“HCSL has been incredibly easy to navigate since we went live on the system on the 1st of October. Our team have people with varying levels of technology literacy and the ease of this system has meant that staff are more confident to use technology and see how it can help to improve time management by not having to double or triple up on written documentation.”
Manager
Alexander House Rest Home
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.
Tracy Holdaway (RN BN)
Facility Nurse Manager
Bethsaida Retirement Village
The below question and answer were published in the New Zealand Aged Care Association industry ‘In-Touch’ newsletter (19th February 2016).
Question: A member asks “if we purchase a comprehensive quality management system from a provider how assured are we that the system will meet full compliance, come certification and surveillance audit time, as requirements and compliance expectations change frequently?
NZACA Clinical Advisor Answer: “You should be purchasing a complete quality management system that will comply with the Health and Disability Standards specifications, health and safety requirements and meet DHB/ARRC contractual requirements.
The provider of the system would normally initially tailor the full quality management package to reflect accurately the site specifications, H.R. component, and best practice guidelines, after consultation with the owner and management on site. These documents need to be site specific. The provider will normally contract to the site, which sets out obligations between the provider and the site management.
The contract will include the full review and updates of policies and procedures on a bi-annual basis, unless specified more frequently, to keep documents accurate and reflective of best practice. There may be an educational element provided within the contract as well, to benefit staff knowledge and skills. There is normally a good document control system in place and cross referencing of information where required.
Quality management systems are reliant on the skills and knowledge of the site personnel working with them, the way the system is managed and the outcomes/reviews, content and information extricated from the use of the system to improve quality care provision/outputs. The documentation system is reflective of the people using them, and the depth to which documentation and information is created, analysed and utilised for improvements.
Auditors on site rely on the provision of robust up-to-date policies and site adherence to them. Partial attainments can sometimes result from staff deviating from, or not following, their sites actual policies or processes as outlined in their quality management system.”
Where can you get such a system?
Here at Healthcare Compliance Solutions Ltd we provide the services described above and noted as being optimal for achieving excellence in care and audit outcomes. To see a brief video about the Aged Care software update and now in use by over 3,800 users in NZ, click here.
Request a no obligation consultation here.
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.
Since the emergence of residential care facilities in New Zealand, the models of care have continued to change, but are they changing fast enough? The clinical needs of residents have escalated and so the way services are provided must also reflect a change in practice to meet changing resident needs. A common theme being reported among older member of our communities is that of isolation and depression. Isolation, according to the Collins dictionary relates to separation, withdrawal, loneliness and segregation.
I was fortunate to visit Greece recently which is reputed to have a larger proportion of older adults than most other EU countries. Gerontology is derived from the Greek words geron, “old man” and -logia, “study of” so it made sense to discuss models of care with families and health care professionals including pharmacists. I discovered there are few residential care services in Greece and those that do exist are found mostly in Athens rather than the islands. Families provide the majority of care with ‘family’ being noted as the key foundation to Greek society. Grandparents are frequently living within the extended family with the younger generations and taking responsibility for caring for their grandchildren. The economy is poor and social networks are heavily relied on to provide support.
From my observations, conversations with others, and literature, the older adults of Greece are kept actively engaged in the community. They are frequently involved in running family businesses if they are not relied on for supporting the needs of their children or grandchildren. Family networks remain strong and when interviewing people about how older adults will be cared for, the automatic assumption is that family will provide that service. Dr Elizabeth Mestheneos told me that approximately 1% of their older population may well be in residential homes. There are Open Care Community centres in virtually every Local Authority which are called KAPI. There are also Help at Home services and Day care centres in some Local authorities.
The models of care and workforce capacity currently in place in New Zealand are unlikely to meet increasing demands so change is needed. The aged care sector could lead change as new models are developed, trialed and advanced. Multiple studies confirm these new models need to include holistic, consumer directed services. Not only meeting physical needs but also social connections and the opportunity to be involved in meaningful activities that contribute to others. This also includes some use of technology to support connections with others. While they are of assistance to some, there is no substitute for human connection, person to person, face to face. The experience of ageing, social network supports, funding models and the context in which care and support are provided certainly differ from country to country.
In New Zealand residential care settings we have activities / recreational programmes which support inclusion and engagement. Being involved in meaningful activities are also key factors in contributing to a sense of well-being. I observed older adults in Greece undertaking meaningful activities in the community like feeding the communal cats of Kos or looking after grandchildren, continuing to run a second hand open-air shop to add to the family income or playing games with friends games. Groups of older men often congregated outside cafes for conversation, coffee and playing cards or board games. A Menzshed story reflects on how one New Zealand community are attempting to address the gap ageing can create in the life of some men. While funding is different in NZ to Greece and the family network is more often scattered geographically in New Zealand, there remains more opportunity to include community. The care setting could also be enhanced more by reflecting the smaller numbers of people we are used to living with in the family home, rather than the larger numbers in some care facilities. A model that more closely reflects the life patterns our community members have been used to, with them directing how these continue into the latter years of life with the goal of ageing in a healthy way, optimising body, brain and social networks.
Mattresses aren’t just something to lie on but if not maintained and cared for appropriately, also have the potential for causing harm.
As I travel a lot for work, I have the opportunity to test many different mattresses, all with varying degrees of comfort. This reminds me how difficult it must be for those who may be suffering painful joints to get a good night’s sleep. Appropriate mattresses are not only required to reduce pain from positioning discomfort but also reducing risk to residents. This include ensuring the mattresses are of a suitable standard and fit for purpose.
I’ve seen a number of mattresses which had hardened and torn linings and were well past being able to provide much comfort or an appropriate degree of pressure support. Some had masking tape used in an attempt to cover splits in the mattress cover. Others had holes in and were badly stained from exposure to body substances. As the residents in care are becoming frailer, with increasing acuity, the need for ensuring appropriate pressure support is crucial to preventing pressure injuries, maintaining comfort and maximizing the opportunity for good sleep.
There is the potential for old and in poor condition mattresses to be a potential source for infection transmission. For those of you operating newer facilities, this may not yet be an issue. For older facilities, part of stock and resource control should include mattress stock checks to verify they are in fact still fit for use. When conducting checks, determine the mix of mattress types you have and speak with your supplier about a replacement programme should this be necessary. As mattresses differ, so do beds and it’s important to make sure the mattress you use is appropriate for the particular bed type and size.
When reviewing your mattress stocks and purchasing new mattresses you might like to think about the following factors:
Harm prevention can also be supported with advances in technology such as Pressure Monitoring sensing devices to ensure appropriate pressure distribution. I’m not aware of anyone who can rent or lease out Pressure Mappers in NZ. However Cubro have one that they can bring onsite to facilities for training and education. Make contact with your supplier to see if they can assist if this could be useful for you.
Also remember that other devices used in beds should be checked as well to ensure they are still safe and appropriate for use eg; wedges, rolls, pillows, seat cushions, mattress covers (where these are appropriate for use), bed sensor monitoring pads. For reading on how to choose the best mattress option for your needs go here.
For more related information view here.
Article compiled by Gillian Robinson (RN, BN, Lead Auditor) for Healthcare Compliance Solutions Ltd.
Empathy and perspective are two concepts well known Leadership author Simon Sinek speaks about in relation to leaders. He talks about the real job of a leader as not being in-charge but taking care of those in our charge. How many leaders play the blame and shame game when things don’t go as planned? Instead how would it be if leaders in aged care services worked in accordance with a Leader’s Oath. My version is noted below as an example.
You may want to create your own for your organisation, or adopt this.
The Leader’s Oath
I focus on the betterment of this organisation above my own career needs
I focus on accountability above the need to be popular
I focus on caring for those in my charge over being in charge
I focus on clarity above certainty
I share clear expectations
I hold myself accountable for all employees poor performance including my own
I welcome respectful challenges
I will table the tough issues
I treat all interactions as though my career depends on a successful outcome
I am committed to personal and professional development
I am focused on excellence.
While the above Leadership Oath forms a focus for clinical leadership, it’s necessary to make sure your nurses are familiar with the ARRC funding agreement responsibilities for Registered Nurses. These are also clearly defined in the HCSL policies and procedures to ensure they’re integrated into practice. The ARRC includes time-frames for nursing documentation responsibilities, while the nursing council guidelines for delegation define staff delegation of staff working under the supervision of Registered Nurses are appropriate led and supported. When we refer to tabling the touch issues, one key aspect of leadership is holding staff accountable. Nurses are often not keen to hold others responsible for their conduct and performance and therefore avoid performance managing staff when performance is below the expected standard. This in turn means the service provided will be below the expected standard. If you want to provide the best care and support to those in your care, these are skills you must learn and put into daily practice. To learn more about these skills and others needed for leading a team of care and support staff, go here.
As we age, the need for spiritual care and pastoral care often come to the fore. This is particularly so as people near the end of their life. The need for comfort and peace of mind on a holistic basis. Let’s firstly lets define the difference between these two concepts.
Pastoral care is an ancient model of emotional and spiritual support that can be found in all cultures and traditions. It has been described in our modern context as individual and corporate patience in which trained pastoral carers support people in their pain, loss and anxiety, and their triumphs, joys and victories. Spiritual care attends to a person’s spiritual or religious needs as he or she copes with illness, loss, grief or pain and can help him or her heal emotionally as well as physically, rebuild relationships and regain a sense of spiritual wellbeing.
For most of human history, in all major religions, an ultimate goal of spiritual practice was accomplishing a good death. When this goal was held in common by the whole society, spiritual care could focus on the interaction between a dying person and his or her caregivers.
A number of clergy have commented to me that spiritual care is not recognised by many aged care facility staff as important. They have frequently commented on services being interrupted by staff activity, or being asked to hold services or provide pastoral care in areas of the facility that are very close to the main entrance or actually in main thoroughfare areas. This is not respectful of the needs of the residents who choose to attend, or the need to peace and calm to receive spiritual care. In learning more about the importance of these concepts, it may support good holistic care for residents if you were to discuss with the clergy and pastoral care workers whether the circumstances being provided for them to support residents are appropriate.
To read more on this topic go here.
Clinical documentation and clinical management relate to section 1.3.1 to 1.3.8 of the Health and Disability Services Standards and are referred to in section D5.4 of the ARRC. There are key reference documents which provide reference at residential care facility level which should be used in conjunction and addition to your organisation policies and procedures. These reference documents include:
Clinical documentation errors of any type noted during audits will result in partial attainments at best. This is an indication there could be risk associated with gaps in service. In a previous article about medication management we noted that even a single signature missing off an administration signing sheet was enough for the auditor to assign a partial attainment finding.
Below are some of the common compliance gaps which relate to clinical documentation:
| General compliance
gaps |
Missed signatures off notations. Not dated. Not signed by the author with a full signature. No designation written with signature. Not legible. Inconsistent structure of resident files. Unclear or unsecured archiving of documents. Privacy breaches due to clinical documents placed in a situation that allowed unauthorized viewing. |
| Initial assessments
including InterRai |
Not completed within time-frames defined in ARRC. Baseline recordings at time of admission not recorded. Assessment outcomes not used as a basis of care planning to link assessment to goals and interventions. Additional detailed assessments not reviewed in a timely manner eg; six monthly to coincide with InterRai reassessments. Failure to re-assess for each period of admission eg; respite care. |
| Clinical risk |
Assessment not describing risk. Risk not reflected in care plan interventions. Lack of risk reviews. Level of risk noted in interRai assessments not included in care planning |
| Progress notes |
Not recorded in on a shift by shift basis. Lack evidence of regular registered nurse input. Writing beyond the bottom line of the page. Failure to put resident identifiers on each side of each page (this applies to other clinical documents as well). Lack evidence of interventions being implemented. Lack evidence of RN response to clinical symptoms reported by care staff. Lack of evidence of rationale for PRN medication administration or the resulting effect. |
| Short Term
Care Plans |
Not developed for changes in clinical status eg; increased pain; infection; wounds, change in medication (to allow evaluation of effectiveness). 24 hours plans not developed for residents displaying behaviours of concern (challenging behaviours). Not evaluated regularly (I suggested at least once every 7 days) by a Registered Nurse. Not recorded as resolved or transferred to Long Term Care Plan. Not developed to implement instructions included in General Pracitioner consultation plans recorded in notes. |
| Long Term
Care Plan (LTCP) |
Not reflective of all presenting potential and actual medical / clinical problems. Not documented within 3 weeks of the date of admission (ARRC requirement). Not changed at the time of health status / functional change. Interventions not reflective of each medical diagnosis. Interventions not changed within LTCP to reflect changes recorded in care plan evaluations. Frequency of clinical assessment for each actual clinical presentation eg; pain. Do not clearly indicate the level of function, assistance required for each component of care / support. Do not clearly evidence input and instruction from Medical or Nurse practitioner / Physiotherapist, Diversional Therapist, Dietitian,Psychiatric services for the elderly etc. |
| Care Plan
Evaluations |
Review of care plans not reflecting changes in residents health status as they occur. Not reflective of how well the care plan goals/ objectives have been met since the previous evaluation. Not completed within ARRC defined time-frames (at least six monthly). |
| Multi-Disciplinary
Input |
Lack evidence of MDT input into care plan reviews and/or evaluations. Lack evidence of resident, Next of Kin (NOK) / Family / Whanau / EPOA input into assessment and care planning. Lack of evidence of timely referral in response to clinical presentation eg; unintentional weight loss not referred to Dietitian. Failure to evidence implementing instructions ofMedical or Nurse Practitioner eg; B/P to be recorded daily for the next 7/7 may be noted in the medical consultation notes however not evidenced as having been done. Lack evidence of notification to NOK / EPOA relating to resident adverse events, change in health status, medical consults etc. |
| Policy and
procedures |
Not consistent with service delivery as noted in clinical documentation. |
Internal audits are available through the online HCSL quality system utilised by our clients which allows tracking of compliance status and corrective actions as part of on-site quality and risk management. This means when the auditors arrive, there will be no surprises and you’ll know you’ve achieved excellence in care in conjunction with providing a compliant service.
If you have any comments to make about this article, please contact us here.
Topics included: Quality & Risk Management, Clinical Leadership, Clinical Documentation, EPoA, ARRC, Communication and Difficult Conversations
I am writing this endorsement on behalf of my colleague and myself, in relation to our attendance at the study day you hosted 5 July 2017.
The topics you presented were most relevant to our Registered Nurse role within the aged care sector, and between us both provided new learning opportunities, as well as refreshing the current knowledge we already held.
You addressed each session in a professional and engaging manner that held our attention, complemented by comprehensive written material as well as PowerPoint presentations, along with plenty of opportunity for questions and comments from the floor.
Gillian you are one of very few speakers that is able to hold my attention for more than one session let alone a whole study day, a perfect balance between speech and conversational styles!
We were also most impressed by the quality of the complementary gift bag that was given to each attendee containing not only goodies to help us through the day, but with something to take back to the workplace, I acknowledge both Cubro and Ebos for their support with this.
The venue was great with easy access and good parking, and it was clean and refreshing providing plenty of comfort and personal space for those attending. I will be recommending my associates to make a note in their diary for next time. Thank you Gillian
Kind regards
Lyn Black
Bloomfield Court Retirement Home – Canterbury