With the introduction of the Food Act 2014and the requirement for most aged care facilities to have registered their food control plan (FCP) by March 2018, I thought I would write this article on a common kitchen practice that will require review.
FCP’s are included in the policy and procedure documentation provided by HCSL specifically designed for residential care facilities.
In many facilities the main meal is served in the middle of the day and the tea meal served at night. The main cook of the day will prepare the tea meal earlier in the afternoon, and then finish his or her shift. The tea meal will be reheated by the afternoon staff and served to the residents.
The process of cooking, cooling and reheating requires careful control of the food safety risk. Many tea options are protein or carbohydrate based; macaroni cheese, egg dishes, savoury mince, chicken options – all of which are high risk foods for bacteria growth.
Foods need to be cooled quickly to avoid time and temperature abuse, which may allow bacteria growth. The guidelines state that when cooling hot cooked foods, the food must cool to at least 21° within the first two hours, and then cool to below 5° in four more hours. Overall, the food must be out of the danger zone (between 5°C and 60°C) within six hours.
A functioning chiller should allow cooked foods to cool within this timeframe. Using domestic fridges that are overcrowded, may mean the cooling guidelines are not met. Using shallow dishes rather than large deep dishes will also allow foods to cool faster.
The food control plan will specify the process the site kitchen must follow with regards to cooling of cooked food. Temperatures during cooling will need to be checked and recorded to ensure the time / temperature targets are met.
Prior to serving, the food must be reheated to above 75°C.
Some sites choose to hold the prepared food hot until service. Food must be held hot at a temperature of at least 60°C, usually in a bain-marie or oven at 70°C. Any food held below 60°C for more than 2 hours, must be thrown out. Note that holding foods hot for this period of time may affect the food quality.
Food safety risk with cooling and reheating foods must be managed with FCP
Cool cooked food to below 21°C in 2 hours and below 5°C in 4 hours
Reheat foods to above 75°C before service
Hold hot prepared foods at 60°C or more
Document food temperatures and any corrective action
Review corrective action implementation to ensure they have been effective
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’sauthors, 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.
We are very pleased to have recently been granted 4 year MOH Certification! No corrective actions and three Continuous Improvements.
This follows on from a fully attained Partial Provisional Audit that was required prior to opening our two new wings earlier this year with no corrective actions.
Make no mistake! HCSL policies, software and support have played a major part in these accomplishments. The HCSL software we use means we have easy access to information in real time.
I started working with Gillian of HCSL shortly after I took on the role of Facility Nurse Manager at Bethsaida Retirement Village six years ago. The facility was not using Healthcare Compliance Solutions policies at the time and perhaps this was reflected in the previous audit results.
Gillian is always responsive to emails and phone calls which is critical when timely advice is required.
The HCSL regular newsletters are interesting with relevant and up to date information on issues affecting aged care.
Gillian is a lovely person to deal with. She is thoughtful, professional, pragmatic and I have always found her to be keen to help, with practical advice on any issues that might arise in the management of a retirement facility.
I thoroughly recommend HCSL to all aged care facilities.
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.
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.
Just passed our two day audit – NO NON COMPLIANCES; NO PARTIAL COMPLIANCES !!!!!!!!!!!!!!!! – thank you so much for your efforts.
The auditor praised your system – said it was a really good system – met all the requirements of the standards, is written in plain language, all the documentation relating to my job ie quality, risk management is outstanding and more than meets the standards and is very well used in the context it should be – thanks!
Testimonial – Chatswood Resthome and Hospital owner (and Clinical Advisor for NZ Aged Care Association)
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 this system is hugely time saving.
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 JessieSnowdon – 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.
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.
Dementia (even if not working in a specific dementia facility)
Moving and handling
Basic seating and wheelchair assessment
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.
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).
Ask for a copy of their professional indemnity and public liability insurance certificates.
Ask to view their (or their employers) health and safety policy.
Ask if they undertake regular supervision or mentoring to help assure their own professional safety.
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).
How will they cover your facility during periods of leave.
Are they a member of Physiotherapy New Zealand – this is not compulsory but demonstrates a dedication to their profession and provides development opportunities.
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.
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.
On the 25th April each year we remember those who went before us to fight for the protection of others. While emphasis is often on those who died in service to their country, it’s also a time to remember those who returned from war changed and altered forever by the experiences they’ve had. Not just for the soldiers going and returning to war but their family.
The mother who describes holding her son as he heads off to the front line. Embracing him, breathing in his smell which a mother knows so well. Holding her head against his chest hearing the beat of his heart wondering if she’ll ever be able to hold him and hear his heart beat again. Feeling the harshness of the fabric of his uniform and wondering what other harshness he’ll encounter.
The soldier as a member of a family, not only left grieving mothers behind but were sometimes already parents themselves going off to war leaving wives and children behind. All family members impacted in their own way from their own perspective of events. How does a wife or child accept the decision of the men in their life going to war, to do ones duty leaving children wondering why they were being deserted in favour of the uncertainty of battle? Those children then growing older day by day until the time they themselves are in their 80’s and find themselves still welling up in tears at the memory of the day their father left to go to battle. Not understanding but seeing the change in the father who returns, different, distant and ill from the effects of sand breathed into his lungs while stationed in Egypt. The soldier returning, having nightmares of horrors seen which cannot be unseen or forgotten. Limbs and body intact but emotional scars and ongoing adverse health issues. Not all wounds are visible.
I visited the Gallipoli exhibit at the Museum of New Zealand ‘Te Papa’ (our place) in Wellington with my mother and sister. I was mesmerized and deeply affected by the raw emotion depicted in the models created for the exhibit by Weta Workshop. The image of this nurse, Staff Nurse Lottie Le Gallais who was on board the hospital ship Maheno which set out from Wellington. She’d hoped to catch up with her brother but the model shows the anguish of the moment she receives her returned letters to him saying “killed, return to sender”. I can’t imagine the strength needed to sustain such pain amidst the anguish of war but still carry on to serve those needing care.
I live in Christchurch and after the recent terrorist attack resulting in the death of 50 people, we’re seeing and feeling the result of war-like destruction of life. You see it in the faces of those closely affected. The internal pain of senseless loss.
A time to ponder on the Anzac values of courage, compassion, commitment and comradeship and see if they are reflected in our own organisations as relevant to care services. This Thursday, 25th April, Anzac day is a time to reflect and be grateful – lest we forget.
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?