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.

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.

Culture Change in Long Term Care

Culture is a word we hear a lot and goes hand in hand with the concept of culture change.  In this article I’d like to touch on how to facilitate culture change and why it is beneficial to your long term care setting.  Let’s face it, aged residential care in New Zealand is changing rapidly and this impacts the experience of residents, staff and visitors to long term care settings. It impacts their desire to be in your care facility or to move somewhere else. This applies to be both residents and staff.  Families often choose the care provider for their elderly relatives.  What do they perceive when they visit you?

There are also barriers and challenges to creating and sustaining a definable and deliberate culture. The experience of the residents and staff is a result of the culture (behaviours) which should be aligned to your organisation values, mission and goals.  There are well publicised workforce shortages and high turnover of staff. Long term care is also in the middle of change from paper-based systems to electronic storage and management of information. The environment in which care is being provided is also changing through new construction of buildings from a institution to non-institutional. The atmosphere being created by those within the long term aged care residential setting is changing to a more relaxed feel.

Nursing care  and direct support is now also being provided within retirement village studios, apartments, villas, homes.  This means a change of not only the context of care.  Ensuring person centred care where each individual feels seen, heard and respected takes consistent focus and strong leadership.  Not always easy in a industry that is changing in so many ways. I wrote in a previous article on workplace culture that behaviours could be a better point of focus rather than simply focusing conversation on culture as a concept.

The behaviours which support a culture you can be proud of and one that sets you as an industry leader, require a long term focus and not just a one time exercise.  The strong leadership needed along with education and ongoing communication is key to setting a desirable culture.  Have you aligned your staff, management and Governance behaviours with your organisation vision and mission statements?  Behaviours reflect actions and they can be optimal actions, good actions, poor actions or non-action.  All will have an outcome which impacts the residents experience and determine how they feel about residing in your long term aged residential care setting.

For change to occur there needs to be a focus on improvement, a reason to change which residents and their families see as beneficial.  We tend to stick to doing what we’ve always done unless we can see a personal gain or something which provides a sense of satisfaction on a personal level.  What’s in it for me?  Culture change is not something that’s going to be achieved from a top-down approach. It’s going to take engagement from all levels of the organisation and create wins for those involved. Without perceived gains or wins, people stay stuck in old habits which don’t fit the new expectations of those seeking care and support.

If you’re the manager or CEO and delegate a ‘change management’ process to someone else, then expect to check in later to find wonderful results without your direct involvement and engagement, you may be disappointed.  Culture change is a team effort. To achieve change, everyone needs to participate.  They need to believe in the outcomes you’re trying to achieve with whatever strategies or initiatives you put in place.

Who is going to lead change?  There is an old saying that everything flows from the top down and this is also true of culture.  If the Board are dysfunctional then there should be no surprise when staff working at all levels of the organisation are dysfunctional. How is communication about strategies of change being done to gain buy-in? How are you going to measure your change initiatives to find out if you’ve been successful?  How are you going to ensure the desired culture is maintained?  There are a number of tools (mostly overseas based) which can be used to start this process. Here is a free online culture change assessment tool you could use.

What is the experience of your resident and your staff on a daily basis?  Would they recommend you to others in a way to reflects loyalty to your care facility as a preferred place to live or work? If not, what are you going to do about it?

Aged Care Managers and Nurses Study Days

April 12th and 13th, 2018 – Christchurch

Presenters: 

 

Gillian Robinson – Bachelor of Nursing, Registered Nurse, Lead Auditor, Management Consultant, Author
Liz Beaglehole – New Zealand Registered Dietitian, with a Post-graduate Diploma in Dietetics (with distinction), Canterbury Dietitians.
Ben HarrisMedical Laboratory Scientist, Honorary Lecturer for the University of Otago

Incorporating clinical and management topics, these study days are designed to provide the opportunity to learn together and gain a greater understanding of each others roles and aged care industry expectations. Gain your professional development hours by joining your colleagues for two fun days of learning.

Topics include:

Day One – Thursday 12th April – 9.00am to 4.30pm

  • Age-related Residential Care (ARRC) – understanding the DHB funding service specifications
  • Quality and Risk Management – striving and achieving excellence
  • Clinical Leadership – how to lead the clinical team effectively
  • Clinical Documentation – What, when, how and why to document
  • Clinical Assessment and Care Planning – bringing it all together for better resident outcomes
  • Microbiome – why understanding this is so important
  • Multi-Drug Resistant Organisms (MDROs) – the current and pending impact

Day two – Friday 13th April (9.00am start, finish approximately 1.00pm) 

  • Urinary Tract Infections – to dip or not?!
  • Norovirus and Influenza – latest updates
  • Food Safety – Food Safety and Nutrition
  • Question and Answer session

Attendees will supply their own lunch.  Morning and afternoon tea will be provided.

Venue: Chapel Street Centre, Cnr Harewood Road and Chapel Street, Papanui, Christchurch.   (Easy access from the airport)

Numbers will be limited so register today.

To register – email gill@agedcarecompliance.com and supply the names and designations of each staff member attending, and confirmation if they will be attending day one or day two or both days?

 

The attendance fee for this content filled education is $155 (plus GST per attendee to cover both days), $85.00 plus GST per attendee to cover either day one or day  two.

We will respond with confirmation of registrations. Certificates of attendance will be provided.

Dysphagia Diets – Are we all understanding each other?

Dysphagia diets and a lack of understanding of how to implement them consistently, is increasing risk to residents in aged residential care services.

Texture modified diets are commonly used in aged care facilities to manage the risk of aspiration pneumonia and choking with eating and drinking.  Residents with dysphagia may be placed on a texture modified diet following assessment with a speech and language therapist.  However there are often a range of terms used for texture modified diets, and differing opinions on exactly how the diets should be prepared.

 

Confusion with terms, and the types of foods and fluids offered leads to increased risk of harm for the resident.  This is particularly obvious when transferring from one facility to another.  Information on texture modified diets is passed to the new facility who may use different terms.  For example a site may report ‘this resident requires a soft diet’ and the interpretation of this diet at the new facility is to puree all food.

 

The International Dysphagia Diet Standardisation Initiative (IDDSI) is a framework to standardise terminology and offer simple testing methods to check that the preparation of the diets are correct. Dietitians New Zealand and Speech Language Therapists of New Zealand have endorsed in principle the IDDSI framework.

The goal is to reduce the risk of harm for our patients and residents due to miscommunication and poorly prepared texture modified diets.  It is important to note that the framework relates to dysphagia diets only.  Residents may be on a modified diet due to other factors not related to dysphagia.  For example a resident with no teeth may need softer foods but can actually manage sandwiches.

The good news is that for many sites, there is very little change needed as they are already using the correct terms.  The diagram above shows the new terminology and the minimal change in wording;
  • ‘Smooth puree’ becomes pureed (which is also extremely thick fluids)
  • ‘Minced and moist’ remains unchanged
  • ‘Soft diet’ becomes ‘soft & bite sized’
  • Moderately thick and mildly thick remain unchanged for thickened fluids
The IDDSI framework assigns standard colours and numbers to assist with easily identifying texture modified foods and fluids.  Some manufactures of texture modified foods and fluids are looking at ways to incorporate the terms, colours and numbers onto their food packaging.

 

Food and Fluid Preparation and Testing

The IDDSI framework offers simple tests to check that the thickness of the fluids or the size of the particles for modified foods are correct.  The tests use forks, spoons, fingers or syringes – equipment that is readily available at sites.

With training and education on how to do these tests, kitchen staff and managers will be able to easily check their texture modified diets and thickened fluids are prepared correctly.

 

IDDSI App and Website

The IDDSI framework have developed many resources and videos to assist with the standardisation process.

Download the app https://play.google.com/store/apps/details?id=com.appdataroom.iddsi&hl=en

or go to www.IDDSI.org

or ask your dietitian and speech language therapist for more information.

 

Where to From Here?

Here are some small steps to help implement the IDDSI framework at your site:

  1. Stop using any terms that are not on the framework. The term ‘mouli’ is not recognised and should not be used to describe a texture modified diet.
  2. Download the app or look at the IDDSI website to familiarise yourself with the framework.
  3. Try testing one of the textures you currently prepare. Does the ‘puree diet’ your site produce pass the spoon tilt test?  Does the size of the minced food for ‘minced & moist diets’ fit between the prongs of a fork?  Is the size of meat offered for residents on the ‘soft & bite size diet’ the size of your thumb nail?
  4. Ask your dietitian or SLT for further training on the correct testing and preparation of dysphagia diets.

This article was contributed by Liz Beaglehole NZRD (Canterbury Dietitians) and Anna Miles PhD, Speech-language Therapist, Senior Lecturer, Speech Science, School of Psychology. The University of Auckland.

Village Manager – Chatswood Retirement Village

I have found that having Gillian’s (the HCSL) system available has been a huge help to our village. Documents are easily accessible at my fingertips and it hasn’t taken long to memorise some of the codes for the more frequently used ones.

 

If we are having trouble finding a document or we want to make any adjustments, Gillian is always very accommodating and helpful. She is easily contacted by telephone or email and if she is busy, always gets back to me as soon as she is able to. I particularly like that if I want to type into a document, Gillian makes this available.

 

When the documents are due for updating, Gillian takes care of this, printing all of the documents and putting them into new folders for us. She even delivers them personally, which is always a pleasure. I find Gillian very approachable and extremely knowledgeable and happy to share her knowledge.

 

Gillian assists us with our training requirements by coming to Chatswood and going through the annual compulsory subjects with myself and my staff. She is great at presenting and the passion about her work shows in the way she shares her own experiences with us.

 

I look forward to our continued working relationship.

Kyla Hurley – Village Manager

January 2017

Bench-marking – Aged Residential Care

This New Zealand designed web based (on-line / in-the-cloud) Bench-marking and quality management system from Healthcare Compliance Solutions Ltd allows you to:

  • Bench-mark in real-time – specific to resident type, event type, date and time of day.
  • Have automated default reports to save you time analysing your data trends and patterns
  • Drill down into your data easily to identify opportunities for continuous improvement
  • Complete your internal audits online and have the corrective actions auto-populate into a corrective action log
  • Log and manage adverse events
  • Bench-marking of adverse events against other aged care providers
  • Support evidencing an active Health & Safety programme is in place
  • Log and manage infections
  • Bench-marking of infections against other aged care providers
  • Log and manage your complaints with time-frame, investigation and response prompts
  • Dashboard view options for level of care and any chosen 3 monthly time-frame review
  • Dashboard view option of adverse events or infections
  • Logs (event registers) appear with individual events in one colour when open and change to another colour when the event is closed. This allows you to see quickly the status of events. 
  • Use in conjunction with your current policies / procedures or update to the HCSL site specific created policies and procedures. 

Your organisation policies and procedures and related documents (if created by HCSL) are also accessible to the lower left of the screen for remote anytime, anywhere access.  The search option on the policies and procedures in addition to precise indexing and coding of documents makes it very quick and easy to locate information for staff to reference.

This is what Rhonda Sherriff, NZACA Clinical Advisor says about using the HCSL QA system:

“I am very happy to endorse your system as the information is invaluable for CNMs to analyse the data/information and make informed decisions on best practice and innovation to decrease hazards, improve outcomes, and mitigating factors for resident welfare. I’m pleased you are delving into the data to the level you are, as it’s time saving for sites in many respects, and so easy to dice and slice the information to get the trends. CNM’s used to spend hours just writing up the collective information before the analysis, so hugely time saving”

To view a brief video explanation of the system click here.

To find out more contact us here.

Medication Management Audit Tips

 

 Medication management relates to section 1.3.12 of the Health and Disability Services Standards and referred to in section D5.4 of the ARRC.  There are key reference documents which provide reference at facility level which should be used in conjunction and addition to your organisation policies and procedures.  These reference documents are (first two are key for residential care):

 

Medication errors of any type, when reporting through the audit process to MoH HealthCert as part of your audit, will receive a higher ‘weighting’ than other partial or non-attainments.  Even a single signature missing off an administration signing sheet may come into this category and mean your audit outcome is diminished.  Below are common errors which continue to be made:

Aspect of medication management 

Common Errors 

Medication charts

Not dated

Not signed by the prescriber

Not signed by the General Practitioner or Nurse Practitioner at each review (3 monthly)

Not legible

Allergies not documented (or inconsistent with other resident documents)

Transcribing on medication charts or PRN signing sheets

PRN medication charting does not include ‘indication for use’

Medication order does not include time, dose, frequency, route, type etc

Signing sheets

Missed signatures on the signing sheets

Only one signature (instead of two) on controlled drug administration records and register

PRN medication not signed for accurately

Self-medicating residents

Competency to verify self-medication not signed by prescriber

Competency for self-medication not signed as having been reviewed by prescriber (3 monthly)

Staff verification of self-medicating occurred not recorded on a shift by shift basis (as relevant to the individual residents medication order)

Not retaining a current list of all medication ordered for self-medicating residents

Storage

Medication not securely stored (also see ARRC D15.3(c)

Controlled drugs not entered accurately into Controlled Drug Register (at time of supply or return to pharmacy)

Controlled drugs not stored in locked cabinet in locked room

Drug trolley left in common areas unlocked

Expired medication continue to be stored on site (should be returned to pharmacy)

Medication for resident who has been discharge or deceased remain on site

Medication fridge temperature not monitored / recorded

Labels on medication containers not clear / legible

Identification of resident

Photograph not representative of current presentation of resident (photograph should be colour)

Photograph of residents not validated regularly

Medication errors

Not reported

Not managed (through an adverse event management process to ensure identification of contributing factor and preventive measures).

Competency

All staff (including Registered Nurses and Enrolled Nurses) involved in medication administration must have first successfully completed a medication competency

Annual review of medication competencies

If you’re uncertain about the competency of a particular staff member, do not be tempted to sign them off and monitor.  The risk is too high for the residents and your organisation.  Medication errors can be classified as ‘sub-standard care’ and due to the possible consequences, are at least a moderate risk.

Remember when changing staff around, the key priority is do you have a medication competent staff member on each duty and if controlled drugs are being administered, you need a minimum of two medication competent staff rostered on each duty.  Registered Nurses cannot be leaving the ‘hospital’ area of the facility to administer medication in other areas as this leaves the hospital residents vulnerable so this also needs to be factored into your rostering.  Refer to the Aged Related Residential Care Contract (ARRC) for further information.

Ensure your internal audits review the above common errors to verify you are providing safe and appropriate services in all aspects of medication management.