NTCOSS Submission to the Royal Commission into Aged Care Quality and Safety

 

NTCOSS is a peak body for the Northern Territory community sector and is a voice for people affected by social and economic disadvantage and inequality. The community sector in the Northern Territory is made up of community managed, non-government, not for profit organisations who work in social and community service delivery, sector development and advocacy.

The community sector plays a vital role in creating social wellbeing for all Territorians and in building safe and healthy communities by providing services that enable people to access and participate in health services, education, employment, economic development, and family and community life.

NTCOSS represents a service sector with a high level of contact with older people. While a number of organisations are funded to work directly with older people, many social service organisations will support older people and their families indirectly through the provision of a wide range of social services, including homelessness support, family support services, childcare, alcohol and drug support and health and wellbeing services.

NTCOSS acknowledges that a number of our member organisations with specific expertise in this area have provided or intend to provide submissions. These members, some of whom are Aboriginal Community-Controlled Organisations, provide a diversity of aged care services from advocacy to residential facilities and transport services.

 

Introduction

NTCOSS welcomes the opportunity to provide this submission to the Royal Commission into Aged Care Quality and Safety.

The Northern Territory represents a unique context for aged care service delivery. With its small, but ageing population, dispersed over a wide geographical area, accessible, affordable and high quality service delivery requires a vastly different operating model to its urban counterparts in more densely populated jurisdictions. Additionally, the Northern Territory has the highest proportion of Aboriginal people in its population, including members of the Stolen Generation, who have unique needs as well as different cultural concepts of ageing.

Despite this, the Northern Territory aged care system continues to operate under a national model that fails to meet to the needs of ageing Territorians. The inadequacy of the aged care system in the Northern Territory has resulted in excessively long waitlists to access higher level support, an overdependence on the health system and, in the community sector, overstretched and under- resourced services that struggle to provide the level of support required within funding constraints.

The Northern Territory needs an aged care system that is tailored to its unique context, recognising the specific needs of diverse, ageing Territorians.

 

Why the Northern Territory is different from other jurisdictions

The Northern Territory represents a vastly different context to other jurisdictions in Australia.

The Northern Territory has a relatively small population spread over a large geographical area, with a significant Aboriginal population. According to the last census, the Northern Territory is the

smallest jurisdiction in Australia at 228,833 people.1 People aged 65 years or older make up approximately seven percent of the Northern Territory population, a percentage that has been increasing over the last five years.2 Twenty-five and a half percent of the Northern Territory population are Aboriginal, many of whom are members or descendants of the Stolen Generation.3 Over forty-three percent of the Northern Territory population resides in remote or very remote locations.4 There are over 600 communities and remote outstations, all with small populations.5 The vast majority of people living in remote and very remote locations are Aboriginal, with approximately eighty percent of older Aboriginal Territorians residing outside of urban areas.6

Importantly, the population of older people is predicted to increase significantly over the next 25 years. It is estimated that the growth rate for non-Aboriginal Territorians aged 65 years or more will be 126% compared with a 290% change for Aboriginal Territorians.7 Due to the younger age structure of the Aboriginal population, this increase is particularly significant as it means that the number of Aboriginal Territorians over 50 years will also substantially increase, placing further demand on aged care services. The high growth rate for Aboriginal people is a reflection of increased life expectancies as more Aboriginal people age into their sixties and seventies.8 This indicates an increased demand for aged care services in the future.

The Northern Territory has the highest rate of burden of disease in Australia9 alongside deeply entrenched disadvantage. Aboriginal Australians are particularly at risk of complex health issues. In 2011, among Aboriginal Australians aged 50 years and over, 750 years of life was lost due to premature death or to living with disease or injury per 1000 people.10 The leading disease burden for Aboriginal people aged 50 years and over across Australia is cardivascular diseases and cancer.11 Rates of hospitalisation for injury and poisoning among Aboriginal people aged 50 years and over are particularly high for people living in remote (over sixty per 1000 population) and very remote (over fifty per 1000 population) locations.12

In the Northern Territory, social and economic disadvantage is experienced particularly acutely, with rates that exceed the national average in homelessness, child removals, adult and youth incarceration, domestic and family violence and significantly lower than average rates of educational attainment levels and health outcomes. Research shows that there is a strong correlation between socioeconomic status and mortality and morbidity rates in the Northern Territory.13 The burden of disadvantage is disproportionately felt by the Aboriginal population with approximately a quarter to a third of the Northern Territory Aboriginal health gap being due to social disadvantage.14

The poorer levels of health mean that older people are more likely to have complex health problems as they age.The Aboriginal population in the Northern Territory is at a higher risk of compex health issues due to the higher rates of chronic disease risk factors, such as dyslipidaemia, high blood pressure, central obesity, diabetes and smoking.15 These risk factors also mean that where Aboriginal older people do exhibit geriatric syndromes, they are often due to non-ageing related causes, such as hearing impairment due to otitis media.16 Given the complex health issues that many ageing Territorians face, aged care services need to be equipped to meet these needs.

Dementia is also on the rise in the Northern Territory. Currently, there is an estimated 1764 people living with dementia.17 Among the Aboriginal population, the incidence of dementia is much higher, with a younger onset of the disease.18 Among 45 to 69 year olds, Aboriginal people are twenty times more likely to have dementia than their non-Aboriginal counterparts.19 The number of people with dementia is expected to increase to over 2700 in the next 10 years, increasing the need for dementia services, that are culturally appropriate, in the future.20

 

The Stolen Generation

In the Northern Territory, twelve percent of Aboriginal people born before 1972 are members of the Stolen Generation. Additionally seventeen and a half percent of the Aboriginal population aged 18 years or more are descendants of the Stolen Generation.21 This group represents a considerable cohort with particular vulnerabilities and needs as they age.

Members and descendants of the Stolen Generation are particularly vulnerable across a number of health and social domains compared with their non-removed Aboriginal and non-Aboriginal peers. In particular, they are more likely to have had contact with the justice system, to be dependent on government payments as the main source of income, be victims of recent physical violence, to not be a home owner, to have poorer physical and mental health, to have experienced homelessness, to have been unemployed and to have recently experienced racism.22 These vulnerabilities mean that members and descendants of the Stolen Generation have complex needs as they age that must be supported by the aged care system. While they do not form the majority of people accessing the aged care system, their acute vulnerability and history of trauma, loss, poverty and disadvantage warrant particular attention.

In particular, it is important that members and descendants of the Stolen Generation do not experience further trauma through reinstitutionalisation. Placing a member or descendant of the Stolen Generation in a residential facility can risk re-traumatisation and cause further harm to the individual. Tailored services for members and descendants of the Stolen Generation that prevents re-traumatisation and supports their needs, independence and freedom are required.

 

Key Issues for the aged care system in the Northern Territory

A national aged care service model is not always appropriate in the Northern Territory The national model for aged care service provision does not always function effectively in the Northern Territory context. Its unique demographic and geographical context, alongside a national system that has been largely designed around the needs of larger urban areas, means that the aged care system is not adequately meeting the needs of older Territorians.

The market-based model adopted by the aged care system to support consumer choice and control, is not always appropriate in small economies of scale. Since 2017, Home Care Packages (HCPs) have been assigned directly to the individual rather than providers to enable individuals’ choice of provider and enabling the opportunity to change providers. However, for this model to be effective, it relies on more than one provider offering the same or similar services to support consumer choice. In a small jurisdiction, there is not often the population density to support multiple providers with the same or similar services, particularly outside of Darwin and Alice Springs. This means that there are often limited choices for individuals and that market-based competition is not present.

The inappropriateness of market-based models of service provision is further exemplified in the cost structure for residential aged care facilities. Historically, residential aged care facilities have been undersubscribed in the Northern Territory due to the economies of scale required to make a facility financially viable.23 The size for a new residential aged care facility has increased to meet the needs of growing older populations in more densely populated areas of Australia. Large facilities are not always viable in the Northern Territory where the population size is comparatively small and organisations could take on considerable financial risks to operate.24 Moreover, the Northern Territory has had a markedly higher number of applicants who do not have any financial reserves and require government subsidies to operate.25 The cost structure for residential aged care facilities exemplifies how the market-based model that is designed for larger client bases is not always viable in the Northern Territory.

The Northern Territory also has a higher cost of service provision by comparison to other jurisdictions due to the smaller economy of scale and the geographical dispersion. For example, the cost for nursing services for older Territorians is over seven times the national average. 26 Equally the cost for an aged care assessment is $1783.74 in the Northern Territory, compared with $680.59 nationally.27 This means that, for the same amount of funding, the Northern Territory has less services. In terms of service provision, the higher cost of service provision means that services are often over-stretched and under-resourced. NTCOSS consulted a number of community service providers that described the limitations of funding structures, particularly home care packages, which do not account for many of the needs they service in aged care support, such as transport costs, outreach and emergency material provisions. As a result, services have to draw on internal resources or source donations in order to meet the care needs of their clients.

The smaller economies of scale in the Northern Territory also mean that what would be small changes or trends at a national level can be felt acutely in services locally.28 For example, national data shows that 236 people on 31 December 2018 had been assessed as eligible for a Level 2 or higher Home Care Package, but were awaiting access to that package level and had not been offered a lower level package.29 The expected wait time to access a package Level 2 and above nationally is twelve months or more.30 This correlates with anecdotal evidence that older people are often waiting eighteen months or longer to access packages. The flow on effect of these long waitlists is that people access as much support as they can through the Commonwealth Home Support Program (CHSP). While other more densely populated jurisdictions may have capacity to absorb this extra demand in existing services, services in the Northern Territory feel the effects of the extra demand more acutely due to the small economies of scale. Services, which are already stretched for resources, face difficult decisions to either restrict the number of people accessing their services by placing caps, leaving people with lower level needs without support, or relying on internal resources to bolster services to meet needs.

 

The inadequate funding for aged care services in the Northern Territory impacts the capacity of service provision to meet local needs

The Northern Territory receives the lowest level of funding per person for aged care services compared with the rest of Australia. Federal Government expenditure is $3582.62 pp in the Northern Territory compared with $4571.61 pp on average nationally.31 Combined with the higher cost of service provision, this low rate of government expenditure has resulted in inadequate service provision in the Northern Territory.

The inability of current services to adequately meet demand is evidenced in a number of ways. Firstly, there is a shortage of residential aged care beds. While the Northern Territory has the highest share of NATSIFACP places (forty-three percent), it is the only jurisdiction with more Home Care than Residential Care places.32 The Northern Territory has the lowest allocation of residential care places in the country at thirty-two per 1000 per target population, less than half the national average.33 The shortage of residential aged care services has resulted in many older people in long stay beds in hospitals while they await transition to a residential home. The Northern Territory has the highest proportion of people awaiting residential placements in hospital in Australia, with nearly sixty percent of people awaiting placement to a residential home doing so for more than 35 days.34 Anecdotally, NTCOSS understands that people can wait up to several years until a residential bed is made available.

Secondly, there is a shortage of respite services, resulting in carers struggling to sustain the caring responsibilities without any breaks. This can affect the quality of care that the carer is able to provide, and can lead to unnecessary emergency situations. Where respite is available, the funding structures mean that respite is offered for longer periods of time only, such as two or more weeks.

For some carers, only a few days of respite or daytime or after hours respite services is preferred. However these services are extremely limited due to funding constraints. For people with dementia, there are limited options available for respite beds in residential aged care facilities with specialist dementia units.

Thirdly, the long waitlists for higher level HCPs also reflect the shortage of aged care services. Many older people are only able to access lower level packages from limited service providers due to the shortage of services. The Northern Territory has almost twice as many lower level HCPs compared with nationally.35 The long waitlists impact on carers, as it often sees carers providing the necessary support as a stop gap measure until a higher level HCP is made available. With limited providers and services available, some carers struggle to find a service that provides tailored care for the older person’s specific needs. The shortage of services therefore impacts on the quality of support and care for older people.

Fourthly, limited transport services restrict access to services in urban locations for people who live in remote communities. For example, flights from remote communities to Darwin (flying is often the only way to access these locations in the wet season) to access respite care or medical appointments is very costly which can create a barrier to accessing needed care supports. Alternatively, due to limited services in remote communities, older people are relocated to urban centres, away from family and country, because their care needs cannot be met. Notably, there are differences in the availability of services in distinct communities, creating geographical inequity of access to services.

For example, some communities with better access to services, such as Mt Liebig where Purple House provides transport and aged care support, or Docker River where there is a flexible aged care service, are far better able to offer ageing residents the opportunity to age on country with kin, ensuring their care needs are met through a combination of caring and service support.

 

The workforce challenges in regional and remote areas

The Northern Territory, with its small population widely dispersed across a large geographical area, represents significant challenges for maintaining a highly qualified, stable workforce.

In the Northern Territory, a key concern for many employers, not limited to the aged care sector, is high staff turnover. According to Industry Skills Advisory Council NT’s most recent report on the Northern Territory Aged Care workforce, staff turnover is around thirty to forty percent with some organisations reporting a turnover as high as sixty to seventy percent. On average it takes employers five to six weeks to fill an aged care position, which on average people hold for only twelve to eighteen months.36 Particularly in remote communities where there is only one provider for aged care, it is difficult for a single provider to sustain a local aged care workforce. It can also be difficult for employers to attract suitably qualified and experienced staff to live in regional and remote communities. The challenges in staff retention and high turnover place great strain on aged care services and can impact the availability of services.

Many workers in the aged care system in the Northern Territory do not have the skilled qualifications needed for their role. Over fifty percent of Community Care service providers do not require an entry level qualification for employment in the Northern Territory.37 While some organisations support their employees through on-the-job training, this often relies on the goodwill of the employer and access to accredited, vocational training programs which can be completed alongside full-time or part-time work. Currently, there is limited access to accredited training opportunities for people in regional and remote locations. Coupled with the complex needs of older Territorians, inadequately skilled workers are often providing a significant amount of care to older people, which can impact the quality of care provided. For example, despite the fact that nationally fifty-two percent of aged care residents have dementia, support staff receive inadequate training in assisting people living with dementia.38 Particularly in remote locations, workers can often be quite isolated, working under minimal supervision or with limited access to specialised staff which can make the working environment challenging. In the Northern Territory, with the high proportion of Aboriginal people, there is also the additional need to be culturally competent in working with older Aboriginal Territorians, being able to provide support in a culturally appropriate way and being cognisant of cultural needs. This training is not provided through the mainstream career pathways and is often dependent on employers to provide this to employees.

A further challenge to the workforce in the Northern Territory is the limited access to specialist services. For example, psychogeriatric services are deeply underserviced in the Northern Territory.39 The Northern Territory also has proportionately less nursing staff in the aged care sector, only three and a half percent of the workforce is comprised of nurses compared with eight percent nationally.40 The specialist dementia units in residential care facilities are restricted to urban and some regional areas. Facilities with specialist dementia units are often inadequately resourced, including a lack of appropriately skilled staff. This can make it difficult to support those residents with responsive behaviours brought about by their dementia symptoms. These clients are seen as a risk to the facility in providing residential support – due to the need to provide a safe environment for other residents, staff and visitors. This has an impact on a residential facility’s willingness to support high needs individuals when they do not have the resources or expertise to support them. This often results in long-term hospital stays or carer burnout. By the time carers opt for respite, the person may no longer be suitable to reside in the general area of the facility (e.g. due to wandering) so respite cannot always be delivered when required. As a result, people with advanced dementia may either miss out on the care they need or remain in hospital for extended periods of time. This also has a flow on effect to carers, who do not always have access to education to understand the challenges of supporting someone with dementia.

The funding constraints and workforce challenges impact the quality of care provided to older people. The Northern Territory has the lowest rate of compliance with quality standards in the country, with just over eighty percent of services meeting minimum standards in 2017 – 2018.41 Historically, the Northern Territory has also been particularly susceptible to having services being sanctioned, particularly in remote communities where reduced financial capacity and a low skilled workforce makes it challenging to meet minimum standards.42

There are opportunities to address the aged care workforce challenges in the Northern Territory by looking to other sectors that require similar skillsets for broad, cross-sector collaboration. In a small jurisdiction, professionals often work in several sectors throughout their working life or, particularly in remote communities, are required to have diverse skillsets to undertake a broad range of tasks as part of their role. Therefore, there is great opportunity to foster collaboration with other social service sectors, such as disability, family services and health and wellbeing services, and skill up a robust local workforce with the expertise to work across multiple domains. Greater opportunities to build the capacity of the local workforce, particularly the local Aboriginal workforce, and provide access to accredited training, will ensure the best quality care for older people, by valuing the local, cultural expertise in communities, alongside nationally accredited qualifications. Supporting the local workforce through greater access to training and supported employment pathways will also benefit the quality of care for older people in the long run by offering greater staff retention and providing a more sustainable workforce to meet future demand.

 

Elder abuse

While the prevalence of elder abuse in the Northern Territory has not been quantitatively assessed, anecdotal evidence suggests that it is widely experienced. A report by Darwin Community Legal Service indicates that in the Northern Territory, seventy-two percent of perpetrators were relatives of the older person.43 Older women are disproportionately affected by elder abuse, with seventy percent of older people experiencing elder abuse being women.44

Financial abuse is the most common form of reported elder abuse, however this is often accompanied with other forms of abuse including neglect and physical, sexual, social and psychological abuse.45 Financial abuse can involve the use of monetary cards without consent, pressuring older people to provide money or spend money in particular ways or influencing older people on how royalty money should be spent. NTCOSS stakeholders raised concerns that some people register as carers in order to receive financial payments but then fail to provide adequate care to older people.

Many older people experiencing abuse do not want to report the abuse due to fear of retribution, shame, cultural obligations or not wanting to get a family member into trouble. Anecdotally, NTCOSS understands that changes to the Community Development Program in remote communities that has correlated with an increase in breaches and reduced income for working age family members,46 has resulted in an increase in elder abuse.

In some instances, for Aboriginal Territorians, issues around elder abuse, particularly regarding neglect, can be a grey area. Reciprocal kinship obligations and different cultural approaches to caring for older people mean that they can be caught in between two competing cultural systems of care that can leave their needs unmet. For example, relative may register as a person’s carer however it may not be culturally appropriate for them to assist with the person’s showering needs. It can be challenging to balance an individual’s desire to age on country with family alongside their care needs and identifying who is best placed culturally to provide care to the individual.

Further research is required to better understand the prevalence and nature of elder abuse in the Northern Territory. Culturally appropriate ways to prevent, address and monitor elder abuse must be developed. Sustainable and well-resourced funding for advocacy and case management must be provided to ensure prevention and protection for people at–risk or experiencing elder abuse.

 

Institutional abuse

The level of institutional abuse is not publically documented in the Northern Territory. While institutional abuse has been in the spotlight across the country, NTCOSS expects that the Northern Territory is not unique in this respect.

In particular, the Northern Territory lacks legislative protections and practice guidelines around the use of restrictive practices for aged care services. Introducing regulation around the use of restrictive practices in residential aged care services will protect the human rights of older Territorians. Policy shifts to address the staffing, operation and culture of aged care services will ensure improvements in the quality of life of older people. The Northern Territory can draw on the experiences of international jurisdictions that are far ahead of practices in Australia.47

There is also a significant gap in monitoring elder abuse in institutional settings. While there are auditing processes to ensure minimum standards, these do not occur on a frequent regular basis. While there is also a complaints system, older people are often in vulnerable circumstances in aged care facilities to report abuse. Cognitive impairment and the dependence on others to have their care needs met can be barriers to reporting abuse. There is also a fine balance to be met between balancing the dignity and autonomy of vulnerable individuals with the safety and protection they need. While it is important to identify and address elder abuse in institutional settings, this must not be at the cost of older people’s dignity and right to privacy, for example through planting hidden cameras to capture the abuse.

Formalised community visitor programs that provide independent oversight and monitoring services on a regular basis provide a strategic mechanism for identifying and reporting abuse and neglect in a way that respects people’s dignity and autonomy. Through regular visits, community visitors are well placed to check that the rights of the older people are being upheld and ensure the appropriate standard of care is being provided. Community visitors are well placed to resolve complaints directly with the aged care facility and advocate on behalf of the older person. Importantly, effective community visitor programs are embedded in legislation to ensure effective monitoring and oversight. NTCOSS notes the current Community Visitor Program run by the Anti-Discrimination Commission for Mental Health Inpatient facilities, Disability Secure Care facilities and previously Alcohol Mandatory Assessment and Treatment Services as an effective independent monitoring and oversight mechanism.

 

Housing and homelessness

The older homeless population is a particularly vulnerable group of people. The Northern Territory has the highest rate of homelessness in the country, at twelve times the national average.48 Older women represent a particularly vulnerable cohort, with sixty-five percent of older women in the Northern Territory living in severely over-crowded dwellings.49 Older people leaving prison are also a vulnerable homeless cohort, with approximately eight percent of the adult prison population in the Northern Territory being over 65 years or Aboriginal and over 50 years of age.50

NTCOSS recognises that there is currently work being done on a number of fronts to address housing and homelessness issues for older people, including addressing physical access barriers for social housing (Tangentyere Design and the University of Newcastle), strategies to address homelessness among older people (through the development of Aged Care Homelessness Action Plans)51, and efforts to address homelessness among older women (the Age Discrimination Commissioner).

 

Key principles for an effective aged care system

While the aged care service system is managed on a national level, there are clear deficiencies for this approach in the Northern Territory. It is clear that the one-size-fits-all approach to aged care fails to provide adequate service provision and consequently, many older people are not receiving the care they need.

NTCOSS recommends that the model for aged care service provision in the Northern Territory be reviewed and reformed along the following principles:

1. Upholding the dignity of the individual

In a small jurisdiction that does not support a market-based model of service provision, supporting older people’s choice and independence can be ensured through inclusive decision-making processes. In the Northern Territory, the diversity of individual people’s cultural backgrounds and lifestyles means that there are different understandings of what it means to have a good quality of life as one ages. The capacity of someone who is receiving care in town to die on country is a prime example of the tension between access to provision of quality care and connection to kin, country and culture. For each person, an ongoing conversation must be had around their care plans to determine what quality of life means for them and how this can be best achieved with the support of the service system. For this to happen, decision-making processes around an individual’s care needs and the development of care plans must ensure the voice of the older person is heard and respected, and not just be based on the assessment of a medical professional or aged care assessor.

2. Strong advocacy and case management services for older people and their carers

The aged care system can be complex to navigate, and particularly for the most vulnerable people, it is important to have an advocate or case manager to provide assistance to access services and protection from abuse. Carers also often experience confusion trying to access tailored support for the older person, as well as respite and care services to assist them with their caring responsibilities. Advocates and case managers play critical roles in helping older people and their carers navigate the complexity of the aged care system as well as preventing elder abuse and intervening early where it does occur. Sustainable and well-resourced funding for culturally appropriate advocacy and case management must be provided to address barriers to accessing support and to ensure prevention and protection for people at–risk or experiencing elder abuse.

3. Services tailored to diverse need groups

Ensuring the dignity and autonomy of the individual is upheld in decision-making processes means that services need to be available to cater to the needs of specific cohorts. For example, this could include the creation of more specialist dementia units in residential aged care facilities, supported independent living options for members of the Stolen Generation and social housing options that enable ready access for ageing people with physical access needs.

4. A place-based, tailored and flexible service model

There is a need for place-based reforms that bolster local solutions for local needs. Models of service provision for aged care need to reflect the local demographic and geographical considerations on a regional level. Block funding structures, such as the NATSIFACP model, represent a positive example of where flexible funding arrangements have been utilised by services to offer tailored service provision to specific communities. It is imperative that funding structures are sustainable and provide a long-term guarantee.

5. Well-resourced and accessible services

There is a need for an equitable funding model that recognises and provides appropriate resourcing to the specific geographic and demographic characteristics of the Northern Territory. The funding structure for services must also reflect the needs of individuals. Service provision models need to be innovative in order to effectively service people ageing on country.

6. Culturally informed services

In a jurisdiction with a high proportion of Aboriginal people, as well as a significant culturally and linguistically diverse population, it is important that services are designed around the cultural needs of their client base.

7. Collaboration between services and systems

In a small jurisdiction with low population density, services and systems need to work collaboratively to ensure effective use of resources and coordinated, quality service provision.

8. A well-qualified, local workforce

There is a need to develop a stable, qualified and culturally competent aged care workforce that prioritises training and employment pathways for Aboriginal people as well as opportunities where other sectors require similar skills sets.

 

Further recommendations

In addition to these principles, NTCOSS further recommends that:

  • A strategy be developed and implemented to address the shortage of specialist services
  • Research be undertaken to determine the prevalence and nature of elder abuse in the Northern Territory and a thorough strategy be developed and implemented in line with the national framework to introduce effective prevention, monitoring and intervention strategies
  • Further research is undertaken to develop an effective community visitor program model for aged care services in the Northern Territory, drawing on the experience of programs locally and nationally
  • A legal framework to permit and regulate the use of restrictive practices in residential care facilities and aged care services is established. This framework will include an authorised decision maker, the ability for review of decisions, appropriate considerations are taken into account, restrictive practices be the least restrictive option as a last resort and behavioural support plans are a requirement with a focus on reducing the use of restrictive practices.

 

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