Fiona Cassie reports on new aged-care manager Anna Blackwell’s journey to turn Ranfurly Manor from a “named and shamed” Fielding rest home into a sought-after facility.
Ranfurly Manor staff used to take off their name badges if popping into Feilding on the way home from work.
They were embarrassed to be working at the home that made headlines for all the wrong reasons.
The damning headlines began back in 2008. A resident hospitalised after being left without oxygen prompted a MidCentral District Health Board audit, which found the home serving under-heated, inadequate food and having residents lying in their urine. The 38-bed hospital and 12-bed resthome facility also breached its contract by having no senior clinical nurse leader.
A DHB statutory manager was appointed – who quickly set to work to step up the registered nurse and enrolled nurse staffing from 1.4 full-time equivalents towards its current 6.6 – and the homeowner’s contract with the DHB was terminated.
Anna Blackwell arrived to take over as facility manager for the new owner on February 1, 2009. Fresh to the aged-care sector, she came straight from a duty nurse manager position at Palmerston North Hospital, with 10 years of clinical nurse management under her belt.
She expected the worst – bad care conditions and a resistant staff but the temporary manager had remedied much of that. “I think a lot of the really horrific stuff that the DHB had seen was all sorted by the time I got there.”
Blackwell was heartened to find that the vast majority of the pre-audit staff were still at the home because they cared so much for the people they were looking after. “They didn’t want to be anywhere else.”
One of the original nurses admitted that, under the former management regime, she felt torn between putting her registration at risk by working in such understaffed conditions and her concern at what would happen to the residents if she left. “It was a real compromise between her own professional safety and her duty of care.”
The manor now has 66 staff on its payroll including 10 nurses and 27 caregivers, but it takes more than staffing numbers to turn a facility around.
Media hype or low expectations?
When Blackwell arrived there was still a strong belief among some staff and relatives’ families that the media had overblown Ranfurly’s problems. “And it wasn’t really the house of horrors that the media made it appear to be.”
But Blackwell says many staff and families just didn’t know things could be any different.
One resident’s family told her they didn’t know what all the “hoo-ha” was about but came back about six months later to say “I didn’t realise that the smell we smelt when we came in here didn’t need to be there”, and “I didn’t realise my wife didn’t have to stay in bed all day”.
One immediately obvious “could do better” area – with a spin-off for staff morale – was improving the scribbled and crossed-out paper rostering system and sorting out complaints about the allocation of hours. (Some staff were working up to 100 hours a fortnight while others were taking on a second job because they were scratching to get 30 hours.)
Blackwell also literally put herself in her caregivers’ shoes and worked alongside them to get an insider’s view of what their job entailed.
“I’d worked pretty much for 20 years in acute care where the work was done by RNs and ENs.” In aged care, she found caregivers were the eyes and ears for the RNs, as it was caregivers who did the daily cares and observed the changes in skin, wounds, appetite and bowel movements.
But Ranfurly’s history meant caregivers needed to be encouraged to report to the RNs and the RNs had to be encouraged to take notice and not belittle or ignore the caregivers’ reports.
Fostering trust, and the smell of home baking
A big focus of her early days was building relationships and trust between staff and between the staff and herself as a clinical leader who took seriously her accountability for the quality of care residents received.
Quality food, somewhat to her surprise, also quickly became a focus, with residents and families complaining about the ready-to-eat meals that were brought in after the previous management couldn’t keep kitchen staff.
Blackwell still remembers the day she appointed her own cook – May 25, 2009 – and the quick turn-around in resident’s well-being. “A lot of that could be psychological – having those home cooking smells wafting out the kitchen.” Anecdotally, the residents appeared healthier, with families reporting residents having a “glow” and staff noticing better weight levels, skin tone and colour plus faster healing of wounds. In particular, one resident who had had to have ulcers dressed daily for about six years healed to the point where the daily dressings were no longer needed.
In the physical environment, Blackwell got the backing of owner Tom Brankin to replace the old manual beds with hospital standard electric beds. “That made a huge difference, as residents could now move their own bed without hitting the call button – and it also stopped staff wrenching their backs.” Commode chairs for the showers and a fully-equipped emergency trolley were also acquired.
Becoming a jack of all trades
Blackwell came to Ranfurly confident in her clinical leadership skills, but quickly added jack-of-all-trades to her CV.
“I’m managing everything – not just clinical management but also repairs and maintenance, appliance testing, fire safety, patient safety, cleaning… there was a lot of learning on my behalf!” As well as complying with the maze of compliance standards, the aged-care sector works under, she can’t forget employment law and budgeting skills.
Her charge nurse experience from the 90s meant she knew how to count the pennies, but before becoming a facility manager she didn’t have to worry about cashflow and ensuring there was enough money in the bank to cover pay day. “Everything you didn’t need to worry about in the public sector!”
The public sector did early in her career give her two excellent “old school” nurse leadership role models and later MidCentral DHB director of nursing
Sue Wood opened her eyes to the place of research, nursing theory and evidence-based practice.
Facing the audit test for first time
The facility faced its first audit under its new owner and management in August 2009 – a big test for a novice facility manager. Ranfurly didn’t get a complete set of tick boxes but the auditors favourably commented on Blackwell’s work in implementing staff training, quality improvement initiatives, incident management process and “excellent feedback” on the new food. Auditors did a follow-up visit in January 2010 and Blackwell’s team not only passed but also got the seal of approval of being put on a three-year audit cycle.
Blackwell is awaiting a spot audit but having now “got her hand in” and all her systems in place, she feels audit-ready for whoever may walk through the door, whether she is present or not. “And if there’s something we aren’t doing right then we need to know so we can improve it.”
What she does struggle with is that the 2005 Standards New Zealand Indicators for safe aged-care and dementia-care for consumers are still just voluntary guidelines. So while she gathers Ranfurly’s statistics on safe care indicators such as fall rates, UTIs and pressure ulcers, the data goes into a black hole. The next step needed she believes is a national benchmarking database for the standards-setting indicators and for facilities to be audited against them. “I know exactly what my fall rates are – but are they good, bad or am I about average? The requirements are not being measured against a gold standard.”
An education for all
Not only was Blackwell learning fast on the job at Ranfurly Manor but she soon had her caregiving staff signed up to the National Certificate with all caregivers required to have the certificate’s core competencies completed within six months of starting at Ranfurly.
Some of the staff were their family’s sole income earner and working split shifts and she knew that study expectations were a big ask. “But for the vast majority of them it’s a bit of peer pressure – their work colleagues are achieving it so they all want to be part of it.” She also encourages her RNs to take part in professional development, develop their portfolios and take professional pride in all they do.
Her part of the bargain was to ensure that the facility was so well run, there would never be cause for them to be under adverse media scrutiny again.
Now, media coverage is positive, with Ranfurly recently being recognised at the regional trades graduation in recognition of their support and commitment to trades training. Five of the home’s caregivers were awarded their national certificates in a graduation ceremony.
The facility has also worked on death and dying, including the Liverpool Care Pathway. “As a lot of what we do is facilitating a safe, dignified journey to death,” says Blackwell.
With the facility’s reputation rebuilt, the facility now has 48 of its 50 beds dedicated to hospital-level care because of demand from the community seeking places for their relatives.
Aged-care nurse managers need voice and recognition
Anna Blackwell did make her own headlines in the early days by resigning from the Aged Care Association. The move was spurred by her frustration at a local branch response to the DHB’s sudden closure of a Palmerston North resthome, but she is now about to eat “humble pie” and rejoin the association representing the majority of aged residential care facilities.
A major motivation for rejoining is ensuring the clinical as well as the business voice of the sector is heard, particularly when it comes to national contract negotiations with the district health boards.
“Combining the clinical and business leadership roles makes an aged-care facility nurse manager role a complex one,” says Blackwell.
And it’s a complex role that is not well supported by postgraduate training, professional guidelines or a national voice.
She is keen to join up with like-minded health professionals in the sector to help start changing that, including stepping up her involvement in professional groups such as the College of Primary Health Care Nurses. Something she hopes to have more time for after advertising for a clinical nurse leader to share the management load with her.
“I’m feeling quite re-energised and excited now,” says Blackwell of the future.
Actions to improve Ranfurly Manor
- Setting up a fair and consistent roster
- Building rapport and communication between caregivers and RNs
- Strong emphasis on staff education
- Building trust of Blackwell as a manager
- Bringing back on-site kitchen and cook
- All management decisions aimed at benefiting residents
- Consultative management style
- Setting up protocols to monitor clinical indicators, e.g. UTIs, pressure sores, falls, etc
- Upgrading equipment.