Staffing levels – is skill-mix the formula for success?

This month we look at the discussion around whether mandated staffing levels in aged care, as a ratio of care hours to residents, would improve care services?

Rather than numbers of personnel alone, to provide safe and appropriate nursing services, staffing skill-mix (taking into consideration the workforce diversity) is essential to ensuring appropriate effective staffing. These factors are not taken into account or provided for within the industry funding levels which puts additional pressure on those working in aged care services.

While performing statutory (temporary) management roles over past years, adequate numbers of staffing alone hasn’t guaranteed safe and appropriate care. Nursing outcomes for residents have been reliant on a mix of highly skilled staff working in conjunction with newer or less experienced staff to guide and mentor.  There could be 10 staff on duty but if none of them have had previous experience working in aged care services, these staff are set-up to fail in performance of their duties, and the resident care outcomes are likely at risk.

SNZ HB 8163:2005 – ‘Indicators for safe aged-care and dementia-care for consumers‘ is a national document which includes formulas for staffing levels based on acuity of residents. This document set industry guidelines and although not mandated, defines staffing from a best practice perspective. Numbers alone as already mentioned are not sufficient.

Outdated for the acuity of residents needs in 2019 and onward, the 2005 guidelines didn’t take into account a range of factors. For example the size and physical layout of the facility, location of resources, the leadership structure and how work teams are configured, economy of scale and appropriate cover.  The minimum staffing requirements in the ARRC   is well below that sufficient to meet resident needs.  Having been implemented in 2005 (SNZ HB 8163:2005) when resident needs were less complex than they are now, it’s well past time to review how staffing skill-mix is determined and more importantly how the industry will be funded for increased staffing to meet the increased needs of residents.

HCSL developed a 5 step acuity assessment tool in response to providers requests after being frustrated by using the two tier InterRai assessment which give outcomes of resthome or hospital level of care. InterRai doesn’t reflect the range of acuity represented in SNZ HB 8163:2005 from a care level perspective.  As reported by numerous registered nurses working in aged care, the complex clinical presentation of residents being admitted into care is not accurately reflected in InterRai which is why they still need to supplement InterRai at times with more detailed clinical assessments.

Achieving desired outcomes for residents and the timeliness of appropriate care support based on individual assessed needs should be the aim for the allocation funding to ensure adequate staffing levels.

Contractor Health and Safety

Managing Contractors from a Health and Safety Perspective

Managing Contractors from a Health and Safety Perspective is a vital component of having external trades people at your workplace.

The use of contractors  is unavoidable in retirement villages and any aged care facility as we look to engage external expertise for specialised work and maintenance tasks.

Section 34 of The Health and Safety at Work Act 2015 provides that all persons conducting a business or undertaking (PCBU) who have duties imposed by the Act in relation to the same matter must, so far as is reasonably practicable, consult, co-operate and co-ordinate their activities with all the other PCBUs who have duties that overlap with them.

There are four main points to remember about overlapping duties:

  • You have a duty to consult, cooperate with and coordinate activities with all other PCBUs you share overlapping duties with, so far as is reasonably practicable.
  • You can’t contract out of your health and safety duties, or push risk onto others in a contracting chain.
  • You can enter into reasonable agreements with other PCBUs to make sure that everyone’s health and safety duties are met.
  • The more influence and control your business has over a workplace or a health and safety matter, the more responsibility you are likely to have.

WorkSafe have made it clear that they expect PCBUs at the top of a contracting chain to be leaders in encouraging good health and safety practices throughout the chain. They also expect these PCBUs to use sound contract management processes.

 

There are six key health and safety steps when it comes to managing your contractors: 

  • Scoping – understand what the body of works is, the risks involved, the training and competencies required, the working environment and any additional measures required.
  • Selection – select the right contractor for job, utilise a contractor selection process that considers the values and systems of the contractor from a safety perspective.
  • Induction – provide the contractor with basic information regarding site hazards, site rules and emergency evacuation procedures.
  • Safe system of work – the contractor must provide (and you must review) safety management information for the job. You must be confident that the contractor has appropriately controlled the risks associated with their works.
  • Monitoring – while the contractor is on site, check that they are carrying out their works in accordance with the safety management information they provided.
  • Review – Examine what went right as well as what can be improved so that both parties may continually improve on their health and safety performance, this should fed-back into future scoping and selection decisions.

 

WorkSafe (New Zealand) have developed Good Practice Guidelines for ‘PCBUs Working Together: Advice When Contracting (June 2019) in order to provide advice on how you can meet your duties under the Health and Safety at Work Act 2015, illustrate different contractual relationships between parties, and provide examples of ways you can build health and safety into contract management.

Author:

Thanks to Shannon Wright, from Imprint Safety Limited for contributing this article. 

Cosman, M., Tooma, M., Butler, A., Marriott, C., Schmidt-McCleave, R. (2018). Safeguard Health & Safety Handbook 2019. Wellington, New Zealand: Thomson Reuters.

WorkSafe. (2019). PCBUs Working Together: Advice When Contracting. Retrieved from https://worksafe.govt.nz/managing-health-and-safety/getting-started/understanding-the-law/overlapping-duties/pcbus-working-together-advice-when-contracting/

Risk Managing Contractors On-site

It’s easy to forget to check contractors staff changes and ensure your risk managing contractors on site is ongoing. Recently I was on site at a care facility when a sub-contractor was working there.  When spoken to, he appeared to speak very limited English. He left empty boxes, a Stanley knife in the main hallway and wet glue and loose carpet at the entrance to a resident’s room. No signage, no clean-up.  I couldn’t help but ask the provider what the contractor knew about health & safety legislation, his responsibilities and risks to residents as a result of his work practices.

The Health and Safety at Work 2015 increased the responsibility on PCBU’s in relation to risk management in the workplace.  When using the services of contractors, there are likely to be overlapping responsibilities. While residents reside in residential care facilities and therefore it’s their home, the legislation defines residential care as a workplace.  As such, contractors coming into your environment must provide evidence of following a health and safety policy and processes which reflects current legislation.

A copy of their document should be kept on file along with verification of contractors (and sub-contractors) orientation to site and confirmation of their acknowledgement of health & safety responsibilities.  These documents are included in the Safe and Appropriate Environment policy manual for services using HCSL in hardcopy and in-the-cloud online. Documents should be re-signed by contractors annually or when changes to the environment occur or a contractors personnel have changed.

Consumer Directed Services

Consumer directed services are core business for retirement villages. The aged care sector has been talking about ‘person centred’ care’ in health and specifically aged care services for a long time now.  Some services express a practice and philosophy of care based on residents being at the centre of all choices. Unfortunately sometimes when you ask the residents in those services, they may not share this view.

An increased focus on consumer directed care was part of the discussion at the Health and Disability Services Standards review workshop I attended recently.  Residents know what they want.  They are not always involved in service development discussions or asked what they need by service providers. When people set their own goals for clear reasons, they are more likely to engage and achieve. Where the support of others to achieve goals is needed, this is reliant on communication.

Retirement and aged care services are in a position to support not only the maintenance of health and well-being but also rehabilitation of those coming into residential based services. “We found that when you engage and motivate people, they do better,” said one of a study’s authors, Eric J. Lenze, MD, a professor of psychiatry.

In Australia “Aged care reforms continue to shift towards increasing choice, control and tailored services for older people and their families. To deliver more innovative and individual services, providers will need to think about their future workforce models and ask which industrial frameworks are best suited to their market and long term goals.”  To read more on this subject, click here.

As always with research, there are other views which should be considered.  These include individual preference for making choices and residents’ ability to make a specific choice in relation to one or multiple aspects of their health.   Read more here on this topic.  Regardless of what decisions are made, I believe we can be sure the time ahead will include challenges.  How those are resolved will be interesting and lead hopefully to more learning.

Clinical Nurse Manager

Bethsaida Retirement Village is a medium sized facility in Blenheim (Marlborough) offering resthome and hospital level of care servicing the Blenheim community.  Our services comprise of 57 care beds and 33 villas in our independent living Village.

We have recently undergone an exciting period of expansion and redevelopment at Bethsaida. Due to this we are seeking the services of an experienced Registered Nurse for the role of Clinical Nurse Manager. This is a full-time Monday to Friday position.

Having achieved four years certification, this is your opportunity to be part of a highly successful team. We are offering competitive remuneration and the opportunity to work with a friendly, caring and competent health care team.  You will have the support of the Facility Manager and contracted Nurse Consultant.  You will also have access to use of the latest New Zealand designed aged care software to streamline and reduce paperwork.

 

To maintain our high standards of clinical care we require a person who:

  • Preferably has experience in aged care
  • Can lead a team of Health care assistants
  • Can communicate effectively with family and allied health professionals
  • A sense of humour
  • Has a current NZ Annual Practising Certificate as Registered Nurse
  • An interest in education
  • Would like to attend the national New Zealand Aged Care Association Conference

 

We value all our staff equally and offer a comprehensive orientation and ongoing education and support. Financial support for relocation will be met where relevant up to the value of $3,500

Applicants for this position should have NZ residency or a valid NZ work visa.

Please supply your CV with a cover letter to Tracy Holdaway, the Facility Nurse Manager  or call at reception for an application form.

Mandated minimum nursing hours – will it work to ensure safety and productivity?

The question of whether mandated minimum nursing hours would work has been asked previously. The workload of care and nursing staff is frequently discussed with staff reporting they are pressured for time to complete all the necessary duties assigned.  The Nursing staff have different but over-lapping functions to care staff.  When reviewing your staffing, it’s important to include a number of factors into any review when looking at the productivity and efficiency of your team.

We suggest you look at not only leadership and skill-mix, which are vital for safe services but also consider other factors. These can include the location of high acuity needs residents within your service.  With an increase in the use of dual beds, the mix between rest home and higher acuity hospital level of care are now intermingled and not specifically allocated to one area of the building.  This means the Registered Nurses providing clinical monitoring and oversight may have to spread their attention to a much more fragmented and broader geographical area in your service than was previously the case.

The location of resources and time spent looking for items of use and equipment could be minimised if more thought was put into the design of new facilities and the locating and management of replenishing stores for ready access by staff as and where they need them.  Who does the running and fetching could also be considered in work roles so staff with high end clinical skills are spending the bulk of their time on performing functions specific to their role and skill.  Not doing tasks that could be better delegated to others.

After the recent sudden closure of a care facility in Australia without apparent planning or communication with families, there has been outrage that such a thing could happen.  The “Queensland Premier Annastacia Palaszczuk announced her Government would order fixed nurse-to-resident ratios in state-owned aged-care facilities.”  The ABC news report (19th July 2019) goes on to say “at least 50 per cent of staff having contact with residents in 16 publicly run aged-care centres to be nurses.”  I don’t know if by nurses they mean Registered Nurses only and not Enrolled nurses but I can’t help wonder if this alone will ensure safety.

One year on from Simon Wallace (NZACA CEO) reporting on staffing shortages, we haven’t seen any improvement it would seem!  In New Zealand an increasing proportion of our Registered Nurses have come to New Zealand to practice with no prior working knowledge of aged care services. They frequently have limited aged care related experience to conduct the complex assessment and clinical management of high acuity residents in a residential care setting.  This is not to diminish their value as we can’t provide the services needed otherwise.

What I’m trying to highlight in the current circumstances is, we’re frequently seeing nurses set up to fail or provide less than safe care as they simply don’t have the experience in this specialised field of nursing.  I recall conversations in the early 1990’s predicting a massive nursing shortage.  It appears that in the time-span between then and now, we haven’t addressed this issue.

We welcome comments and suggestions of how this could be addressed here in New Zealand before we end up in the depths of a staffing crisis which halts care.

Facility Manager for Award Winning Aged Care Facility

We are an award winning Aged Care Facility in Christchurch compromising of a Hospital Unit; a specialised Hospital Unit and a Secure Dementia Unit. 66 beds in total.

 

What you can expect:

  • Excellent remuneration package
  • Well respected supportive, reflective private company
  • Professional development support
  • A great team of staff
  • Audit & Standards compliance requirements met

 

What will you do:

  • Overall day to day management of the facility working to long term goals
  • work Monday to Friday, with some on-call responsibilities
  • Lead, coach and manage the team successfully
  • Ensure a high level of clinical care and resident satisfaction
  • Manage the budgets and financial aspects to maintain profitability

 

What you need to have:

  • Experience as an Aged Care Manager – preferably a Registered Nurse
  • Knowledge of the Aged Sector and relevant legislation is extremely advantageous
  • Strong experience in a leadership role
  • Great financial knowledge and proven results
  • Excellent communication skills at all levels, both internally and externally
  • Willing to roll up your sleeves and pitch in when needed
  • A good sense of humour

 

Please apply with CV and cover letter via this link.

If you have any questions or would like to discuss this great opportunity please call Lucie Kaal on (+64) 0210707777 – Rosewood Rest Home and Hospital

What does a Physiotherapy programme look like in Aged Care?

Prior to contracting a Physiotherapist, or as part of your Physiotherapy service review process, you should consider what your goal is in having physiotherapy input.  These should include key values such as Meaningful Outcomes for residents.

We asked Jessie Snowden of On The Go Physio what should felt was important for a Physiotherapy programme to which she offered the following:

For us this means we carry out thorough assessments, find out what is important or meaningful to the resident, their whānau and how this impacts their functioning in the aged care environment. Our input with people can range from rehabilitation to a previous level of function.  This may be intensive physio input for a few weeks, to ensuring someone is safe and comfortable with appropriate seating and pressure care at the end of life (which could be one visit only).

This level of assessment means that you need to ‘budget’ for 40-60 minutes (sometimes longer for complicated admissions) of physiotherapy time for a new assessment and possibly longer if they are needing to make referrals, liaise with other services and family. Follow up visits will be shorter. It is recommended that if you have a set number of hours per week that your staff and the physiotherapist are clear on expectations and priorities. If you only contract 2 hours per week it is not fair to have 10 new assessments on your ‘urgent’ list!

Some facilities have a set standard of 6 monthly reviews of all their residents. Although we do undertake these if asked, it is often more meaningful to use physiotherapy skills for those residents who may improve with input, or who your staff need assistance with due to functional decline. We suggest  if a 6 monthly review is wanted, then the RN is able to carry this out by considering if there have been changes in mobility, falls rates or other physical changes affecting function. If not then your physiotherapy dollar could be better spent on residents with clear rehabilitation needs or declining function.  The key goal here being to optimise mobility and maintain as much independence as possible.

Once the Physiotherapy service is up and running you can expect your physiotherapist to provide a clearly written assessment and a clear treatment plan, including either a discharge comment or a review date. Ideally you will maintain data related to Physiotherapy input and be able to see clearly if your allocated time is meeting the needs of your staff and residents.

Finally consider which residents will be eligible for physiotherapy assessments. If you are funding a Physiotherapy service you may choose to extend this to your hospital level and rest home level of care residents but not to independent studio units/apartments as these residents will usually be eligible for DHB funded services. Some DHBs will happily provide physiotherapy to rest home level of care residents and some put guidelines around who they will see. Depending on your DHB and care philosophy you may choose only to fund Physiotherapy services to hospital level of care residents or to extend this to rest home. In our company we work with aged care facilities who operate under both of these models and the key is to have it clear to both your Physiotherapist and staff who are completing referrals.

Spend your dollar wisely!

A final note here. Physiotherapists are highly skilled healthcare professionals who will be an asset to your team. The days of Physiotherapists spending all their time on walking programmes are long gone and you should set your expectations high for a physiotherapist who will add quality of life to your residents and cost benefit to your organisation. To use your physiotherapist wisely I strongly recommend you have the expectation that your care staff will have time to walk with people who are safe to do so.  We also encourage you to employ or allocate a Physiotherapy assistant hours into your roster to implement Physiotherapy plans. For information on using Physiotherapy assistants please look at an earlier article here .

This article was kindly contributed by Jessie Snowdon – Director of On the Go Physio. On the Go Physio provide physiotherapy services to over 20 facilities in Christchurch and Moving and Handling training to many more facilities and the CDHB.

Maintaining independence – maximising mobility

When it comes to maintaining functional ability for residents whether in a retirement village setting or in an aged residential care facility, the input for a skilled Physiotherapist is a huge advantage in setting up strengths and balance or falls prevention programmes.

Getting in the support of that type of expertise is certainly going to help residents maximise their potential.  Not all professionals are created equal and physiotherapists are no different to other professionals!  How do you go about choosing a Physiotherapist though and what should you check for when selecting the right person to support physical therapy for your residents.

I asked local well know registered Physiotherapist Jessie Snowdon what she thought on this topic.  Here’s what she recommends:

How to choose a physiotherapist for your aged care facility.

Physiotherapists are a key member of the healthcare team in aged care facilities. Having physiotherapy input can improve quality of life for your residents, improve safety and lessen workloads of your care staff. Many physiotherapists are also able to offer moving and handling training onsite as part of their service.  Physiotherapists who are passionate about aged care are usually very special people – so how can you pick them?

This article is written with contracted physiotherapy services in mind but many aspects will apply to employing a physiotherapist directly.

Ask about their experience

In order to meet the varied needs of residents in aged care, physiotherapists need to have a broad clinical background. I would suggest that your physiotherapist should have experience in most of the following clinical areas.  Because this is a long list you should be seeking a physiotherapist with a minimum of 5 years’ experience – or actively supervised by a more senior colleague.

  • Orthopaedics
  • Neurology
  • Dementia (even if not working in a specific dementia facility)
  • Cardiac respiratory
  • Moving and handling
  • Basic seating and wheelchair assessment
  • Falls prevention
  • Arthritis
  • Chronic Pain
  • Pressure injury prevention

Ask about their professional development

To maintain registration in New Zealand, a physiotherapist must adhere to The Physiotherapy Board Code of Standards which is available to the general public here. They must also have a minimum of 100 hours CPD per 3 years, show evidence of reflective practice and have one professional peer review per 3 years. At On the Go Physio we require a peer review each year and active ongoing engagement with colleagues and professional development.

It is not uncommon for aged care facilities to directly contract a physiotherapist working as a sole trader. This can be an isolating role for a physiotherapist and it is important they regularly engage in professional development and in supervision and peer review.  If you are employing, rather than contracting, a physiotherapist you will need to budget for this as it is reasonable that you meet these costs.

Eight quick questions when choosing a physiotherapist contractor

As well as the right experience and compliance with physiotherapy regulations, contractor physiotherapists are also businesses in their own right (whether a sole trader or employee of a company) and need to operate as such. These are some legal requirements and compliance issues you should consider.

  1. Ask to see and maintain a copy of their Annual Practicing Certificate (APC – a new one will be issued annually and you should have a copy of this prior to 1st April of each year).
  2. Ask for a copy of their professional indemnity and public liability insurance certificates.
  3. Ask to view their (or their employers) health and safety policy.
  4. Ask if they undertake regular supervision or mentoring to help assure their own professional safety.
  5. Ask them to arrange for a colleague to undertake a clinical notes audit within 3 months of starting in the role and annually following this. Ask for a copy. (You may need to negotiate this and if there will be a cost it would not be unreasonable for you to consider paying this).
  6. How will they cover your facility during periods of leave.
  7. Are they a member of Physiotherapy New Zealand – this is not compulsory but demonstrates a dedication to their profession and provides development opportunities.
  8. What moving and handling training experience do they have? Will they be happy to provide training or will you need to contract those services separately.

 This article was kindly contributed to by Jessie Snowdon – Director of On the Go Physio. On the Go Physio provide physiotherapy services to over 20 facilities in Christchurch and Moving and Handling training to many more facilities and the CDHB.

A further article will follow on how to set up a Physiotherapy service in your facility.

Disaster Management should include security measures

This is a good time to be reminded that disaster management or your security policy may need to be extended to include management of threats, both internal and external to your organisation.  During the past years I’ve been personally involved with facilities where a resident entered the facility with a fire-arm, an intruder break-in during the night with a fire-arm, and another where intruders who entered the facility went into an occupied residents room. This last case related to intruders who had allegedly held-up the local bottle store earlier that same day.

Things happen which we don’t expect and we must be prepared as best we can.  It’s impossible to cover every possible eventuality but when events such as the shootings in Christchurch occur, it’s a reminder to ask are we doing enough?  For example, staff security rounds should be strictly enforced and documented to verify these were carried out. If you have surveillance cameras, where are your blind spots? If it’s the staff car park for staff going off duty late at night, improvements are desirable for staff safety. What about your processes for visitor verification? 

Security isn’t just about the people and environment but also about assets and information.  These should all be detailed in your policy documents.

HCSL are currently updating the security policies we provide ARC services to include reduction of risk from internal and external threats. This includes a procedure for lock-down. Let’s hope we never need to use it! 

For those of you wondering about how to debrief with your staff as a means to support them, there are some great resources available here.  For more resources on supporting others in relation to disaster type events, go here