An alleged assault on an unconscious Tauranga man with dementia, during the final stages of his life, demonstrates "a pattern of suboptimal care" says the commissioner for Aged Care.

The man was in specialist dementia care at Radius Althorp in Pyes Pa.

The Aged Care Commissioner Carolyn Cooper has found Radius Residential Care Ltd - (Radius Althorp) in breach of the Code of Health and Disability Services Consumers' Rights (the Code).

During his time as a resident, the man was involved in a number of reported incidents concerning another resident entering his room, which led to some aggressive altercations.

The final incident involved the man being allegedly physically assaulted while he was unconscious and in his final stages of life.

The complaint raised a number of issues, including the quality of the man's end of life care, the standard of documentation maintained, communication with the man's family, and the staffing levels in the specialist dementia community at the time.

'Radius Althorp had a responsibility to operate the specialist dementia community in a manner that provided its residents with services of an appropriate standard,” says Carolyn.

"The overall deficiencies in the end-of-life care provided to this man, the inadequate documentation and staffing levels at Radius Althorp, and the inadequate communication with the man's family, demonstrate a pattern of suboptimal care and a lack of critical thinking from Radius Althorp staff members."

Aged Care Commissioner Carolyn Cooper. Photo: Supplied.

The Commissioner found these shortcomings attributable to Radius Althorp who, "failed to provide services to this man with reasonable care and skill and therefore breached Right 4(1) of the Code”.

Carolyn also found Radius Althorp breached Right 4(4) of the Code, which gives every consumer the right to have services provided in a manner that minimises potential harm to, and optimises the quality of life of, that consumer.

"Radius Althorp had a duty to keep this man safe from harm. I consider they failed to put in place effective measures to minimise harm to this man from another resident."

The Commissioner has recommended that Radius Althorp:

- Provide a written apology to the man's family for the breaches of the Code.

- Provide the Health and Disability Commissioner with a further update on the implementation of the corrective actions set out in Radius Althorp's internal investigation.

- Conduct a random audit of end-of-life care plans, progress notes and charts for ten residents over the past six months, to ensure compliance with relevant Radius Althorp policies.

Radius Althorp has made a number of changes including:

- Provided training to all new staff on incident/accident reporting.

- Increased staffing levels to ensure all residents receive regular checks, and provided training on the importance of regular checks.

- Confirmed that its processes for end-of-life care were audited in July 2020 and there were no partial attainments.

- Confirmed that staffing levels have been adjusted in line with the Safe Staffing Index guidelines, and that staffing levels are adjusted in accordance with need and acuity.

- Put in place a corrective action concept plan to allow for further development of person-centred outcomes, as well as a review of dementia services and support in clinical assessments and decision-making

Additionally, as a result of an internal review, Radius Althorp have made and completed a number of internal recommendations.

The full report of this case can be viewed on HDC's website - see HDC's ' Latest Decisions'.

HDC promotes and protects the rights of people using health and disability services as set out in the Code of Health and Disability Services Consumers' Rights (the Code).

In 2021/22 HDC made 402 recommendations for quality improvement and providers complied with 98 per cent of those recommendations.

Learn more: Education Publications

Radius Althorp chief executive officer Andrew Peskett says they acknowledge there were issues at Radius Althorp, and are "sorry they affected a resident" in their care.

"We take responsibility for the incident and enacted a number of actions to ensure further risk has been minimised, the largest of which has been to increase the number of nurses and other staff at the facility.

"Radius Care takes the comfort and wellbeing of our residents seriously, and our hearts go out to the affected family.”