Peel Manor 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
Focus of improvement
Variety/cultural diversity in menu items
Key actions
- Incorporate new ethnic dishes.
- Introduce cultural foods to accommodate respective cultural/ethnic festivities.
- Provide a variety of sandwiches and fresh seasonal fruit.
Outcomes of action
- Implemented and completed June 2024.
Activation
Focus of improvement
Increased recreational activities.
Key actions
- Hire a Horticultural Therapist.
- Hire a Music Therapist.
- Hire an Art Therapist.
Outcomes of action
- Implemented December 2024
- In progress
Nursing
Focus of improvement
Take time to talk and listen to me.
Key action
Provide Emotion-based care training to staff that work in TBSU and Butterfly Resident Home Areas.
Outcomes of action
- Implemented May 2024
- Ongoing
Key action
Provide training to staff on the Gentle Persuasive Approach.
Outcomes of action
- Implemented March 2024
- Ongoing
Laundry
Focus of improvement
My laundry is cleaned and returned to me.
Key actions
- Implement a revised “Clothing Request Labeling Form” and process.
- Implement “New Admission Move-in Checklist”.
Outcomes of action
- Implemented and completed January 2024
Key action
Facility Services Supervisor to conduct frequent huddles and audits with laundry staff.
Outcomes of action
- Implemented December 2024
- Ongoing
These are the priority areas identified for the year 2024/25. Peel Manor’s Quality Improvement Initiatives align with annual submission of Quality Improvement Plan (QIP).
Focus of improvement 1
Reduce rate of emergency department (ED) visits.
Key action
Utilize PreviewED tool.
Outcomes of action
Implemented and completed April 2024.
Key action
Provide PoET refresher training and certification.
Outcomes of action
Implemented and completed June 2024.
Key action
Equip registered staff with SBAR training.
Outcomes of action
- Implemented November 2024.
- In progress
Focus of improvement 2
Reduce number of falls.
Key action
Conduct RNAO Gap Analysis with Best Practice Implementation Coach.
Outcomes of action
Implemented and completed April 2024.
Key action
Initiate PDSA project for reducing falls.
Outcomes of action
- Implemented September 2024.
- Ongoing
Key action
Implement weekly fall huddles.
Outcomes of action
- Implemented January 2024.
- Ongoing
Focus of improvement 3
Maintain current strong performance related to Percentage of LTC residents without psychosis who were given antipsychotic medication in the 7 days preceding their resident assessment.
Key action
BSON to engage with care planning for all new residents who move into the Home with anti-psychotic medications and to assist in identification of non-pharmacological approaches.
Outcomes of action
- Implemented December 2024
- Ongoing
Key action
Implement an antipsychotic review pathway for new admissions.
Outcomes of action
- Implemented May 2024
- Completed
Focus of improvement 4
Improved staff communication techniques.
Key action
Deliver training sessions for TBSU staff on Emotion-based and Relational Care.
Outcomes of action
- Implemented May 2024
- Ongoing
Key action
Provide online training to all staff on Customer Service and Handling Complaints.
Outcomes of action
- Implemented November 2024
- In progress
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 during the Resident Council meeting on May 14, 2024 , and the outcomes set to be communicated on October 11, 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 28, 2024, with outcomes scheduled to be shared on October 29, 2024.
Both Residents and Families were informed about the action plans through postings on the information boards.
Staff: Updates were shared via CLT and CQI meetings, where action plans were discussed regularly. The outcomes were presented during the CLT meetings on March 20, June 26 and July 17, 2024, and the CQI meetings held on May 22 and August 14, 2024. Ongoing updates about the plan’s implementation are posted on the quality board.