The concept of quality residential aged care has changed considerably in recent years as care models have moved from institutional to person-centred principles of practice and organisational quality measures shift from a focus on inputs and outputs to outcomes for residents. A recurring theme in the evidence presented to the Commission has been that the staffing levels and skill mix within aged care has been insufficient to support quality outcomes for residents.

There is strong evidence from the health sector about the relationship between staff levels and skill mix to quality of care and safety of clients (Australian Commission on Safety and Quality in Health Care 2019). This is not the case for the aged care sector, due to a combination of data limitations as well as organisational and cultural factors (OECD/European Commission 2013a).

This report draws on data collected as part of the RUCS project which was undertaken by the Australian Health Services Research Institute (AHSRI), University of Wollongong in 2017-18 and which underpinned the development of the proposed new casemix funding model for aged care, the Australian National Aged Care Classification (AN-ACC) (Eagar et al. 2019). The RUCS included independent assessments of approximately 5,000 aged care residents, the standardised collection of operational and staffing costs associated with 140 homes across Australia, and the collection of service utilisation data from around 1,600 care staff across 30 care homes. We are confident that these data are representative of the broader Australian residential aged care sector.

Key points:

- Debate regarding staffing levels in aged care homes is premised on evidence in health services where a direct relationship between nursing staff mix and quality of care has been established. As with health care, quality in aged care is impacted not only by staffing levels. It is also driven by organisational culture, skill mix and consistency in staffing personnel.

- A key finding in this study is that, among comparable countries, the USA Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare system employs the most comprehensive approach to staffing levels. This is the best system currently available internationally to evaluate existing Australian staffing levels. Further, it provides a useful model that could be progressively refined and adapted in Australia to inform future staffing requirements.

- The CMS system uses a 5 star rating to define adequacy of care staffing levels in residential aged care services, with ratings adjusted to take account of differences between homes in terms of the complexity of their resident’s care needs (‘casemix adjustment’). Refining the USA model to make it suitable for use in Australia, our judgement is that:

• 1 or 2 stars represent unacceptable levels of staffing
• 3 stars is acceptable
• 4 stars is good, and
• 5 stars is best practice

- More than half of all Australian aged care residents (57.6%) are in homes that have 1 or 2 star staffing levels.