Winston Lodge, NSW

Behaviour Management Program

Winston Lodge is a dementia specific nursing home that has implemented evidence based better practices in behaviour management to enhance residents' quality of life. The practices adopted encompass restraint minimisation, environmental adaptation, diversional therapy, pain management and a focus on person centred care.

Better practices adopted include:

• Reduction in psychotropic medications and elimination of chemical restraints: We have become actively involved in monitoring use of these types of medications and in consultation with residents' doctors have been successful in reducing their use.
• Elimination of physical restraints: Restraints were removed to reduce anxiety and frustration of residents and avoid physical de-conditioning. Extensive consultation with residents' family members and re-education of staff was required to overcome opposition to this change arising from a belief that restraints were required for resident safety.
• Hip protectors: We provide hip protectors to all mobile residents to protect them from injury in the event of a fall.
• Physiotherapy: Each resident has an individually tailored exercise program that has been designed by a physiotherapist.
• Pain management: Better assessment of residents has resulted in better control of pain with a corresponding reduction in disruptive and aggressive behaviour.
• Stimulating environment: Environmental changes were made to provide a stimulating yet familiar environment and assist to orient residents. Families are encouraged to bring in personal items to help create a homelike environment for residents.
• Resident portraits: We are fortunate to have a budding artist amongst our staff who has produced sketches of each of our residents. These are decorative, assist in resident orientation and demonstrate the person-centred approach taken within our service.

These changes have resulted in:

• 20% reduction in falls
• 45% reduction in skin tears
• 71% reduction in aggressive incidents

The functional ability of two residents improved to such an extent that they were able to move into a hostel for their ongoing care needs.

Staff Education Program

Winston Lodge is a dementia specific nursing home. We found that some of our new staff reported feeling overwhelmed and lacked confidence in their abilities. We reviewed our orientation and education systems to ensure staff are getting enough support and are confident in their abilities to care for our residents.

A comprehensive competency based orientation program was introduced that uses a package to facilitate self paced learning. The package is designed to be completed over a period of seven days. The package includes questions and activities to promote active learning. Photos are used extensively throughout the package to demonstrate staff practices. Sample copies of forms are included in the package. A mentoring system was adopted to support new staff and individual learning and development plans were developed for all care staff.

In order to create a learning culture we implemented a policy that all carers will undertake one hour of education per week during work hours. We also developed a resource library for use by staff and family. Financial support is provided to staff undertaking university education.

This program has assisted us to attract and retain staff. As a result, Agency staff usage has reduced by 76%. Most importantly, our residents receive better care as staff have a thorough understanding of our systems and residents' needs, are able to anticipate their needs and provide more individualised care.

Nutrition and Hydration Program

Many residents are prescribed a pureed diet and thickened fluids while in hospital as part of their acute care. We engaged a speech pathologist to re-assess all residents with dysphagia. We found that most no longer required a pureed diet. A Robocou machine was purchased to enable meals to be prepared with a consistency that meets each resident's assessment needs and staff education was provided on the preparation of different consistencies of foods and fluids. These changes resulted in residents showing improved appetite and 66% of residents gained weight over five months, with the average weight gain being 2.2kgs. A policy has been introduced where speech pathology assessments are arranged for residents who have an acute illness that results in a change in diet, who has had a change in their appetite or who is found to be losing weight.

Each resident's weight and body mass index are regularly monitored as weight loss and malnutrition are often associated with dementia and contribute to impaired physical and cognitive functioning. A set of digital scales which can be used with seated residents were purchased. Research showing how to use lower leg length as an indication of height was applied to determine the body mass index of those residents who are unable to stand or who have kyphosis.

Hydration was improved by the introduction of twice-daily jelly rounds, in addition to morning and afternoon tea. Jelly is an alternative way to increase resident fluid intake as water is the main ingredient. We have found that jelly is eagerly consumed by most residents, including those who generally refuse fluids. Urinary tract infections have reduced by 50% since the commencement of the hydration program.