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OPCAT COVID-19 report: Report on inspections of aged care facilities under the Crimes of Torture Act 1989

Issue date:

Executive summary

This report outlines my key findings, suggestions, and recommendations in relation to OPCAT COVID-19 inspections of six secure aged care facilities[1] (the Facilities) between 17 April and 8 May 2020. These inspections took place during Alert Levels 3 and 4 (also referred to in this report as ‘lockdown’).[2]

As expected, the focus of all Facilities was on their residents’ wellbeing. It was clear from these inspections that this was a challenging time, however, the Facilities were taking steps to keep residents safe. Overall, managers and staff were committed to minimising the impact that COVID-19 was having on residents.

Health and safety

All Facilities were able to provide policies and plans on infection control, and access to handwashing and hygiene facilities was good. All but one Facility had hand sanitisation stations mounted on walls.

All Facilities applied the ‘bubble’ strategy to prevent COVID-19 from entering their premises. While it was reassuring to find that all Facilities were applying this practice in line with infection prevention measures, I had some concerns about the definition of some Facilities’  ‘bubbles’. In some Facilities it was unclear whether the ‘bubble’ was an individual unit or the entire Facility. Facilities had established entry and exit procedures as an infection control procedure – for example, signing a health declaration, hand sanitisation, temperature checks. Personal protective equipment (PPE) practices varied across Facilities. In some Facilities PPE was not applied consistently by visitors. This was particularly concerning as the use of PPE by those not included in the Facility ‘bubble’ should be applied consistently.

Most Facilities had not carried out COVID-19 tests on residents. Where it was done, testing practices varied. All Facilities recognised the COVID-19 test as invasive and potentially distressing for residents.

Contact with the outside world

All Facilities recognised the significant impact the ‘no visitors’ policy implemented as a result of COVID-19 had on residents. I was encouraged that the Facilities had processes in place to allow residents to remain in contact with loved ones outside of the Facility. Digital communications, such as Zoom and Skype, were successful methods facilities employed. Some Facilities had exercised discretion in allowing family members to visit residents, including to visit a dying relative.

Dignity and respect 

Overall, my Inspectors observed staff treating residents with dignity and respect, apart from one isolated exception. There were warm interactions between staff and residents, and a commitment by Facilities to ensuring minimal disruption to residents’ day-to-day experience. All Facilities said they would explain COVID-19 and its effect on practices at the Facility if they were asked by residents. Some Facilities were proactive in their communication with residents about COVID-19, using for example ‘question and answer’ sessions, easy-read booklets and signs about handwashing. I reminded several Facilities of the need for residents to be provided with information on matters that affect them, in various accessible formats and displayed in communal areas.

Eighty-five percent of surveyed whānau said Facility staff kept them informed about how the Facility was responding to COVID-19.

Tailoring the environment, activities and cultural responsiveness to be appropriate for all residents during Alert Levels 3 and 4 was a challenge for Facilities. While efforts were being made, I did make some suggestions where this could be improved.   

Protective measures

All Facilities advised that protective measures such as complaints processes had not changed or been adversely affected by the COVID-19 restrictions. However, I was concerned that residents’ ability to raise issues or concerns in private was reduced during Alert Levels 3 and 4. Whānau were unable to visit, and communication using digital means was available only with the assistance of staff. Complaints boxes were usually in reception areas, not commonly used by residents. I reminded Facilities of the need for residents to have direct access to complaints mechanisms.


The Facilities’ staff showed resilience during this unprecedented, stressful time. From my inspections, it appeared that management and staff had good rapport, and management had taken steps to respond to staff’s changing needs during this time.

Recommendations and suggestions

I made specific recommendations and/or suggestions for improvements to residents’ treatment and conditions in individual reports to each Facility. The Facilities were provided with an opportunity to comment on my findings, suggestions, and recommendations.


[1]     The Chief Ombudsman inspects aged care facilities where residents are unable to ‘leave at will’.

[2]     See Appendix 1 for more about New Zealand’s COVID-19 alert system.

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