested earlier, more often and more quickly than other children. </p>
<p>This is important <a href="https://www.sentencingcouncil.vic.gov.au/sites/default/files/publication-documents/Reoffending_by_Children_and_Young_People_in_Victoria.pdf">because we know</a> that the earlier a child comes into contact with the justice system, the more deeply he or she is enmeshed, and the more protracted their exposure to crime is likely to be. Yet my research also found an <a href="http://unsworks.unsw.edu.au/fapi/datastream/unsworks:38185/SOURCE02?view=true">Australian policy vacuum</a> when it comes to recognising the link between out-of-home care and crime.</p>
<h2>We need to make the links</h2>
<p>There is <a href="http://www.legalaid.vic.gov.au/sites/www.legalaid.vic.gov.au/files/vla-care-not-custody-report.pdf">compelling evidence</a> children in care are more likely to re-offend than other children, and that prisoners who have grown up in care are more likely to commit multiple offences and <a>return to jail</a>. </p>
<p>Yet there are still no Australian government policies, programs, training or care-specific statistics to help us understand how to respond to children in care who get caught up in the justice system.</p>
<p>For a start, our child welfare agencies do not publish information on the number of children who go to jail while in care. Police don’t include care status on their official forms. Children’s courts don’t record it either. Neither does the NSW Bureau of Crime Statistics and Research. Or the Victorian Sentencing Council. Or the departments that run our jails.</p>
<p>Other countries have adopted a decidedly different approach. While the UK has a far-from-perfect record in responding to the needs of children in care, its government has <a href="https://theconversation.com/why-have-so-many-people-in-prison-spent-time-in-care-as-children-66941">channelled millions of dollars</a> into reducing the disparity between the arrest rates of children in care and other children. Theirs isn’t a complete solution, but at least the UK has made the link and is having the conversation about how to fix it. </p>
<p>Recently, a New Zealand service, established by the government to assist people who had been abused in state care, estimated 40% of the country’s prisoners had been in care. The service blamed <a href="https://www.dia.govt.nz/diawebsite.nsf/Files/Confidential-Listening-and-Assistance/$file/Confidential-Listening-and-Assistance-Service-Final-Report-Some-Memories-Never-Fade.pdf">its child welfare system</a> for creating the criminal gangs that now fill its jails. </p>
<p>Australia’s silence on this issue is costing us. In addition to the devastating impact for the individual children involved, creating criminals through the child welfare system <a href="http://www.justreinvest.org.au/wp-content/uploads/2016/02/report.pdf">costs society billions of dollars</a> in the long term. That’s more money for police and courts, more money for youth detention centres and more jails.</p>
<p>Governments, and the agencies they work with, must be transparent and honestly inform the public the child welfare system is creating criminals. Only then can we start to solve the real issues behind our youth justice crisis.</p><img src="https://counter.theconversation.com/content/72217/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Katherine McFarlane was part of a CSU research team which was awarded a Criminology Research Council grant in 2016. She has been contracted to conduct a review for the NSW Children's Guardian (2017) and was previously the Chief Investigator in a government tender to review juvenile bail (2010).
She was formerly a Chief of Staff in the NSW Government (2011-2015).
</span></em></p>Few people are talking about how children in residential care and those in juvenile jail are essentially the same people.Katherine McFarlane, Senior Lecturer, Centre for Law & Justice, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/684902016-12-15T19:27:14Z2016-12-15T19:27:14ZNSW bail laws mean well but are landing homeless kids in prison<figure><img src="https://images.theconversation.com/files/149809/original/image-20161213-1592-3xmrjp.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Some homeless youth facing criminal charges in NSW are being accommodated in prisons.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/69187071@N02/14661293083/in/photolist-okyXDe-n49Lc-jVAiNZ-81JCL1-8369Jd-8YxYDd-dXN62e-81FtLe-dXTKYf-6xHubk-81JA6w-dXTEmq-bquHLZ-oCkSyH-jVzBKp-eS2MWB-4vkDgi-7N6NAd-opp47E-82sbFp-7aopVg-bquGYH-bpwA57-6A7hgW-jVAnvi-4AdXXN-8YxYHb-pWcH5-dXN1YF-dXN1yn-dXTH6o-6rU2zs-dXTGmL-dXTEvC-6bwUVR-dXTFsA-eci1Nb-EdBVLh-dXTGd7-4m2Gu-n8xNGF-dXTGwb-83zxqq-dXTKEJ-dXN31x-dXTF65-8ZQTRs-qy2hW3-jVzzqp-jVzzNi">Adrian Fallace/flikr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span></figcaption></figure><p>Every year in New South Wales, scores of children are locked up because they don’t have a safe place to live. About one-third of them are Indigenous; about half are in the care of the state. Some are fleeing domestic violence, others have a mental illness, or are waiting on a place in a refuge or rehab for a drug or alcohol addiction. </p>
<p>The <a href="http://www.justice.nsw.gov.au/Documents/Annual%20Reports/JusticeAnnualReport2015-16.pdf">NSW Department of Justice</a> reports that children charged with a criminal offence who were unable to meet their bail conditions were kept in custody on 67 occasions in 2015-16 alone.</p>
<p><a href="http://www.community.nsw.gov.au/__data/assets/pdf_file/0007/319921/endorsed_practice_guidelines.pdf">Under NSW law</a>, a child awaiting trial is presumed innocent of charges and has a right to be at liberty. So why are homeless kids ending up in custody?</p>
<p>In part, it’s because there’s section in NSW’s Bail Act that disadvantages these children. Despite being designed to protect children, it operates as an example of a policy that looks good on paper but, in reality, can have disastrous results.</p>
<h2>A well-meaning section of the NSW Bail Act</h2>
<p>Under Section 28 of the <a href="http://www.austlii.edu.au/au/legis/nsw/consol_act/ba201341/s28.html">Bail Act</a> a court may impose an “accommodation requirement” when granting bail – that is, bail is dependent on the child having suitable accommodation. If accommodation is not available, the child will not be released. </p>
<p>The law was designed to overcome the fact that <a href="http://www.juvenile.justice.nsw.gov.au/Documents/Annual%20Report%202007-08%20(part%201).pdf">hundreds of homeless children</a> each year were remanded in custody despite conditional bail having been granted.</p>
<p>Approximately 90% of them spent an <a href="http://www.dpc.nsw.gov.au/__data/assets/pdf_file/0008/33794/Executive_Summary_and_Recommendations_-_Special_Commission_of_Inquiry_into_Child_Protection_Services_in_New_South_Wales.pdf">average of eight days in custody</a> as a result.</p>
<p>Homeless children were often required to “to reside as FACS directs” – a bail condition that presupposed that Family and Community Services (FACS) would provide them with accommodation. </p>
<p>But the Children’s Court was unable to compel FACS to provide accommodation to children. As some commentators <a href="http://www.austlii.edu.au/au/journals/CICrimJust/2009/18.pdf">have noted</a>, FACS either could not, or would not, find children accommodation and there was no legally enforceable obligation on it to do so. </p>
<p>According to one <a href="http://unsworks.unsw.edu.au/fapi/datastream/unsworks:38185/SOURCE02?view=true">NSW Children’s Court</a> judge: </p>
<blockquote>
<p>… the detention of such children … because they have no appropriate bail accommodation starkly demonstrates … how the criminal justice system may be inappropriately used for essentially welfare issues.</p>
</blockquote>
<p>The <a href="https://www.parliament.nsw.gov.au/committees/DBAssets/InquiryReport/ReportAcrobat/5396/9%20to%2014%20Report%20Volume%201.pdf">NSW parliament</a> attributes this failure of support and care services to a dramatic increase in the juvenile remand population, which <a href="http://www.bocsar.nsw.gov.au/Documents/CJB/cjb128.pdf">increased by one-third</a> between 2007 and 2008 alone.</p>
<h2>Section 28 has not fixed the problem</h2>
<p>Championed by the <a href="http://www.dpc.nsw.gov.au/__data/assets/pdf_file/0008/33794/Executive_Summary_and_Recommendations_-_Special_Commission_of_Inquiry_into_Child_Protection_Services_in_New_South_Wales.pdf">NSW Ombudsman</a> and many children’s advocates and legal representatives, Section 28 was meant to ensure that children were not turfed out onto the street or kept in jail because they hadn’t anywhere safe to go.</p>
<p>Anecdotally, bureaucrats and judicial officers say Section 28 is working because it puts pressure on agencies – such as FACS – to find children granted bail safe and suitable accommodation. But statistics show the proposed solution has failed many children who remain in custody. </p>
<p>The state still cannot be compelled to provide accommodation to homeless children. At best, the Children’s Court can only require agencies to report every two days on what progress has been made to find accommodation. If none has been found, the child remains in custody.</p>
<h2>An offence against UN and local laws</h2>
<p>Section 28 goes against UN <a href="http://www.ohchr.org/en/professionalinterest/pages/crc.aspx">Convention on the Rights of the Child</a>, the <a href="http://www.un.org/en/universal-declaration-human-rights/">Universal Declaration of Human Rights</a> and the <a href="http://www.ohchr.org/en/professionalinterest/pages/ccpr.aspx">International Covenant on Civil and Political Rights</a>. </p>
<p>It breaches a range of UN rules and guidelines: the <a href="http://www.un.org/documents/ga/res/40/a40r033.htm">Standard Minimum Rules for the Administration of Juvenile Justice </a> (the “Beijing Rules”), the <a href="http://www.un.org/documents/ga/res/45/a45r112.htm">Guidelines for the Prevention of Juvenile Delinquency</a> (the “Riyadh Guidelines”), and the <a href="http://www.un.org/documents/ga/res/45/a45r113.htm">Rules for the Protection of Juveniles Deprived of their Liberty</a>. </p>
<p>While some of these instruments are not enforceable in Australia, they hold considerable sway.</p>
<p>Section 28 also offends against local law. Section 6 of the <a href="http://www.austlii.edu.au/au/legis/nsw/consol_act/cpa1987261/">NSW Children (Criminal Proceedings) Act</a>, for example, requires that the penalty imposed on a child for an offence should be no greater than that imposed upon an adult who commits an offence of a similar kind. </p>
<p>The effect of Section 28, however, is that a child without suitable accommodation may be detained in circumstances where a homeless adult, charged with a like offence would not. </p>
<h2>Children in out-of-home care are still disadvantaged</h2>
<p><a href="http://www.unsworks.unsw.edu.au/primo_library/libweb/action/dlDisplay.do?vid=UNSWORKS&docId=unsworks_38185">My research</a> shows children in state care – who make up less than 1% of the NSW population – are especially vulnerable to being incarcerated because they lack suitable accommodation. </p>
<p>I found that twice as many children in care had been homeless at some point in their lives, compared to children who had never been in care (48% to 22%). I also found that placement in care was no guarantee a child would receive stable, secure accommodation or assistance from the child welfare department. </p>
<p>This is a long-standing problem. In 1992, girls in care were <a href="http://trove.nla.gov.au/work/34862027?selectedversion=NBD9070474">40 times more likely</a> to be remanded in custody than girls who had never been in care, purely because they were unable to meet bail conditions related to their welfare status (poverty, homelessness, exposure to abuse and lack of agency support).</p>
<p>Last year, the <a href="http://www.csi.edu.au/research/project/cost-of-youth-homelessness/">largest survey of homeless youth in Australia</a> reported that two-thirds of children had been in care. NSW Premier Mike Baird has also said that people who had grown up in the care of the state make up <a href="http://www.smh.com.au/nsw/mike-baird-announces-reform-to-states-broken-child-welfare-system-20161117-gsrbb6.html">60% of the homeless population</a>.</p>
<h2>The ‘university of crime’</h2>
<p>Being in custody, even for short periods of time, <a href="http://netk.net.au/Prisons/Prisons2.pdf">increases the likelihood of criminal behaviour</a>. Prisons are “universities of crime” where offenders can learn new techniques from their peers.</p>
<p>Prisons fracture community and family ties, may harden and brutalise inmates, and can worsen a person’s mental health. They can lead to physical and psychological hardship and the risk of assault or of death in custody. </p>
<p>The crime-producing effects continue post-incarceration: former inmates are labelled, de-skilled, less employable, and may rely on criminal networks established in custody to get by. They have access to benefits and social programs, and families of offenders and their communities may also be drawn into crime and the criminal justice system.</p>
<p>The UK’s Prison Reform Trust has described the detention of children in care for <a href="http://www.prisonreformtrust.org.uk/portals/0/documents/punishingdisadvantage.pdf">reasons unrelated to their offending</a>, such as homelessness or absconding, as a breach of the child welfare authorities’ statutory duty to protect and promote child welfare.</p>
<p>It is about time that NSW authorities were likewise held to account for their plans and policy tweaks that have achieved nothing to help our most vulnerable children stay out of jail.</p><img src="https://counter.theconversation.com/content/68490/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kath McFarlane was Chief Investigator for a NSW Labor Government-awarded tender to Charles Sturt University to examine bail practices in the Children’s Court, and has advised on the Family & Community Services Pathways of Care study. In 2015 she was Chief of Staff to the NSW Coalition Minister for Family and Community Services.</span></em></p>Homeless children charged in NSW with a criminal offence who are unable to meet bail conditions are being kept in custody. It’s due, in part, to a well-meant but flawed section of the Bail Act.Katherine McFarlane, Senior Lecturer, Centre for Law & Justice, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/688222016-11-18T00:51:27Z2016-11-18T00:51:27Z‘The single biggest reform to child welfare’ is a re-run of decade-old promises<p>After ABC TV’s <a href="http://www.abc.net.au/4corners/stories/2016/11/14/4572365.htm">Four Corners</a> aired horrifying evidence of abuse and mismanagement in the out-of-home care system for foster children, New South Wales Premier Mike Baird announced what he <a href="http://www.smh.com.au/nsw/mike-baird-announces-reform-to-states-broken-child-welfare-system-20161117-gsrbb6.html">called</a> the “single biggest reform to child welfare in NSW”.</p>
<p>While I have no doubt Baird is trying to improve the lives of children, his “solution” is a re-run of failed promises made by the Carr government more than a decade ago.</p>
<h2>The NSW department failing to meet industry standards</h2>
<p>The <a href="https://www.pic.nsw.gov.au/RoyalCommission.aspx">Wood Royal Commission</a> into police corruption in the late 1990s exposed evidence that police and the child welfare sector were ignoring cases of paedophiles abusing children in out-of-home care. As a result, the NSW government introduced new standards that child welfare agencies were supposed to meet to prove they could properly care for children. This was known as “accreditation”. </p>
<p>The huge disaster here is that the biggest player in the sector – the NSW government’s own department in charge of child welfare, Family and Community Services – has never itself received accreditation. This was highlighted in a report released after the Four Corners program by the <a href="https://www.audit.nsw.gov.au/publications/latest-reports/volume-six-2016-facs">NSW Audit Office</a>, which also criticised the department’s inability to track what happens to children in care. </p>
<p>The fact that Family and Community Services has not achieved accreditation, after so many years, shows how deeply flawed the system is.</p>
<h2>A cause for action</h2>
<p>The Four Corners <a href="http://www.abc.net.au/4corners/stories/2016/11/14/4572365.htm">program</a> exposed the sexual abuse and wholesale neglect of children in residential care, leading authorities to order <a href="http://www.abc.net.au/news/2016-11-15/tasmanian-resi-care-service-runs-threadbare-operation-ex-worker/8024938?section=tas">safety checks</a> on young people under the care of agencies featured in the program.</p>
<p>Baird was forced to <a href="http://www.smh.com.au/nsw/mike-baird-announces-reform-to-states-broken-child-welfare-system-20161117-gsrbb6.html">admit</a> that the out-of-home care system:</p>
<blockquote>
<p>… is failing to improve long term outcomes for children and to arrest devastating cycles of intergenerational abuse and neglect. </p>
</blockquote>
<p>Appalled that 60% of homeless people have been in care, he <a href="http://www.smh.com.au/nsw/mike-baird-announces-reform-to-states-broken-child-welfare-system-20161117-gsrbb6.html">declared</a> the dismal prognosis facing the state’s children was: </p>
<blockquote>
<p>… not just a cause for concern but a cause for action.</p>
</blockquote>
<p>But actions, and dollars, only count if they’re directed at programs and reforms that work.</p>
<h2>A multi-billion-dollar industry</h2>
<p>Providing care to vulnerable people is a multi-billion-dollar industry. In NSW last year alone a <a href="https://www.audit.nsw.gov.au/ArticleDocuments/106/Media_Release_Volume_Six_2016_FACS_17_November_2016.pdf.aspx">reported</a> A$2.8 billion was directed to non-government agencies.</p>
<p>The announcement that further funds would be channelled into fixing the broken system is a response to a damning assessment by respected public servant David Tune. The review is yet to be released in full, but you can read a summary <a href="https://www.facs.nsw.gov.au/__data/assets/file/0005/387293/FACS_OOHC_Review_161116.pdf">here</a>.</p>
<p>The Tune report found that A$300 million per year is being spent on support programs without any evidence that they actually work. <a href="https://www.facs.nsw.gov.au/about_us/media_releases/kids-in-care-at-centre-of-reform">According</a> to the NSW government, this is now set to change, with new models of evidence based, individually targeted support packages to ensure that children and families will receive the help they need. </p>
<p>Children have been raped and have died while in the care of the state. The need for concrete action is very real and the commitment to reform is to be welcomed. But these children deserve more. The NSW government’s belief in its reform package should not be doubted, but what’s been announced appears unlikely to fix the problem.</p>
<p>In the late 1990s, the Carr government also pledged reform of the child welfare system. It launched a multi-million-dollar Families First program (later renamed <a href="http://www.community.nsw.gov.au/for-agencies-that-work-with-us/our-funding-programs/brighter-futures-program">Brighter Futures</a>). </p>
<p>This program, then-premier Bob Carr declared, would provide early intervention and assistance to at-risk families. It would involve comprehensive training for child welfare staff, systematic and usable data collection, and – most significantly of all – would be thoroughly evaluated. </p>
<p>Within five years, its own architects had <a href="http://www.smh.com.au/news/National/Millions-for-programs-but-results-are-sparse/2005/03/13/1110649059053.html">condemned</a> the <a href="http://www.smh.com.au/news/National/Falling-between-the-cracks/2005/03/11/1110417688464.html">program</a> for wasted money, confusing overlap and missed opportunities.</p>
<p>Carr was forced to head off mounting public concern about the outcomes for children in care by <a href="http://www.abc.net.au/pm/stories/s750270.htm">injecting a further A$1.2 billion</a> into the department just weeks before the 2003 state election. He replaced the minister and the child welfare department’s director-general at the same time. </p>
<p>Labor won the election, but just five years later the <a href="http://www.dpc.nsw.gov.au/__data/assets/pdf_file/0008/33794/Executive_Summary_and_Recommendations_-_Special_Commission_of_Inquiry_into_Child_Protection_Services_in_New_South_Wales.pdf">Wood Special Commission</a> into child protection once again highlighted the inability of the system to keep children safe.</p>
<h2>Can failed agencies reform themselves?</h2>
<p>The real challenge for Baird lies in how the out-of-home care agencies will implement his grand plan. Details are still sketchy, but there was no talk yesterday of starting over with new providers. It appears the reforms will be carried out by the same agencies that currently dominate the system. </p>
<p>In many instances, these are the same players that have shaped child welfare in NSW for the last 100 years. In many instances, they are the same agencies that have featured before the ongoing <a href="https://www.childabuseroyalcommission.gov.au/">Royal Commission into Institutional Responses to Child Sexual Abuse.</a></p>
<p>This is the crux of the problem. Historical funding models, long standing religious and charitable loyalties, a belief that agencies that provide care to children in turn care for children, and the sheer difficulty of simply beginning again, means the same agencies that have failed to live up to previous government agendas will be the ones expected to now usher in the newest “single biggest reform to child welfare”. </p>
<p>Care-leavers (people who were in care as children but are now adults) have been telling governments for decades that there is a problem. For example, John Murray <a href="http://www.aph.gov.au/%7E/media/wopapub/senate/senate/commttee/S7291_pdf.ashx">told</a> a Senate committee in 2004 that:</p>
<blockquote>
<p>… the social services on offer are generally run by the very organisations that failed us in the past … we should no longer have to suffer at the hands of rank amateurs.</p>
</blockquote>
<p>Will Baird be the premier to stop the intergenerational cycle of abuse and neglect of children in the care of the state by the very agencies entrusted to care for them? </p>
<p>If that’s the legacy he is striving for, he’ll have to do more than he’s promised so far.</p><img src="https://counter.theconversation.com/content/68822/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Kath McFarlane was Chief Investigator for a NSW Government-awarded tender to Charles Sturt University to examine bail practices in the Children’s Court, and has advised on the Family & Community Services Pathways of Care study. In 2015 she was Chief of Staff to the NSW Minister for Family and Community Services.</span></em></p>The NSW government’s latest promised solution to well-documented abuse in the out-of-home care system is, in fact, a re-run of promises made by the Carr government more than a decade ago.Katherine McFarlane, Senior Lecturer in Justice Studies, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/687432016-11-15T00:45:16Z2016-11-15T00:45:16ZNothing to see here? The abuse and neglect of children in care is a century-old story in Australia<figure><img src="https://images.theconversation.com/files/145906/original/image-20161114-5101-11qlgwq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Former carer Natalie Ottini shared her experiences of working in residential group homes on the ABC's Four Corners program. </span> <span class="attribution"><span class="source">ABC/Poppy Stockell</span></span></figcaption></figure><p>Last night’s <a href="http://www.abc.net.au/4corners/stories/2016/11/14/4572365.htm">Four Corners program</a> presented evidence of widespread abuse and neglect suffered by children in the out-of-home care system. Sadly, it was an all too familiar story. The Australian care system has been subject to criticism for over a century.</p>
<p>Children described bullying, harassment and sexual abuse inflicted by other children who share their homes. Children also described adult men preying on and sexually exploiting girls in “resi” or residential care.</p>
<p>There were allegations of 12-year-olds being left without adequate clothing, stable accommodation or sufficient food, abandoned by the agencies that were supposed to care for them. Private, for-profit agencies were accused of financial mismanagement and rorting of taxpayer funds.</p>
<p>Some of the most horrific allegations didn’t make it to air, but were reserved for the <a href="http://www.abc.net.au/news/2016-11-14/four-corners-broken-homes-child-protection/7987450">digital broadcast</a> available online immediately after the program. This included recent revelations of an alleged rape in New South Wales by UnitingCare staffers who had been entrusted with the care of 13-year-old “Girl X”. The girl <a href="http://www.coroners.justice.nsw.gov.au/Documents/m-finding.pdf">died from a drug overdose</a> just weeks before she was due to give evidence against her alleged attackers.</p>
<p>The digital broadcast also included the sexual predation by adults of children in Victorian state care, revealed in a “searing condemnation” by Victorian Children’s Commissioner Bernie Geary. This is an issue that the South Australian <a href="http://www.agd.sa.gov.au/child-protection-systems-royal-commission">Child Protection Systems Royal Commission</a> has also exposed. </p>
<h2>A familiar story</h2>
<p>Depressingly, the Four Corners program did not reveal much that was new. My <a href="http://www.unsworks.unsw.edu.au/primo_library/libweb/action/dlDisplay.do?vid=UNSWORKS&docId=unsworks_38185">own research</a> has identified equally devastating statistics of abuse and neglect of children in care. Almost a quarter of the children in my study had been abused while in care, in what were meant to be safe placements.</p>
<p>The abuse, which was confirmed by state authorities, took the form of physical beatings, violence and sexual assault. The younger the child, the more likely they were to have been hurt while in care. A third of children under 13 years of age had been abused and a quarter had attempted suicide.</p>
<p>It would be naive to assume that the child welfare system is always benevolent and focused on providing nurture, protection and support. It cannot be guaranteed that the type of placement or the level of care provided is always based on a child’s needs. But across Australia, outcomes for children in care are generally regarded as highly unsatisfactory.</p>
<p>The United Nations (UN) has called attention to the “<a href="http://www2.ohchr.org/english/bodies/crc/docs/co/CRC_C_AUS_CO_4.pdf">widespread reports of inadequacies and abuse</a>” in Australian care systems. The UN has complained of the inadequate screening, training, support and assessment of carers. It has also complained of the inappropriate placements of children, and the mental health issues that are “exacerbated by (or caused in) care”.</p>
<p>Children in care have worse life outcomes than their peers. Whether we’re measuring health, education, employment, stability, well-being, social inclusion, financial and emotional security or involvement in the criminal justice system, children in care perform badly, even when compared to children of roughly comparable backgrounds and problems. </p>
<h2>A century-old problem</h2>
<p>In the 1870s, a scathing assessment of the Australian care system by British child welfare reformers the Hill Sisters led to a <a href="https://archive.org/details/whatwesawinaustr00hilliala">royal commission into charities</a>.</p>
<p>On average, there has been a major inquiry into aspects of the child welfare system every three years since then.</p>
<p>The abuse suffered by children in care is exposed regularly. Every time, it’s met with the same excuses and promises. The children are presented as damaged, rather than the systems that are failing them. Agencies hide behind their professed best intentions and talk about “difficult” children.</p>
<p>Governments spruik their support for “salt of the earth carers” and the “<a href="https://members.nsw.liberal.org.au/news/state-news/upton-urges-people-open-their-hearts-and-homes-part-families-week">saints</a>” of child welfare. These governments are afraid that if they probe too deeply into the failings of the system and agencies, they will be left holding the baby. The focus shifts from the care agencies’ failure to protect vulnerable children, to airing agencies’ calls for additional funding and even earlier intervention.</p>
<p>The UK House of Commons <a href="http://www.publications.parliament.uk/pa/cm200809/cmselect/cmchilsch/111/111i.pdf">has said</a> that:</p>
<blockquote>
<p>many of the things we wish would happen in the care system would follow naturally if the system and those who work within it were minded, and enabled, to act more like parents.</p>
</blockquote>
<h2>The failure of government</h2>
<p>Government interventions to enforce this have proved spectacularly unsuccessful. The mountain of memorandums of understanding, guidelines, compacts, heads of agreement, committees, regulations, legislation, independent inquiries and reports established over the past 20 years in New South Wales alone have failed to improve things for children in care. Measures designed to protect children have not overcome the system’s inadequacies nor even begun to address the often questionable motivation and practices of the various players in the child welfare sector.</p>
<p>Government failure to hold the bureaucracy and its non-government sector partners accountable for poor decisions, inadequate oversight and accountability and the inefficient use of resources that erode the effective operations of the out of home care system is an indictment on us all. </p>
<p>These failures have allowed the problem of abuse and neglect in care to seem insurmountable, regardless of the devastation caused to the children concerned. There have been repeated professions of political goodwill and the commitment of countless millions of dollars across child welfare, juvenile justice, homelessness, education and health services. Despite this, we have failed to stop kids being abused by the very people we have trusted to care for them. </p>
<p>That the matters reported last night on Four Corners are occurring at the very time we have a <a href="http://www.childabuseroyalcommission.gov.au/about-us">royal commission</a> watching the system shows the practitioners and agencies responsible for the neglect and abuse of children in their care have little to fear.</p><img src="https://counter.theconversation.com/content/68743/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Kath McFarlane was Chief Investigator for a NSW Government-awarded tender to Charles Sturt University to examine bail practices in the Children’s Court, and has advised on the Family & Community Services Pathways of Care study. In 2015 she was Chief of Staff to the NSW Minister for Family and Community Services. </span></em></p>We have decades of evidence showing the widespread abuse and neglect suffered by children in the out-of-home care system. The agencies responsible for allowing the abuse have little to fear.Katherine McFarlane, Senior Lecturer in Justice Studies, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/501422015-11-04T12:13:44Z2015-11-04T12:13:44ZWhy the UK is heading for a care-home catastrophe in the next 20 years<figure><img src="https://images.theconversation.com/files/100634/original/image-20151103-16542-asrgvc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">How to build nearly 800 new care homes each year?</span> <span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=care%20home&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=262066235">Photographee.eu</a></span></figcaption></figure><p>Care homes are already in crisis. Up to 50% of them could close due to the shortfall between what councils can pay and what the care costs, <a href="http://www.theguardian.com/society/2015/oct/31/half-care-homes-could-close-cash-crisis?CMP=share_btn_link">according to reports</a> in The Observer. But when you look into the future, I’m afraid the news gets considerably worse. </p>
<p>Old age might seem a long way off to many. But when a recent YouGov survey <a href="https://www.caremanagementmatters.co.uk/nhs-should-prioritise-care-for-the-elderly/">asked us</a> which should be the NHS’s priority areas over the next five years, care for the elderly came top, on 57%. And the reality is that the population of over 85s – the main users of UK care homes – is <a href="http://www.kingsfund.org.uk/time-to-think-differently/trends/demography/ageing-population">forecast to</a> more than double over the next 20 years. </p>
<p>The big question is, what will we need to build exactly? This is not as straightforward as it might first appear. By the 2030s, new technologies that make it easier to look after people remotely should have become standard. For example the worldwide market for mHealth – healthcare via mobile phone – is <a href="http://www2.deloitte.com/content/dam/Deloitte/uk/Documents/life-sciences-health-care/deloitte-uk-connected-health.pdf">expected to</a> have increased 54% between 2013 and 2018, to US$22 billion (£14 billion). These changes are likely to mean that a lower proportion of tomorrow’s over-85s will need to be in care homes than today’s. </p>
<p>But if this saves money on care homes to some extent, someone will still have to pay for the technology. And remote care won’t always be enough on its own. Suitably equipped houses will be required. So we need to think about the future requirement for homes fit for everything from “independent living” through to <a href="http://www.gov.scot/Publications/2008/01/11131906/17">very sheltered housing</a>. According to <a href="https://connect.innovateuk.org/documents/3301954/11214094/Health_KTN_LongTermCare_Frost%26Sullivan_report.pdf/167cff1d-020f-4dcb-a2b6-0610238c7d29">estimates made in 2013</a> the future will look like this:</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/100631/original/image-20151103-16542-131ruxq.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/100631/original/image-20151103-16542-131ruxq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/100631/original/image-20151103-16542-131ruxq.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=319&fit=crop&dpr=1 600w, https://images.theconversation.com/files/100631/original/image-20151103-16542-131ruxq.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=319&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/100631/original/image-20151103-16542-131ruxq.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=319&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/100631/original/image-20151103-16542-131ruxq.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=401&fit=crop&dpr=1 754w, https://images.theconversation.com/files/100631/original/image-20151103-16542-131ruxq.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=401&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/100631/original/image-20151103-16542-131ruxq.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=401&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://connect.innovateuk.org/documents/3301954/11214094/Health_KTN_LongTermCare_Frost%26Sullivan_report.pdf/167cff1d-020f-4dcb-a2b6-0610238c7d29">Knowledge Transfer Network: Healthcare and Medicine</a></span>
</figcaption>
</figure>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/100633/original/image-20151103-16542-gikvs9.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/100633/original/image-20151103-16542-gikvs9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/100633/original/image-20151103-16542-gikvs9.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=326&fit=crop&dpr=1 600w, https://images.theconversation.com/files/100633/original/image-20151103-16542-gikvs9.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=326&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/100633/original/image-20151103-16542-gikvs9.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=326&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/100633/original/image-20151103-16542-gikvs9.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=410&fit=crop&dpr=1 754w, https://images.theconversation.com/files/100633/original/image-20151103-16542-gikvs9.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=410&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/100633/original/image-20151103-16542-gikvs9.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=410&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption"></span>
<span class="attribution"><a class="source" href="https://connect.innovateuk.org/documents/3301954/11214094/Health_KTN_LongTermCare_Frost%26Sullivan_report.pdf/167cff1d-020f-4dcb-a2b6-0610238c7d29">Knowledge Transfer Network: Healthcare and Medicine</a></span>
</figcaption>
</figure>
<h2>Time for a national plan</h2>
<p>In total, our estimate at the Institute for Sustainable Construction is that the UK will need to build more than 15,500 residential “care” developments by 2035, each of which would accommodate 40 to 70 people. That is 780 a year, and a huge rise on the 18,000 plus that we have in the country at present. At say £5m per care home, we are talking about an investment of around £4 billion a year. To that we may add the cost of designing homes for a new class of older people who would currently need to live in care homes/sheltered housing – assuming it wouldn’t be cheaper for this to continue rather than taking advantage of new technology. </p>
<p>The government is pursuing <a href="http://www.planningportal.gov.uk/buildingregulations/approveddocuments/partm/adm/admvol1">new building regulations</a> to make it easier for people to stay in their homes for longer, while the pan-UK Technology Strategy Board has been <a href="https://connect.innovateuk.org/documents/3217986/15712426/New+Horizons+for+Self-Care/04a73003-a199-4936-be41-f14acbabb265">focusing on</a> remote-care technologies. But to a large extent, those at local level are being left to fend for themselves, and we are in danger of over-focusing on technology that will never help everyone. Instead we need a national infrastructure plan to support councils and care providers to make the necessary changes. </p>
<p>Normally infrastructure is associated with major transport systems and utilities, but it should also be relevant to major changes in where we need to live – and how we navigate around these places. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/100635/original/image-20151103-16507-14ljdt5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/100635/original/image-20151103-16507-14ljdt5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/100635/original/image-20151103-16507-14ljdt5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/100635/original/image-20151103-16507-14ljdt5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/100635/original/image-20151103-16507-14ljdt5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/100635/original/image-20151103-16507-14ljdt5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/100635/original/image-20151103-16507-14ljdt5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/100635/original/image-20151103-16507-14ljdt5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">From care to where?</span>
<span class="attribution"><a class="source" href="http://www.shutterstock.com/cat.mhtml?lang=en&language=en&ref_site=photo&search_source=search_form&version=llv1&anyorall=all&safesearch=1&use_local_boost=1&autocomplete_id=&searchterm=care%20home&show_color_wheel=1&orient=&commercial_ok=&media_type=images&search_cat=&searchtermx=&photographer_name=&people_gender=&people_age=&people_ethnicity=&people_number=&color=&page=1&inline=73696801">Monkey Business Images</a></span>
</figcaption>
</figure>
<p>This is not just about funding but also strategy: we will <a href="http://www.bpf.org.uk/media/press-releases/property-industry-urges-local-authorities-prioritise-care-homes">need to</a> identify gap sites in cities, towns and villages to enable as many elderly people to stay in their local communities. For those that can’t stay at home, this is essential for enabling them to see family and friends, and reduce feelings of loneliness and isolation. </p>
<p>We need to start responding to this immediately, over and above the current funding difficulties. With the right foresight, any rich country should be able to care for those who helped build it. History will look very unkindly on those who failed to take the necessary decisions at the appropriate time.</p><img src="https://counter.theconversation.com/content/50142/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Edinburgh Napier’s Institute for Sustainable Construction hosts the Centre for Sustainable Communities and Prof Sean Smith serves on the Construction Scotland Innovation Centre technical advisory group.</span></em></p>Reports on the current crisis in elderly care are set to be dwarfed by problems caused by the imminent explosion in the over-85s.Sean Smith, Director of Institute for Sustainable Construction, Edinburgh Napier UniversityLicensed as Creative Commons – attribution, no derivatives.