This is a difficult question. How to measure wellbeing and quality of care? And, if we can identify indicators, how can we link wellbeing to the audit process? There is bound to be subjectivity, as I concluded in an earlier blog (11/4/16).
One possible measure is the number of rest homes being given four year licenses, indicating high scores for quality of care (based on set standards). If more facilities are being given longer license terms this could indicate an overall increase in quality of care. Since 2011 there has been a marked increase in awarding of 4 year licenses; around 87% of facilities now receive 3 or 4 year certification periods. But surely we need something more detailed.
In general, my voluntary sector interviewees (see previous blog) see value in rest home audits and many quoted examples of how they have prompted improvement – especially around staff training and openness. Audit information can be used to compare rest homes in the same area. But there were many criticisms – audits are still too paper-based and do not adequately reflect the experience of residents. “Effect is on documentation not on care.” “How do auditors capture the balance between humanity and the clinical approach?”
Evidence from audit reports
There have been improvements –
• Staff training – many rest homes now use outside education programmes – ACE, Careerforce – as well as programmes from a parent organisation; and also get help from local DHBs. Some have special initiatives to encourage and reward staff.
• Where rest homes are part of “chains” (e.g. BUPA, Ryman) they have access to research and evaluation tools – quality and risk management systems, newsletters to update clinical issues and allow benchmarking between facilities.
• There is also evidence of chain-wide systems of audit and quality monitoring (Oceania, BUPA, Presbyterian Support, Ultimate Care).
• Under the integrated approach, help is available from DHBs– education, advice and consultation, specialist advice, for example on wounds and dementia.
• Better review and follow-up of accidents, incidents and complaints.
• Wider use of satisfaction surveys for family and residents.
• Involving families and volunteers, e.g. male volunteers organising recreational activities for male residents; residents and families helping in gardens.
There were certainly cases where care was inadequate or residents were put at risk. But a lot of criticisms in the audits related to inadequate or incomplete documentation, or communication. A rest home could fall down on staff standards because appraisals and performance reviews were not up to date. Deficiencies in documentation about accidents and incidents may or may not mean that actual events were adequately dealt with. Perhaps records were not signed off or not adequately presented or discussed at meetings.
Satisfaction surveys for residents and their families are a requirement of regular audits. The reports show that generally the results are good, but sometimes surveys were not conducted or the results were not acted on. There seems to be more faith in satisfaction surveys when they are conducted by outsiders, such as voluntary organisation staff, rather than when they are run internally. Residents are more willing to be open when reports are anonymous. “People don’t want to rock the boat”. Talking to residents individually may also give a truer impression of satisfaction, but this can be hard when residents are very handicapped or cognitively impaired. Sometimes surveys are coordinated by the parent organisation, allowing monitoring and comparison.
Other changes in residential care
I asked my voluntary organisation interviewees about more general change in ARC, apart from the audit process. Clearly change can come from a variety of influences, including policy and regulation, market forces, public requirements and expectations. Overall, respondents considered that there have been improvements – especially a higher emphasis on person-centred care, but also more activities for residents, new wound procedures, more education for care assistants (and they are more involved in decisions).
But less positive changes were also mentioned. The commercial model, especially for rest homes located with retirement villages, brings in the profit motive. There may now be add-on costs for “extras”. “Charging residents for everything – they even charged a blind woman for a garden view”. Larger and more modern rest homes can pay more for staff and have more facilities, but some respondents thought that the loss of small rest homes may have reduced the “family feeling”.
Suggestions to improve quality of care
The people I interviewed were voluble about such changes. The most common remarks concerned staffing- the problem of finding quality staff, higher staff numbers, more money to pay staff more, better training, valuing of staff. These are common issues in recent commentaries on ARC.
Culture was often mentioned, both in the form of culturally appropriate care, but also relating to leadership and quality (business ethos). This includes culture in the sense of the feeling and approach of the facility in general. Improvements in this area would include “more humanistic approaches”, tuning to the wishes of residents and their families; talking to residents and finding out their needs, more meaningful activities for residents – “we still see people sitting around with lack of stimulation”. And a final suggestion – “Let family members and clients write audit reports”.