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Media release

Ombudsman COVID-19 report highlights safe practices but some concerns remain

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An inspection by the Chief Ombudsman of six secure aged care facilities during COVID-19 Alert Levels 1 and 2 last year has found they were safe and hygienic but a lack of staff was having an impact on services.

Chief Ombudsman Peter Boshier today published the second of two summary reports following inspections of the treatment and conditions of residents in six aged care facilities between May and June 2020.

Mr Boshier made nine recommendations across four facilities and 23 suggestions across all six covered in the report published today.

“In terms of good practice, it was pleasing to see that facilities were using innovative ways to connect residents with loved ones and the wider community. These included an activity board on the gate of one facility. Another facility invited an organist to play in the carpark so its residents could enjoy the music.”

Among Mr Boshier’s concerns are that, while facilities had plans for infection control to respond to the risk of COVID-19, staff in one facility did not appear to be aware of, or knowledgeable about, guidance and plans to manage suspected, probable or confirmed cases of COVID-19.

He also found one facility had not kept thorough records of COVID-19 tests of residents.

“I found several facilities did not have sufficient staff to provide the necessary services to residents.” He made three recommendations about staffing.

Mr Boshier raised serious concerns with one facility about the repeated practice of physically restraining two residents.

“I found one resident had spent over 11 hours tied to a chair between 9:30am and midnight,” he said. “While the use of restraints or enablers were part of their care plans, I was concerned there were often only minutes between the restraint being taken off and then put back on.”

“Since I raised my concerns, one resident is no longer being restrained and the use of restraint has steadily reduced for the second resident over the past six months. I have also been advised that restraint minimisation is now a focus across the facility, and there has been no use of restraints in its special care unit for the past two months.”

A report on the first six inspections was published on 18 August 2020. Today’s report covers six facilities inspected in Hastings, Whanganui, Palmerston North, and Nelson.

“These were short and targeted inspections of randomly selected facilities that provide dementia and psychogeriatric beds, using specific COVID-19 relevant assessment criteria. The inspections provide independent assurance that the measures being taken to manage the virus did not impact on residents’ human rights.

Mr Boshier says that by releasing his report today, he hopes his recommendations and suggestions may provide useful insights for facilities throughout the country, as may the areas of good practice where the human rights of people in these facilities are supported and respected.

“Last week the Greater Wellington region moved to level 2. This was a timely reminder that we must all be prepared to respond rapidly to potential COVID-19 outbreaks,” he says.

“The residents of secure aged care facilities are among our most vulnerable citizens and it is crucial that the facilities they live in are providing the best possible care.”

Mr Boshier has also published today his draft expectations for the conditions and treatment of residents in aged care facilities who cannot leave at will.

“These expectations will guide my staff when doing inspections and will provide residents, whānau, facilities, Parliament and the public with an understanding of some of the matters I consider when monitoring aged care facilities,” Mr Boshier says.

Feedback is welcome on the expectations and, as a living document, it will be updated when appropriate. Please send feedback to [email protected].

Mr Boshier also today announced he will start his full programme of formal inspections of privately run aged care facilities where people cannot leave at will, such as dementia and psychogeriatric units, from July 2021, as planned.

“Some 50 orientation visits and 12 COVID-19 inspections have been conducted so far to help me to familiarise myself with the sector. I am taking a considered approach – scaling up and further refining my inspection programme in 2021/22, with the aim of progressively increasing the number of visits and inspections.”

Inspections will be both announced and unannounced. The Chief Ombudsman will provide feedback to a facility about what he thinks are areas of good practice, and what areas may need improvement. He might make recommendations about specific things he would like to see change at the facility. His feedback to a facility may be in a variety of formats, such as a report. This will be determined on a case by case basis.



  • The Chief Ombudsman has been tasked by the Minister of Justice to monitor health and disability facilities, including aged care facilities, where people are not free to leave at will. This includes parts of privately run aged care facilities, such as dementia and psychogeriatric units.
  • Monitoring helps ensure people are treated humanely and their rights are respected and protected. It also ensures Aotearoa New Zealand adheres to international human rights standards.
  • The Chief Ombudsman’s OPCAT inspections under the Crimes of Torture Act focus on conditions and treatment of people in places of detention, with a human rights lens. They are not regulatory audits.
  • The Chief Ombudsman has chosen to not name individual facilities in his reports summarising observations from his COVID-19 inspections. Given the unprecedented nature of the time and circumstance, he decided not to release the names, or publish the individual reports concerning these facilities. His published thematic reports draw together what he saw at the facilities concerned, and includes recommendations and suggestions that other facilities may find useful.
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