Quality Measures in aged care

Pressure injuries are more likely to develop if someone is frail or must stay in bed or a chair. As people get older, it is common for skin to become drier, thinner and less elastic. These factors increase the risk of developing pressure injuries.

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

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

The 5 stages of pressure injuries that contribute to the Quality Measures rating are:

• stage 2 pressure injury
• stage 3 pressure injury
• stage 4 pressure injury
• unstageable pressure injury
• suspected deep tissue pressure injury.

Stage 1 pressures injuries do not contribute to the Quality Measures rating. Each pressure injury stage is weighted, with more serious injuries (i.e. stage 4 pressure injury, unstageable pressure injury and suspected deep tissue pressure injury) making a larger contribution to the rating.

Developing a pressure injury can affect quality of life, particularly if the injury becomes severe. Pressure injuries are very painful, can be difficult to heal, and can make it difficult to move.

The risk of getting pressure injuries can be reduced by having effective care strategies in place.

The best way to prevent pressure injuries is to minimise pressure or friction on the skin. An example 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.

It is important to keep skin clean and protected and maintain good nutrition. A diet with plenty of fresh fruit, vegetables, and water can help the skin stay healthy and less likely to become injured.

A pressure injury can develop in just a few hours so residents skin should be regularly assessed for dryness, moist patches such as from incontinence, and areas of localised pain. This can identify if they need help to change positions, or if something else can help like a specialised mattress.

These assessments should be carried out as part of routine personal care (for example, bathing and toileting) where possible.

Pressure injuries can be hard to heal. Healing can take more time for those who are elderly, frail, do not eat well or move much, and have other health problems. Treating the injury is essential so that it does not get worse.

If a resident develops a pressure injury, they should see a doctor. The aged care home should also make sure the resident sees a wound care nurse, occupational therapist, or dietitian if needed.

If you want to know more about the quality of care you or your loved one is receiving, talk to your aged care home.

You might like to ask some of these questions:

• What are you doing to prevent pressure injuries?
• How often do you assess people 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?
• What do you do to check for poor nutrition? 

There are 5 types of restrictive practice:

• Environmental restraint: restrictions on a person's access to all parts of their environment (including items and activities)
• Mechanical restraint: devices that stop, restrict, or reduce a person's movement
• Physical restraint: the use of physical force to stop, restrict, or reduce a person's movement
• Seclusion: stopping a person from leaving a physical space in which they are confined
• Chemical restraint: the use of medication or a chemical substance to influence a person’s behaviour.

The restrictive practices quality measure uses data relating to all restrictive practices, excluding chemical restraint. Read more about the types of restrictive practices on the Department of Health, Disability and Ageing website.

Continued use of restrictive practices can be an indicator of poor quality of care, as they can cause physical and psychological harm and can have a significant impact on the quality of life of residents.

Restrictive practices must only be used as a last resort to prevent harm to an older person or others, after considering how it might impact the person.

Aged care homes must:

• trial and document alternative strategies before considering a restrictive practice
• use the restrictive practice in the least restrictive form and for the shortest time needed
• ensure the older person or their representative gives informed consent for the use of the restrictive practice
• only use the restrictive practice in line with the rights and responsibilities of people receiving care outlined in the Aged Care Rules
• monitor and regularly review the use of the restrictive practice.

There are strict legislative measures in place to reduce the inappropriate use of restrictive practices as set out in the Aged Care Rules.

Read more about restrictive practices in aged care – a last resort on the Department of Health, Disability and Ageing website.  

A restraint-free environment is the recommended standard of care for aged care homes. Some alternatives to restrictive practices include:

• reducing the risk of falls and injury by using equipment such as 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, and
• taking care of related health concerns, such as poor eyesight or balance, mental health, or unstable blood pressure.

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

You might like to ask these questions:

• How do you assess if a restrictive practice is needed?
• How do you gain consent for the use of a restrictive practice?
• How often is the agreed use of a restrictive practice reviewed?

If a restrictive practice is used:

• Can you explain why a restrictive practice was needed?
• What alternative strategies were considered and trialled?
• Has a thorough assessment been completed and recorded?

Unplanned weight loss can happen when a person does not eat enough of the right foods to meet their daily needs. It can also be caused by illness, certain health conditions and negative dining experiences. 

There can be complex reasons why a person does not eat enough food. It may be the quality of the food, choice of foods or a person may have difficulty eating.

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

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

Older people are at increased risk of unplanned weight loss and malnutrition. Proper care strategies can reduce the risk of unplanned weight loss.

Aged care homes must monitor the weight of residents and address changes as early as possible.

They should consider the quality and taste of food, and any special dietary needs.

It is also important that staff receive training to support people with their meals, 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, healthy food at the right temperature and serving smaller meals more often
• providing a relaxed and sociable dining environment with enough trained staff to help people who need it
• ensuring dental health, swallowing, and special dietary needs are addressed by appropriate specialists and any recommendations are followed
• 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 hours of the day, and
• enabling visitors to bring meals to eat at the aged care home.

If a resident loses weight when they are not planning to, they should see a doctor. The aged care home should make sure the resident sees 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, talk to your aged care home.

You might like to ask these questions:

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

Falls can reduce physical functioning, decrease independence, cause minor and major injury, psychological impacts, and occasionally death.

Fall prevention is not always possible, but awareness of risk factors and some simple steps can reduce the risk of falling and injury occurring.

Aged care homes can focus on three areas to prevent falls:

• assess an individual’s risk of falling by assessing specific risk factors
• put in place prevention or interventions to target the risk factors
• prevent injuries in people who experience falls.

If you want to know more about the quality of care you or your loved one is receiving, talk to your aged care home.

You might like to ask some of these questions:

• What processes are in place to assess the risks of falls?
• How are you reducing the risk of falls?
• What are you doing to prevent injuries in people who fall?
• How do you respond to a fall?

Polypharmacy is the prescription of 9 or more medications to a person in aged care.

Excluded medications are listed in the National Aged Care Quality Indicator Program Manual 4.0 Part A (pages 35–36).

Antipsychotics are medications primarily prescribed for the treatment of a diagnosed condition of psychosis.

Psychosis refers to a collection of symptoms that affect the mind, where there has been some loss of contact with reality. Psychosis symptoms can include delusions, hallucinations, perceptual disturbances, and severe disruption of ordinary behaviours.

Diagnosed conditions of psychosis may include disorders such as schizophrenia, bipolar disorder, Huntington’s chorea, delusions and hallucinations. End-of-life care recipients may also experience psychosis.

Polypharmacy is an increasing concern amongst older people.

Polypharmacy monitoring is needed as it can lead to a reduced quality of life, medication side effects and hospitalisation.  It can also impact memory, thinking, and decision making.

Regular monitoring of the use of antipsychotics is important as inappropriate use can lead to poor health outcomes.

Age-related risks can make older people more vulnerable to negative outcomes connected to the use of antipsychotics.

If you want to know more about the quality of care you or your loved one is receiving, talk to your aged care home.

You might like to ask some of these questions:

• How do you ensure appropriate medication use?
• What triggers a medication review?
• How does the provider manage the behavioural and psychological symptoms of dementia?
• Who can I speak to if I have concerns about the use of medications at this aged care home?