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Report on inspections of aged care facilities under the Crimes of Torture Act 1989

Issue date:

Executive summary

This thematic report outlines my key findings, suggestions, and recommendations in relation to OPCAT COVID-19 inspections of six secure aged care Facilities (the Facilities) between 27 May and 18 June 2020 (during Alert Levels 2 and 1).

I am empowered by section 27 of the Crimes of Torture Act 1989 to make recommendations for improving the conditions and treatment of detention and for preventing torture and other cruel, inhuman or degrading treatment or punishment in places of detention. In some instances, where a statutory recommendation was not required, I made suggestions to Facilities for improving conditions and treatment. The Facilities were provided with an opportunity to comment on my findings, suggestions, and recommendations.

My recommendations and suggestions may provide useful insights for secure aged care facilities throughout the country, as may the areas of good practice I identified – where the human rights of people detained in secure aged care Facilities were supported and respected.

I made nine recommendations across four Facilities, and 23 suggestions across all six Facilities.

Health and safety

Six of my nine recommendations related to health and safety. Overall, I found Facilities provided an adequate level of health care, and safe and hygienic physical environments for residents. However, I had concerns about restraint use.[1] I expect Facilities to work towards minimising restraint. I was pleased that following issues raised in my provisional report, one Facility put in place an electronic restraint monitoring process to ensure comprehensive documentation for each episode of restraint. I made one recommendation regarding restraint.[2]

I found that Facilities had plans for infection control to respond to the risk of COVID-19. However, in one Facility, staff did not appear to be aware of or knowledgeable about guidance and plans to manage suspected, probable, or confirmed cases of COVID-19. I also found one Facility had not kept thorough records of COVID-19 tests performed on residents. I made recommendations on these two issues.

I also made eight suggestions in this area, concerning improvements to the physical environment, independent access to healthy snacks and drinks, the provision of activities in a timely manner, the clear definition of ‘bubbles’, and regular checks that residents were freely able to access secure outside areas.

Contact with the outside world

Facilities were using innovative strategies to connect residents with loved ones and the wider community, despite the continued limits on visits under Alert Level 2. These included connecting with the local community via an activity board on a Facility’s gates, and inviting an organist to perform in a Facility’s carpark. Most Facilities required visitors to book before visiting, even at Alert Level 1. However, I was pleased that Facilities reported they would accommodate visitors if they arrived unannounced, or needed to visit a loved one in exceptional circumstances, such as when they were undergoing palliative care.

Several Facilities had adopted virtual communication methods during Alert Levels 4 and 3, and were continuing to use them under Alert Level 2, even with the resumption of visits. I made no recommendations under this criterion, and two suggestions related to internal and external activities provided for residents.

Dignity and respect

Overall, my Inspectors observed staff treating residents with dignity and respect, apart from an isolated instance. Openness to communicate with residents and provide information about COVID-19 is an important part of respecting residents’ dignity. I found the Facilities used a range of strategies to engage with residents about the pandemic, including resident meetings, visual aids, written updates, and/or conversations with residents to explain why staff were wearing masks or why there were no visitors.

I was pleased that all Facilities showed good understanding of the communication needs of disabled residents, such as those with hearing impairments and mobility needs. However, several Facilities were not able to discuss with confidence how they met residents’ cultural needs, including the needs of Māori residents.

I was pleased to learn that Facilities had made efforts to facilitate residents’ access to their faith practices despite the COVID-19 restrictions.

I made no recommendations under this criterion, but made six suggestions.

Protective measures

Protective measures, like complaints processes, are safeguards against ill-treatment and are of particular importance when there are increased restrictions within an aged care facility. Residents should have safe and accessible ways to raise concerns and complaints and have them considered and responded to. Although I did not make any recommendations related to protective measures, I found the majority of Facilities had gaps in their systems for handling residents’ complaints and I made suggestions for improvement. I made six suggestions to address this issue.


Facility staff demonstrated resilience during this unprecedented, stressful time. Inspectors observed staff interacting warmly with residents and finding ways to emulate ‘normal life’ within the Facilities. Staff also took extra measures, like shopping for personal items for residents to mitigate the impact of COVID-19 related restrictions.

Inspectors observed good rapport between staff and management, and encountered managers who were empathetic to the stresses faced by staff working in the aged care environment during the pandemic. In individual interviews, staff at all six Facilities said they had felt well-supported by management, and had received clear communication. Several Facilities provided specific training related to the COVID-19 pandemic.

However, I found several Facilities did not have sufficient staff to provide the necessary services to residents. Therefore, I made three recommendations about staffing, and one suggestion.


[1]     Restraint involves using personal, physical, or environmental methods to restrain a person who is at risk of harming themselves or others. See the Health and Disability Services (Restraint Minimisation and Safe Practice) Standards NZS 8134.2 at

[2]     The same recommendation was made to two different Facilities.

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