The 83-year-old moved into an aged care home in Victoria in July 2009 after breaking her right ankle, leaving her in a wheelchair. Loading Ms Johnson described mornings at the aged care home as "harrowing", with two staff members struggling to get 20 people awake, to the toilet, showered, dressed and to the dining room for breakfast within about 40 minutes. "Because they are rushed, they try to do things as quickly as possible and not all residents can move quickly or respond quickly," she said. "In my case, keeping me in my wheelchair, they will push the lifter so that my ankle hits the steel footplate in the wheelchair which can be very painful.

"There is a bit of manhandling and this is a danger, could lead to abuse of residents ... maybe not always intentional, but it does lead strongly to the possibility of residents being badly treated." Ms Johnson said initially she was treated well but after changes to management in 2010 and 2011, staff members were cut and employees rotated through four wings. It was difficult for them to understand care requirements and the time to respond to the call bell blew out from three to 24 minutes, or longer. Residents were told to go to bed at 9pm because after that there was only one staff member on duty per 40 residents, she said. The former accountant said as staff were rotated frequently, they did not know she was able to care for herself, including showering.

Loading "It's very frustrating to have your independence taken from you," she said. When she entered the facility, Ms Johnson was classed as low care for funding purposes, but that was changed to high care in 2014 after a change in ownership. She was not told about the change and initially could not given access to her care plan, the royal commission heard. "Everyone has the right to know what their treatment is ... so you know what to expect and also to know whether you are getting the care that your care plan says you are getting," she said.

"And if the care plan is incorrect, then surely the provider is claiming funds from the government under false pretences." Ms Johnson became a member of the facility’s continuous improvement committee in May 2011, the first and last resident to have a position. She relayed complaints about "inedible" food and the chef was sacked and replaced but she was removed two years later, without a replacement, Ms Johnson said. "It means that they’re not really interested in hearing what the residents have to say," she said. Ms Johnson complained to a representative of the Aged Care Complaints Commission about staffing in 2015 but was told she should bring it up with management.

"(They said) that it wasn’t anything to do with the commission, even though I told them I’d already been down that route and tried to solve it," she said. "If you can’t sort it out with management, who do you turn to? Why have a commission?" Queensland Public Guardian Natalie Siegel-Brown said the aged care model was "anything but focused on the human rights of the client". Ms Siegel-Brown said restraints could be signed-off by a resident's enduring power of attorney, often a solicitor they had only met once. "When it comes to chemical restraint, there's actually no requirement for consent at all other than to advise a consumer representative that it's being used," she said.