Maggie Beer’s Big Mission – Episode 3

New Aged Care Standards

The key recommendation from the Royal Commission into Aged Care Quality and Safety was the drafting of a new Aged Care Act. Within the new Act there would be new strengthened Aged Care Quality Standards which puts the individual’s rights foremost. The new Quality Standards have been developed and were in final draft form in November 2022, but as a delay to the new Aged Care Act was necessary due to several reasons, unfortunately the new Quality Standards will not become live until the new Act exists.

Aside from the new Quality Standards putting the person at the centre of the framework (in the same way a holistic care model puts the resident at the centre of the care), there are an expectation statement, an intent statement, and several outcomes set out for each Standard. The outcomes are more detailed than previously with expected actions to demonstrate how the outcomes are being met.

Previously, food and nutrition has been found within other Quality Standards. Up until 2019, catering was considered within a Quality Standard named “Physical environment and safe systems” in a single expected outcome (out of a total of 44 outcomes) named “Catering, cleaning and laundry services.” The current Quality Standards have 42 requirements, with food being considered in Requirement (3) (f) of Standard 4, which states “Where meals are provided, they are varied and of suitable quality and quantity”.

In recognition of its importance, the strengthened Quality Standards dedicate a whole standard to food and nutrition – Standard 6. The proposed expectation statement for this Standard acknowledges not only the food itself, but also the dining experience:

“I receive plenty of food and drinks that I enjoy. Food and drinks are nutritious, appetising and safe, and meet my needs and preferences. The dining experience is enjoyable, includes variety and supports a sense of belonging.”

You can find out more about the new strengthened Aged Care Quality Standards here.

Food Safety

With over 5 million cases of food poisoning each year, it is important to manage food safely and even more so in aged care facilities. Western Australian aged care facilities are regulated by 3 main instruments: Food Act 2008; Food Regulations 2009; and the Australia New Zealand Food Standards Code.

To ensure compliance to these, aged care facilities are periodically audited by an independent food safety auditor. In theory, the longest duration between monitoring is 2 years, but due to the vulnerable nature of aged care residents it is often a maximum of 12 months in practice. Food safety monitoring by an auditor examines all aspects of food storage, production, and service in a facility, as well as appraising the whole Food Safety Program identifying hazards and managing them appropriately.

To demonstrate compliance, extensive records such as cleaning records, temperature records, and risk assessments are required to be kept. It is also important to demonstrate how common food allergens are managed safely and correctly so not to expose a person who be affected by a specific allergy. However, while being able to demonstrate compliance is essential, staff practices are the key to preventing adverse food incidents and that requires the correct knowledge and actions to be taken by staff.

While we must comply with the Food Act because we are effectively selling food to customers, we also have a standard of care to discharge when it comes to friends and relatives bringing in food. We do this by providing visitors information on risk foods, appropriate storage, and reheating where applicable.

Buffet

There are many benefits of buffet style dining experience in aged care such as promoting choice, supporting mobility, encouraging residents to be actively involved, and removing the need for meals to be rushed or strictly regimented. Choice is recognised as being a key driver for improving nutritional intake and satisfaction in aged care.

However, it is important to also note that there must be significant management of a buffet by staff to ensure that residents remain safe from potential physical injury from participating in a buffet, such as scalds or breakage. Good buffet management is also needed to ensure good food safety practices and allergen control for individuals.

The need for buffet management should not be regarded as a drawback, but as a necessary quality intervention to enable the benefits to be gained. Prior to the project, we had trialled buffet breakfasts in 2 care areas across Meath Care with moderate success. However, the training and support from Elizabeth and Julie took this to a much higher level and improved satisfaction.

Resident Activities and Jobs

One of the key baseline findings was that over 2/3 of residents expressed that they wanted to help around the facility. This was considerably more than we had previously thought; for many of the residents this desire was from their preference to be busy and have a role to play within their community.

During the project we found that once job roles were available for residents, they took these on with dedication and felt that they contributed to the mealtime. Roles varied from ironing napkins to filling salt cellars, and the roles were apportioned according to their ability to ensure that they could succeed.

However, while not all residents wanted to take on a job role or were able to do so, the use of activity boxes allowed for residents to participate in familiar activities based on real-life tasks. These were designed for people requiring cognitive support and have been a welcome addition due to the simplicity of the activity and the ability for people with impaired function to achieve.

Dining Room Environment

It had long been recognised by us that having up to 44 residents in a single dining area was not conducive to an optimal dining experience. Up until October 2022, the main obstacle to being able to split into 2 dining areas was the ability to staff these areas at mealtimes.

However, from October 2022 all government-subsidised aged care facilities became funded for higher staffing that was to meet a mandated care minutes requirement. This meant that Meath Care were able to increase direct care staffing by 20%, which would have been impossible under the previous funding model.

With the additional staffing available, creating 2 dining areas for each level at the Centre was essential to enhance the dining experience – allowing for lower noise levels, providing space for buffets, and improving the presentation of the tables.

In all, there were several works undertaken to improve the dining areas. The areas were painted, new lighting installed, new window dressings, and of course a buffet. The designs were created by an architect (Felice) and there were different budget options available to complete the works.

The second dining area was created from an area that was previously a lounge and activity room. The small lounge nook remains for residents to use, and there are other lounges available on the floor. The activities function was relocated to another dedicated room on the level that had previously been used as a staff training room. With other areas able to accommodate training, this has proved an extremely successful transition.

Outdoor Spaces and Gardening

There were 2 main outdoor spaces that needed work – one was a balcony on the same level, the other was the main courtyard that serves the whole facility. Both areas were underutilised, and at the beginning of the project, the courtyard could not be used due to storm damage to the eaves of the building. Another factor that had prevented these spaces being used in the past was COVID and the public health directives around visiting.

The landscaping designs created useable spaces that aim to bring people to them, from sensory plants to functional barbecues, and of course, a colourful mural on the balcony. We already had shade provided on the balcony, but shade was desperately needed in the main courtyard, as well as ground treatment to reduce glare. With a large shade umbrella and the new pergola, the central courtyard is now able to be used more.

Gardening is a popular pastime for older people, but accessibility can be limited depending on their physical abilities. Using raised planters allows for resident involvement at an achievable level, while some residents are more involved in the upkeep through watering and pruning. Gardening remains a popular structured activity on our lifestyle timetable, as well as residents having access and being able to garden at other times.

Intermediate Results

There were 3 points in time where the research team gathered data: baseline at the beginning of the project (July 2023), at the end of the project (January 2024), and the final data 3 months later (April 2024). By the end of episode 3 the project had been completed and so the second suite of research results were available.

• Protein intake: this had increased from an average serving of 8.8g to 17.5g per meal and 64% of the residents sampled were seen to have increased their protein intake.
• Buffet: 46% of residents were able to access the buffet in some manner, whether independently or supported by others.
• Person-centred interactions: the number of staff-resident interactions related to choice at mealtimes that were person-focused increased from 25% to around 75%.
• Purposeful engagement – 38% of residents had taken on roles and were completing tasks to improve mealtimes.
• Weight: this was a mixed result as 32% of residents gained 2.5% of their total body weight or more, while 28% of residents lost 2.5% of their total body weight or more during the project.
• Mealtime satisfaction: the average resident response increased from 46/56 to 49/56.
• Risk of malnutrition: this was also a mixed result as during the project, 4 residents’ risk of malnutrition reduced while 6 residents’ risk of malnutrition increased.
• Job satisfaction – the average staff response increased from 90.8/110 to 94.5/110.

In addition to these quantitative results, the qualitative responses and statements from residents and staff reflected a degree of success.

Costs of the project

All costs incurred within the project were paid for by Meath Care except for:

• Costs relating to Maggie Beer’s time and expenses;
• Maggie Beer Foundation costs;
• Production company costs; and
• A portion of the research costs.

During the project the food costs per resident per day increased from $12.95 in July 2023 to $15.67 (December 2023 / January 2024 average). However, when inflation related increases were excluded by using comparable data from our other Centre, the actual zero inflation increase was $1.95 per resident per day.

In total, the annualised increase for food costs totals over $90,000. Moreover, before the project, our pre-prepared and brought in foods represented 12.1% of our food costs; this reduced to 9.6% by the end of the project.

The largest operational cost outlay related to the training and support which was critical and necessary. This was the equivalent of $598 per staff member when you consider the costs of training provision, the cost of practical support, and the replacement of shifts to allow specific staff to attend training.

The non-capital expenditure for items such as chairs, crockery, cutlery, activity boxes came to the equivalent of $250 per resident.

It should be recognised that capital expenditure for our facility might not be necessary in other facilities – it will depend on building age, function, and condition. While this will vary between facilities, an appropriate asset management and prior depreciation should allow funds for such an exercise. Our Board approved a budget for $250,000 in capital works for this project and the final total capital expenditure totalled $243,535.

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