The eight-volume final report of the Royal Commission into Aged Care Quality and Safety was handed down last week.

Sadly, it got somewhat lost, being overtaken by the government’s imbroglio over a lack of respect for women and a farrago of issues about sexual assaults. It wasn’t helped by the government refusing to release advanced copies of the report for review before the press conference.

Nevertheless, the report is extremely important. It highlights the almost total failure of current aged care, and it lays much of the blame on the Howard government’s decision in 1997 to effectively privatise the sector and leave it to market forces. The report makes 148 recommendations that touch on all aspects of remedies for the current malaise, and two of those are directly targeted at the design of future aged care buildings.

One way of summarising the vast amount of research and proposals in the report is contained in changing just two words: no longer nursing homes but now RACF’s or residential aged care facilities; changed because current facilities no longer employ nurses and no longer resemble homes. It is the second of those two words that are parsed in Chapter 6, leading to the two recommendations that concern us here.

The commissioners assert the importance of design: “Where older people live affects their sense of security and their quality of life. Accommodation that is well designed to meet people’s needs can improve their lives and their wellbeing.” They lament that was once a ‘home’ is now an ‘institution’, citing an increase in facilities with 60+ persons from 39% in 2008 to 60% in 2019.

They favour smaller facilities that more closely resemble homes: “…good design in residential aged care, particularly for people living with dementia, usually involves smaller, lower-density congregate living arrangements rather than larger, more institutional settings. Smaller, lower-density congregate living arrangements generally promote better quality of life for everyone. Large, noisy institutional environments can worsen the adverse consequences of dementia.”

In part 1.3.6, ‘Designing accommodation for Quality of Life’, (p105) they propose that: …the Australian Government should develop and publish a comprehensive set of national aged care design principles and guidelines on accessible and dementia-friendly design for residential aged care. The National Aged Care Design Principles and Guidelines should permit flexibility in their application in different circumstances. This leads to the later recommendation #45 on design, with a timetable for implementation (set out in full in the appendix below).

They also heard about the restrictive nature of the NCC building codes on innovative design and have suggested that the NCC be re-visited at the highest level to ensure that the new approach is facilitated. Here’s one example, where the NCC defines the class according to the means of escape: “Class 9c … are aged care buildings… defined as residential accommodation for elderly people who … are provided with personal care services and 24-hour staff assistance to evacuate the building in an emergency. Sprinklers yes but no more smoke doors and fire curtains.

Further on, the commissioners recommend financial support for this design transformation: “The Australian Government should actively promote and encourage their adoption by approved providers, builders, architects and others. Financial incentives should be paid to providers that demonstrate the adoption of the Design Principles and Guidelines for their residential aged care buildings.” This leads to recommendation 46 on financing (set out in full in the appendix below).

It may only be 2 recommendations in 148, but I am very impressed with the depth and power of the suggested initiatives. The recommended amounts of financial assistance for new designs are encouraging: “Commissioner Briggs recommends that the amount of annual grant funding should be increased to $300 million in 2021–22, $600 million in 2022–23 and $1 billion in 2023–24 and should be indexed for inflation in subsequent years.” You could invest in some serious re-designs for that money.

But already Treasurer Josh Frydenberg has flagged that, as a Liberal, he stands for lower taxes. Meaning less money for social programs, and most likely a NDIS-like Medicare levy. So, don’t expect any support from the LNP; design hopes dashed again. Expect that promises on aged care will be front and centre in the election campaign later this year (for an election on November 6 – you read it here first).

Whilst we wait for a federal government that will take the report seriously, we can turn our minds to The National Aged Care Design Principles and Guidelines. We’ve got just over a year to write and publish the first set. The core premise is to make the current institutional RACF’s more home-like.

Having had some involvement in retirement and aged care design I would offer the following thoughts for the new set of guidelines, all in the name of pursuing innovation. Here’s my starting list:

The overarching intention should be to create a home-like environment.
Everywhere there should be a feeling of domesticity.
The entry should be like a home foyer, with a less-institutional design solution disguising the security and control.
The number of residents in any grouping should be kept below 12.
Communal rooms should be smaller and resemble a house rather than a large institution.
Rooms for residents should be on a corridor that feels close to a home setting.
A resident's room should have abundant natural light, preferably from two sides.
A resident's room should have natural ventilation, capable of being easily opened.
Ensuites should feel as close as possible to a traditional bathroom, despite the need for accessibility to meet AS1428 (more generous circulation, grab rails, special equipment etc).
Consider how some residents could have access to private external spaces or doors that open onto small gardens.
Hallways and corridors should appear to be as domestic as possible.
Bump rails for trolleys should be disguised in wainscoting (to maintain a residential /home-like feel).
All medical equipment should be hidden from immediate view.
Distinguish between residents whose residency is from physical frailty, and those who require more secure accommodation as a result of dementia, and don’t design accordingly (NOT for both at the same time).

These are some of the key issues that architects will address in the next two years as we firstly contribute to the establishment of good guidelines, and secondly we work to design new, and to retrofit existing facilities, to improve their re-direction back towards being a nursing home, with the emphasis on the word home.

Tone Wheeler is principal architect at Environa Studio, Adjunct Professor at UNSW and is President of the Australian Architecture Association. The views expressed here are solely those of the author and are not held or endorsed by A+D, the AAA or UNSW. Tone does not read Instagram, Facebook, Twitter or Linked In. Sanity is preserved by reading and replying only to comments addressed to toneontuesday@gmail.com

Appendices

Recommendation 45: Improving the design of aged care accommodation.

The Australian Government should guide the design of the best and most appropriate residential aged care accommodation for older people by:

a. developing and publishing by 1 July 2022 a comprehensive set of National Aged Care Design Principles and Guidelines on accessible and dementia- friendly design for residential aged care, which should be:

i. capable of application to ‘small household’ models of accommodation as well as to enablement and respite accommodation settings amended from time to time as necessary to reflect contemporary best practice

ii. amended from time to time as necessary to reflect contemporary best practice

b. implementing by no later than 1 July 2023 a program to promote adoption of these National Aged Care Design Principles and Guidelines in design and construction of residential aged care buildings, which should include:

i. industry education, including sharing of best practice models

ii. financial incentives, whether by increased accommodation supplements or capital grants or other measures or a combination of such measures, for residential aged care buildings that comply with the Guidelines

c. advancing to the National Federation Reform Council by 1 July 2025 a proposal for any amendments to Class 9c of the National Construction Code to reflect accessible and dementia-friendly design standards for new residential aged care buildings, or those proposed to be substantially refurbished, according to specifications informed by the National Aged Care Design Principles and Guidelines.

Recommendation 46: Capital grants for ‘small household’ models of accommodation.

1. From 1 January 2022, the Australian Government should provide additional capital grants for building or upgrading residential aged care facilities to provide small-scale congregate living.

2. The amount of annual grant funding should be increased to $300 million in 2021–22, $600 million in 2022–23 and $1 billion in 2023–24 and should be indexed for inflation in subsequent years. (Commissioner Briggs).

3. Priority for these capital grants should be given to approved providers whose premises have or will have a majority of aged care residents who are (within the meaning of section 7 of the Grant Principles 2014 (Cth)) in one or more of the following categories:

a. low-means care recipients, supported residents, concessional residents or assisted residents

b. people with special needs

c. people who live in a location where there is a demonstrated need for additional residential care services

d. people who do not live in a major city.

4. The capital grants program for building or upgrading residential aged care facilities to provide small-scale congregate living should continue after the introduction of the new Act.

Tone Wheeler

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