Like so many people who face a decision about placing a parent into residential aged care, for Litsa Beck it was a struggle.
Seven years ago her father George Poulos was living with dementia and could no longer look after himself. His family moved him into Bupa Aged Care Templestowe, in Melbourne.
"I was expecting specialist dementia care. I was expecting a workforce that were highly trained," Ms Beck said.
"That was my impression … that is not what I found as time went on."
George, 87, is still a resident in the Memory Support Unit, or MSU, at the Bupa home.
In recent years, even before COVID-19, Ms Beck says care standards had fallen.
"There's most definitely been a decline in staffing levels," she said.
"I would say it's become more and more frequent where I've gone in and found soiled sheets . . . I would come in at lunchtime or in the afternoon, and his bed sheets were soiled."
But that issue pales in comparison to what she alleges happened in December last year, after her father returned to the home after a stay in hospital.
Visitors were barred from entering the home due to COVID-19, so Ms Beck called to check he had returned safely. She called again the next day to follow up.
"It was late afternoon; I rang again and the nurse on duty was telling me that they couldn't get him out of his hospital gear," she said.
The nurse arranged for Ms Beck to come into the home.
"When I came in, I found him in his chair, asleep with just his gown and no pants and just the nappy that he had on from hospital," she said.
"I was pretty distraught when I saw him like that."
At that stage, her father had been back at the home for at least a day and a half.
The ABC asked Bupa about the incident, but a spokesperson said, in a statement, that they were unable to respond due to privacy laws.
Despite what Ms Beck said she observed, the Bupa spokesperson said staffing levels had not changed in the dementia unit, with "a minimum of three team members -- which usually includes two personal care assistants and one enrolled nurse — managing the care of the residents at all times."
Families stepping in due to poor care
Litsa Beck is not alone in her concerns.
In all, five families with direct experience of Bupa Aged Care Templestowe spoke with the ABC, including three women whose parents now reside in the Memory Support Unit.
Altogether, that's the families of one-quarter of the unit's current 12 residents
Sarah's mum has lived in the MSU at Bupa Templestowe for seven years. The ABC has changed Sarah's name at her request.
She says her family, particularly her father, are not the "complaining type".
That she's speaking out now is an indication of how seriously they view the decline in care.
Between them, she, her father and her brother make two visits a day.
"We feed her. We shower her. We change her," she said.
Sarah said the difference in staffing was the most noticeable change since COVID-19 hit.
She believes the dementia unit has become much more reliant on agency staff to fill shifts.
"They come in to work for a shift or two, you know, a week here and there. They don't know the residents," she said.
Sarah said her mother had been left on the toilet for up to an hour, and agency staff did not know how to properly operate a hoist to lift her out of bed.
In a statement, Bupa acknowledged it has had to rely on agency staff.
"The COVID pandemic has created significant workforce challenges across aged care and the wider healthcare sector, and we have had to engage agency employees to cover unplanned absences," a spokesperson said.
Bupa also said it prioritised the use of permanent staff in the Memory Support Unit, and "if agency employees are required, they are placed in other areas of the home".
Families say 'nothing's changed' after royal commission
The families who spoke to the ABC are adamant the staff are not to blame, saying they either do not have adequate training or there simply are not enough of them.
Mara Pigatto's mother Natalie died last year after more than three and a half years in the Bupa Templestowe dementia unit.
She said her mother struggled with weight loss due to the poor food she was served, and she constantly worried about the cleanliness of her mother's room.
One year on from the final report of the Aged Care Royal Commission, she's disappointed.
"We've spent taxpayers' money, millions on this royal commission, and what's come out of it?" she said.
"I don't see anything. I see staff cuts. I see poor quality food. Poor quality care. Nothing's changed."
Bupa has 59 aged care homes across Australia, making it one of the largest aged care providers in the country.
It has been the centre of allegations of poor care before. In 2019, the chief executive of Bupa for Australia and New Zealand, Hisham El-Ansary, apologised after numerous failings were reported by the ABC's 730 program.
The ABC revealed from 2018 to 2019, Bupa nursing homes were cited by the aged care regulator for failures including understaffing, and physical and sexual assaults of residents.
Accreditation reports analysed by the ABC during that period revealed 30 per cent of Bupa's home were putting the health and safety of the elderly at "serious risk".
Bupa said in a statement:
"We're continuing to work hard to improve the standards of care offered in our homes and we recognise that despite significant progress, and a lot of hard work, mistakes can still occur," the statement said.
"So, where we've not met the standards our residents and their families expect and deserve, we are committed to putting things right as soon as possible.
"We've made significant improvements in our homes since the period from July 2018 to May 2020, when we had 15 homes under sanction.
"Since May 2020 … only one of our homes has been subject to sanction."
Aged care homes sanctioned by the Aged Care Quality and Safety Commission (ACQSC) regulator lose access to government funding and are unable to take new residents.
Information about aged care facilities 'hard to navigate'
But problems remain.
Eleven of Bupa's homes — about one in five — currently have non-compliance orders issued by the ACQSC. Homes are able to operate with non-compliance orders, but they are meant to fix the problems raised by the ACQSC as soon as possible. Finding out the details of those orders is a cumbersome process.
On the ACQSC website, due to the "exceptional circumstances" of COVID-19, the most recent compliance update for Bupa Templestowe is more than two years old. The last audit of the home is nearly three years old.
Residents and families can also check on a home's performance through the MyAgedCare web portal. Navigating to Bupa Templestowe on that site reveals contradictory information.
The home receives only a 2 out of 4 rating for service compliance, with the words "significant improvement needed".
But click on the "Quality" tab and the home meets all requirements in all eight categories.
The site notes there is a current non-compliance order for Bupa Templestowe, but there are no plain language details about what it is regarding.
Geriatric medical specialist and researcher Joe Ibrahim said publicly available information about aged care homes was not helpful for families trying to find places for their loved ones.
"The information that's provided is, I think, both vague and not in a user-friendly approach," Professor Ibrahim said.
"It doesn't provide the level of information or detail that you would want. It's hard to find. You've got to navigate through a number of portals and understand what you're looking for."
'This has to stop': Families feel speaking out the only way to spread awareness
One year after the royal commission, access to information for those considering aged care homes has not improved.
"There's a real lack of transparency," Professor Ibrahim said.
"You end up with legalese document[s], which makes no sense to the partner of an 80-year-old with dementia trying to work out: is this place going to provide the care that's needed?"
In response to inquiries about efforts to improve transparency, the ACQSC said: "The Australian Government's MyAgedCare website should be the starting point for accessing information about government-funded aged care services."
The regulator also said it was working with the federal Department of Health to develop a star ratings system for aged care homes, as recommended by the royal commission.
The families interviewed by the ABC believe collective action is the only way to spread awareness of the actual conditions in aged care homes such as Bupa Templestowe — and to make sure that information is publicly available.
"I think these people are very brave to speak out," Ms Pigatto said.
"That's why I'm here. This has to stop. It has to stop. What will it take? What will it take?"
Editor's note: This story has been updated to reflect the staffing levels on Bupa Templestowe’s dementia unit, as well as measures Bupa says it has implemented to improve standards of care since the period from July 2018 to May 2020, when 15 of its homes were under sanction.
