Davis Centre action plan
The annual Resident Experience survey took place in August, 2023 and Family/Caregiver Experience survey took place in October, 2023. Resident surveys were administered in-house with the assistance of volunteers, while family surveys were distributed both by mail as paper copies and via email with a SurveyMonkey link for online completion. Paper surveys were later entered into SurveyMonkey, and the results were compiled.
The analysis of our 2023 Resident Experience Survey results indicated overall satisfaction with the accommodation, care, services, programs, and goods provided to our residents. Additionally, it highlighted specific areas where targeted improvement efforts are needed to further enhance the resident experience.
Dietary services
Focus of improvement
To improve overall dining experience and satisfaction with the quality of food and snacks.
Key actions
- Expanding the dining area by ensuring that both the nursing stations have their own dining area.
- Reducing the time that the residents wait for their meals in the dining room.
- Providing more time to residents to enjoy their meal.
Outcomes of action
- Implemented February 2024.
- Completed
Activation services
Focus of improvement
To improve gardening programs.
Key actions
- Ensuring extensive indoor and outdoor gardening program.
- Involving residents in purchasing plants.
- Building 2 gazebos to ensure that residents could enjoy gardens.
Outcomes of action
- Implemented May 2024.
- Completed
Focus of improvement
To increase outings provided to the residents.
Key actions
- Organizing visits each week as per the available resources and schedule.
- Engaging residents in deciding outdoor activities.
Outcomes of action
- Implemented April 2024.
- Completed
Focus of improvement
To ensure that all residents have access to the information about the activities available to them throughout the home.
Key actions
- Installing activity board near both the nursing stations.
- Planning 2 separate activity calendars for both the nursing stations for improved participation.
Outcomes of action
- Implemented June 2024.
- Completed
Housekeeping services
Focus of improvement
To ensure that the gardens and grounds are clean and tidy.
Key actions
- Onboarding new vendor.
- Ensuring new vendor has clear directions and expectations on servicing the grounds of the home.
Outcomes of action
- Implemented November 2023
- Completed
Focus of improvement
To ensure that the mattresses used in the rooms are comfortable.
Key actions
- Planning regular audit of mattress and replacing if damaged.
- Replacing and labeling bedsheets as per the mattress requirements.
Outcomes of action
- Implemented July 2024.
- Completed
Nursing care
Focus of improvement
To ensure that doors of the room are closed after the staff leave during night.
Key actions
- Reminding staff to close the doors after the required care is provided for all residents residing in the room during night.
- Monitoring any ongoing issues.
Outcomes of action
- Implemented May 2024
- Completed
Focus of improvement
To provide awareness to the residents regarding informing about missing items.
Key actions
- Reminding staff to ensure that the residents are informed about completing missing things form if something is missing.
- Reminding resident council about immediate reporting of the missing items.
- Following up with the residents/SDM as per the policy.
Outcomes of action
- Implemented May 2024.
- Completed
Focus of improvement
To ensure that the residents are provided with timely assistance.
Key actions
- Educating staff on 4Ps.
- Providing customer services education to staff.
- Monitoring call bell response times.
Outcomes of action
- Implemented July 2024.
- Completed
These are the priority areas identified for the year 2024/25. Tall Pines’ Quality Improvement Initiatives align with annual submissions of Quality Improvement Plans.
Focus of improvement 1
To reduce the rate of ED visits.
Key actions
- Utilizing previewED tool.
- Recertifying PoET project.
- Initiating PDSA project for reducing ED visits.
- Using SBAR tool.
- Using diagnostic equipment.
Outcomes of action
- Implemented March 2024.
Focus of improvement 2
To ensure staff complete equity, diversity, inclusion, and anti-racism education.
Key actions
- Providing DEI training to staff members.
- Implementing employee ambassador program.
Outcomes of action
- Implemented June 2024.
Focus of improvement 3
To improve communication skills of staff.
Key action
Educating staff on effective communication techniques.
Outcomes of action
- Implemented October 2024
- In progress
Focus of improvement 4
To ensure residents can provide feedback and complaints without fear.
Key action
Raising awareness of resident bill of rights.
Outcomes of action
- Implemented May 2024
Focus of improvement 5
To reduce the number of falls.
Key actions
- Sustaining preventing falls and reducing injuries from Falls best practice guidelines.
- Initiating PDSA project for reducing falls.
Outcomes of action
- Implemented July 2024
Focus of improvement 6
To reduce the number of residents who are having antipsychotic drugs without diagnosis of psychosis.
Key actions
- Implementing evidence-based interventions, monitor medication practices, and provide targeted education to interdisciplinary teams.
- Implementing an antipsychotic review pathway for new admissions.
Outcomes of action
- Implemented April 2024
The Resident Council holds monthly meetings where members can ask questions, share their expectations, and discuss their preferences for care and treatment. Quality Improvement plans are discussed regularly at Resident Council and Family Council meetings. Regular updates on the status of action plans are provided, and feedback from both councils is collected and documented in meeting minutes. Additionally, ongoing updates about the plan's implementation are posted on the information board.
Quarterly Continuous Quality Improvement (CQI) meetings are held to provide progress updates and identify areas needing further attention. Discussion on Quality improvement initiatives is a standing agenda item at CQI committee meetings. The CQI Committee aids in implementing the action plan by offering recommendations and continuously assessing the effectiveness and sustainability of the actions taken.
Including outcomes based off RES, FCES, and Home’s Priority Areas
Residents: Information was shared to residents through the Resident Council meeting minutes. The action plan was discussed in the Resident Council meeting on May 14, 2024, and the outcomes were communicated on September 12, 2024.
Families: Details were provided to families through the Family Council meeting minutes. The action plan was discussed during the Family Council meeting on May 15, 2024, with outcomes scheduled to be shared on October 16, 2024.
Both Residents and Families were informed about the action plans during the Family Information Night on June 26, 2024, and through postings on the Resident and Family Council boards on August 19, 2024.
Staff: Updates were shared via CLT and CQI meetings, where action plans were discussed regularly. The outcomes were presented during the CLT meeting on July 24, 2024, and the CQI meeting on August 23, 2024. Ongoing updates regarding plan implementation were posted on the quality board on August 19, 2024.