Planning for dealing with COVID-19 in the aged care sector was insufficient, the royal commission has found, and lessons learnt from early outbreaks in NSW weren't passed on before the Victorian outbreak, with tragic consequences.
More than 2000 residents of aged care homes have contracted the virus and 665 have died, 635 of which were in Victoria.
The royal commission has made six recommendations for preventing and responding to COVID-19 outbreaks in residential aged care, and supporting aged care residents' quality of life.
Aged Care Minister Richard Colbeck said on Thursday the government had accepted all the recommendations, but did not say how much it would cost to implement them.
The report found measures implemented by the federal government on advice from the peak health emergency decision making committee were "in some respects insufficient to ensure preparedness".
"Confused and inconsistent messaging from providers, the Australian government, and state and territory governments emerged as themes in the submissions we have received," the report read.
"All too often, providers, care recipients and their families, and health workers did not have an answer to the critical question: who is in charge?
"At a time of crisis, such as this pandemic, clear leadership, direction and lines of communication are essential."
Senator Colbeck rejected the finding planning was insufficient, despite accepting the recommendation to establish a national aged care advisory body and establish a national aged care plan for COVID-19 in consultation with the sector.
"There is a clear need for a defined, consolidated, national aged care COVID-19 plan," the report said.
"We will continue to develop our plan, as we should, this should not be a static document," Senator Colbeck said on Thursday, maintaining the government had a plan.
Other recommendations included ensuring facilities had adequate staff to to allow continued visits, acknowledging that lack of interaction with family members and friends during COVID-19 lockdowns had seriously impacted the quality of life of residents.
"The reduction in visitors means that staff time is stretched just trying to meet the day-to-day care needs of residents. Some providers have increased staff numbers to meet these additional needs," the report said.
"But many providers, according to the evidence of union surveys, have reduced staff numbers. This deficiency must be addressed urgently."
The commission also recommended items be added to the Medicare Benefits Schedule to increase allied health services offered in facilities, and ensure any barriers to allied health professionals entering homes were removed unless justified on public health grounds.
The aged care royal commission held its hearings in August, when the Victorian crisis was still at its height, with that state's response not examined by the commissioners due to the time constraints on when the final report must be handed down.
"It is unclear whether the lessons learnt from those outbreaks [in NSW] were shared widely before community transmission put people living and working in aged care in Victoria at risk," the report said.
Despite its findings that mistakes were made and people were left without clear actions and lines of communication, Commissioners Tony Pagone and Lynelle Briggs did not lay blame.
"Now is not the time for blame. There is too much at stake. We are left in no doubt that people, governments and government departments have worked tirelessly to avert, contain and respond to this human tragedy," they said.