Changing to Meet Aged Care Needs at Richmond Lodge

Richmond Lodge is a 30 bed aged care facility in Casino on the Far North Coast of New South Wales. It is operated by the United Protestants Association of NSW (UPA). For many years it has provided low care or hostel type services, but like so many other facilities it has over recent years, transformed to a facility that could be better described as a mixture of high and low care. This article describes how the facility has embraced both the challenge of looking after residents with greater needs and implementing continual quality improvement at the same time.

"Knowing residents and assessing them well is the essence of good care" claims Facility Manager, Colleen Page. To achieve this we have developed a formal clinical training program which is linked to resident needs assessment. Our clinical staff members attend this focus training twice every year, along with other training conducted throughout the year.


Aged care has changed in the past 5-7 years. The residents are generally older and have much greater needs. Many of the residents admitted to Richmond Lodge today would have automatically gone to the town's dedicated high care facility five years ago. In those days we did not have enough RN staff on board to manage such residents. Basically, if the resident needed two staff at night to assist them, we just could not accept them. If the resident could not walk, if they required regular lifting, or had complex pain issues, it was more appropriate to refer them on to somewhere else. We now have additional RN resources, a higher staff to resident ratio and a remedial massage specialist to assist with the higher level requirements. Richmond Lodge did care for palliative care residents in the past, but not where the palliative care was particularly complex. A key development that occurred 5 years ago was a government initiative that provided funding for a palliative care service to help the aged care facilities take on an expanded role in palliative care. The person involved in this program helped initiate our current palliative care service model and he gave us the confidence to develop our own service and expertise base. Eventually, the seeding funding ceased but by that stage our service had been developed, and was working well. A major first step towards providing higher care and meeting the changing needs of the community had been achieved.

Change in Staff Mix
To meet the needs of our current residents we have had to double our level of registered nurse coverage and it is now approximately 1 hour per resident bed day. This has been an expensive exercise. The times that needed the most coverage were the high penalty rate times of night, weekends and public holidays. When targeting registered nursing staff for employment, we are keen to understand their clinical assessment skills and this criterion has been a priority in the selection process. As mentioned above, good care starts with good assessment and we needed to cover our formalised pre-admission visits to the hospitals and the home where necessary. The resident is also formally re-assessed on day one of admission and then ACFI assessments are commenced seven days later, in conjunction with other holistic assessments.

The three stage process for assessment and admission is important. It involves a range of different staff and it helps to ensure that we look at the resident's needs from different angles and minimises the chances of overlooking something. It is a full team effort. It also recognises the fact that symptoms like pain can emerge over time.

Pain Management
The recognition of pain and its resultant management has played a big part in the journey of our facility towards a higher level of care. Years ago, pain was something that was complained about and dealt with accordingly. Today, we start with the assumption that all residents will have some form of pain, the question is where and how severe? We have a pain survey that goes to all residents and is worked through with the clinical staff. With our three stage assessment process, we are better meeting the needs not only of the higher care residents, but the lower care ones as well.

Richmond Lodge employs a remedial massage therapist to assist with routine pain management therapy. Residents also have access to a physiotherapist service for special pain management or rehabilitation programs.

Activities and Passing The Time
When considering the role change from traditional low care to a higher level, it is important to consider the impact on the activities staff and programs. With a mixture of low and higher care residents it has been necessary to integrate our residents for certain programs but separate them for others. There has been an increased need for specifically designed activities to compensate for 'sundowning' issues.

Gardening, one to one foot massages, one to one reminiscing sessions, afternoon bus trips, an increase in brain games like puzzles, and arts and craft activities are rotated to meet the needs of the higher care residents. There was also a need to enhance and make more suitable our outdoor areas. This resulted in a substantial works program to improve pathways and implement more sensory type features such as increased coloured plants, raised garden beds, herb gardens and water features.

Pet therapy was also introduced and an exhaustive search was undertaken to find Harry, our pet spoodle. There is also Elvis our canary.

Building and or Equipment Changes to Meet the Role
To enable an effective transition from low care to higher care requires strategic thinking in the planning and design stages of any building. Richmond Lodge has been operating for 45 years but its current building is just 12 years. The UPA management had always planned on meeting the increased needs of an ageing population. The original design provided accommodation, bathrooms and facilities that could be used for higher care residents without any subsequent renovation. The rooms and bathrooms are large enough for the equipment required, demonstrating excellent outcomes from the planning processes put in place over a decade ago. This was a critical element for successfully meeting the needs of the population.

Richmond Lodge has also benefited from a substantial bequest. This had enabled us to build on the original design by investing in our outdoor areas, gardens and equipment such as a bus, new beds, lifters and water chairs. The transition from low to higher care comes with a cost and to have the financial resources to adequately deal with such issues in a timely manner is another critical element for a successful outcome.

Staff Workplace Cultural Development
Communication and teamwork is critical during any transitional phase and possibly our biggest asset is the fact that all staff members feel that their input into resident care is valued. Our point of difference is that every morning there is 20-45 minute discussion by all staff (this includes kitchen, general service officers (GSOs), and nursing). That is everyone, except for 1 or 2 people who observe the residents.

All staff members have an input. Sandra (GSO) has a big input into infection control and is on the infection control committee. To solve the common 'clothes going missing' problem Sandra suggested that each staff member have personal responsibility for tidying the room and accounting for the clothes of a particular resident. This innovative suggestion has had the twofold benefit of bringing together the staff and the residents in a way that emphasises the home environment; and, the more intimate knowledge of the resident and their belongings has resulted in a marked reduction in complaints about lost clothing. A least one staff member knows who owns which piece of clothing. More importantly, GSO's have contributed significantly to resident assessment processes by identifying such things like a very early change in the character of the resident's urine as a result of toilet cleaning.

Kitchen staff members are also good participants in the daily meeting. They are particularly observant when it comes to identifying changes in resident eating habits. In one recent review the kitchen staff assisted a resident who appeared to lose total interest in eating what might be considered the 'usual food'. The care plan has been amended to provide snack type finger food for this resident. Whatever she wants to eat, she gets. If she wants crumpet, she gets it, finger food, she gets it. Short order cooking has become more necessary as the residents have moved towards a higher level of care. The cooks have also suggested and implemented food 'grazing' options for certain residents and above all the residents' choice of food is respected. Residents are provided the opportunity to make choices on their food based on both dietary advice and their own particular preferences. Richmond Lodge is their home and having the opportunity to eat what they like is considered very important.

Simply trudging along the same path and doing what we have done before is no longer an acceptable outcome. In modern aged care we cannot dig our heads into the sand and say that everything will remain the same. The needs of our ageing population are changing. Residents are becoming on average increasingly frail. We need strong teamwork and innovative decision making if we are going meet these challenges. Our next initiative is laughter boss training, so stay tuned for another contribution to the QPS newsletter from Richmond Lodge.