Quality indicators in aged care homes

Pressure injuries are more likely to develop if someone is frail or has to stay in bed or a chair. They are also related to changes associated with ageing, such as skin becoming thinner and more fragile.

Other factors that may contribute to the development of pressure injuries include:

• poor nutrition
• reduced mobility
• chronic disease
• incontinence, and
• the use of restraint.

Thousands of people in Australia are affected by pressure injuries, including older Australians. The risk of getting pressure injuries can be reduced by having effective care strategies in place.

Aged care homes can use the results from the pressure injuries quality indicator to:

• identify and manage risks
• support continuous quality improvement, and
• improve quality of care.

The best way to prevent pressure injuries is to minimise pressure or friction on skin. An example of this may be staff helping people who are unable to move on their own to change position regularly. Managing regular pain can also help people stay mobile.

Keeping clean, looking after the skin, and having a healthy diet are also very important. Plenty of fresh fruit, vegetables, and water can help the skin stay healthier and less likely to be injured.

Care recipients should be assessed regularly. This can identify if they need help to change positions, or if something else can help such as a specialised mattress. A care plan can be developed if needed. A pressure injury can develop in just a few hours, so regular skin checks by care staff are necessary.

Pressure injuries can be hard to heal. Healing can take more time for those who are elderly, frail, do not eat properly or move much, and have other health problems. The injury must be treated to stop the wound from getting worse.

If a care recipient develops a pressure injury, they should be referred to a doctor who can look into what may be causing it. The aged care home should also make sure care recipients see a wound care nurse, occupational therapist or dietitian if needed.

If you want to know more about the quality of care that you or your loved one is receiving, a good first step is to talk to your aged care home about it. You might like to ask some of these questions:

• What are you doing to prevent pressure injuries?
• How regularly are people living in this aged care home assessed for pressure injuries?
• What do you do to treat pressure injuries?
• Are your care staff trained to prevent, recognise and treat pressure injuries?
• What are you doing to improve the prevention and treatment of pressure injuries?
• How do you support physical activity and exercise?

Physical restraints may include:

• bed rail/s
• chairs with locked tables
• seatbelts other than those used during active transport
• safety vests
• shackles
• manacles
• the placement of furniture
• use of concave mattresses
• lap rugs with ties
• the intentional locking of a care recipient’s room, or
• any other device used where there is the intention to restrict free movement.

Physical restraint can cause physical and mental harm, even if it is put in place as a safety measure. This can include bed rails that may have been requested by the care recipient. Physical restraint can impact on a care recipient’s rights and dignity and can also lead to:

• pressure injuries
• incontinence
• loss of muscle strength
• falls
• cuts and bruising
• pain
• poor nutrition
• difficulty moving
• mood swings including anger, withdrawal, and aggression
• confusion, anxiety, and depression
• loss of trust between older people and their families, and staff
• distress for family members
• in the worst case, death.

Aged care homes should regularly review their use of physical restraint. By carefully considering their processes, they may find other methods that better support the health, wellbeing and quality of life of care recipients.

Aged care homes can use the results from the use of physical restraint quality indicator to:

• identify and manage risks
• support continuous quality improvement, and
• improve quality of care.

Physical restraint is sometimes used to manage behavioural and psychological symptoms of dementia. It is sometimes also used in situations where there is concern that people may experience a fall. People are more likely to be restrained if they have poor health, dementia, physical disabilities, or mental health issues.

Minimising the use of physical restraint

In 2019, legislative changes were introduced into the Quality of Care Principles 2014. Providers are now required to satisfy a number of conditions before restraint can be used. These include:

• the consumer is assessed by an approved health practitioner as posing a risk of harm to themselves or others
• informed consent by the consumer or their representative
• alternatives to restraint must have been considered or used where possible
• use of physical restraint must be the least restrictive form possible and a last resort.

This is unless its use is necessary in an emergency.

A restraint-free environment is the recommended standard of care for aged care homes. Some alternatives to physical restraint that can be used by services to minimise the use of restraint include:

• reducing the risk of falls and injury by using equipment such as low beds, non-slip mats, and hip protectors
• educating families and staff about dementia and discussing alternative behaviour management strategies
• increasing the safety of the home to allow safe wandering
• exercise and social activities
• taking care of needs such as poor eyesight and mental health, or problems such as poor balance or unstable blood pressure.

If you want to know more about the quality of care that you or your loved one is receiving, a good first step is to talk to your aged care home about it.

You might like to ask some of these questions:

• What is the home’s process of assessing if a physical restraint is required?
• What is your process of gaining consent for the use of restraint?
• How often is the agreed use of a physical restraint reviewed?

If a physical restraint is being used:

• Can you explain why it is needed?
• What alternative ways of managing this issue have been considered and tried?
• Has a thorough assessment been completed and recorded?

Unplanned weight loss occurs when a person does not eat enough food to meet their daily requirements. There can be many and complex reasons why enough food is not eaten. It may be because of the quality of the food. It might be that a care recipient is having difficulty eating. If a care recipient eats a healthy nutritious diet, unplanned weight loss might be caused by a specific health condition.

Unplanned weight loss is more likely to happen to older people with:

• dementia
• swallowing difficulties
• poor dental health
• chronic disease
• depression
• pain
• the need to take multiple medicines.

Older people are at increased risk of unplanned weight loss and malnutrition. However, the risk of unplanned weight loss can be greatly reduced by having good care strategies in place.

Aged care homes can use the results from the unplanned weight loss quality indicator to:

• identify and manage risks
• support continuous quality improvement, and
• improve quality of care.

Aged care homes must monitor care recipients' weight to pick up any changes as early as possible, so that they can help address any issues. They should consider the quality and taste of food, and also whether a special diet is needed. Staff should be trained to help people with their meals, with taking medication, and with looking after their teeth.

Other areas an aged care home can focus on include:

• encouraging people to eat well by providing tasty, nutritious food at the right temperature and serving smaller meals more often
• providing a relaxed and sociable dining environment in which to eat with enough trained staff to help people who need it
• ensuring dental health, swallowing and special dietary needs are addressed by appropriate specialists
• reviewing medicines and medical conditions and considering any possible side effects
• providing choice, discussing food preferences, and developing nutrition care plans together
• getting enough exercise to encourage a healthy appetite
• providing nutritious snacks and finger foods, as well as plenty of water at all times - not just at set meal times
• enabling visitors to bring and eat meals at the aged care home.

If a care recipient loses weight when they're not expecting to, they should be referred to a doctor who can look into what may be causing it. The aged care home should also make sure care recipients see a dietitian, dentist or speech pathologist if needed.

If you want to know more about the quality of care that you or your loved one is receiving, a good first step is to talk to your aged care home about it.

You might like to ask some of these questions:

• What do you do to make sure people are a healthy weight?
• What meal choices are available?
• What happens if people experience unplanned weight loss?
• How do staff make sure people have enough to eat, and drink enough water?
• Are staff available to help people eat their meals?
• What is your home doing to continue to improve nutrition?