JUDE BARBACK discovers the ingredients of the truly person-centred approach taken by Elizabeth Knox Home and Hospital.
It is Election Day. There is a buzz at Elizabeth Knox Home and Hospital as staff and residents watch voters come and go from the polling station across the road.
I’d love to quiz the residents on which way they will vote, or have voted – especially as Knox is located in the strategic Epsom electorate – but I refrain; although from my experience, older people are usually very forthcoming on their political views.
I get the sense from Knox chief executive Jill Woodward that the residents here are not shy of an opinion, either. Woodward clearly thrives on this.
“The resident is at the heart of everything we do here,” she says, and she outlines the Knox organisational structure for me, which is like a circle with the resident and family at the centre, the care partners on the next layer, the nurses, physiotherapists, occupational therapists, and other support staff on the next, the clinical mentors on the next, and the board and management on the outermost layer.
Woodward likens it to a district nursing model, calling on expertise when needed, but more focused on the day-to-day relationships between the residents and care partners.
It is not the first time I’ve heard facilities talk about putting the resident in the centre. Ever since my involvement began with INsite and the aged care sector, I’ve heard the term ‘person-centred care’ used frequently. It’s a nice concept, the idea that care delivery is tailored to the specific needs of an individual. However, the more facilities I visit, the more I realise that person-centred care is much easier to talk about than it is to actually deliver.
This year’s New Zealand Aged Care Association’s conference is all about the delivery of person-centred care. It is a timely topic. The funding for aged care is failing to keep step with the increasing ageing population and older people’s rising expectations of residential care. The conference will look at how providers can create an environment that supports choice and flexibility in spite of the regulatory and financial constraints to meet the changing needs and wants of residents.
It feels like they have achieved such an environment at Knox. It is as close to person-centred as I’ve seen in a rest home.
Creating this sort of environment is no easy task. Many factors come into play – a clear organisational structure and vision for a facility is certainly a good place to start – but it needs to translate into its day-to-day operation. Good management certainly plays a big part, but much of this comes down to the staff and the physical environment.
“The best care could be delivered in a tent,” says Woodward of the latter, although she acknowledges the role that the design and layout of Knox plays in achieving an environment that is person-centred.
Although construction is still underway, the new “household” set-up at Knox is exemplary. Fifteen residents share what is essentially an open-plan kitchen-dining-living area.
Woodward would love to take the household concept a step further and have the bedrooms feeding directly into the living spaces, to reflect a layout that is homelier still. Fire regulations currently forbid this, but Woodward says she is prepared to take the council on over this matter.
As things stand, meals are served in the household dining tables, where the residents eat together. Woodward expects the large communal dining room will eventually not be used for meal times, as the household set-up is proving to be so effective.
But what catches my eye are the full working kitchens with plenty of bench space and modern appliances. The fridges are filled with food, all labelled with the residents’ names. It is reminiscent of a student flat.
“Imagine being restricted to only the food that is cooked for you,” Woodward says disdainfully. While all meals are provided, sometimes a resident may fancy cooking something for themselves.
On weekends, a breakfast buffet lasts all morning, and residents can eat at their leisure. Care partners often eat with the residents.
Certainly, the household set-up seems to lend itself to closer staff-resident relationships.
In one household I visit, there are some residents watching TV, a couple having a cup of tea with the household’s home maker, and a care partner sitting with them at the dining table writing her notes.
The care partner’s presence in the room does more then she is possibly aware. She chats away while she’s writing, in much the same way a student would complete her homework in the kitchen. Instead of being tucked away writing notes in the nurses’ station, she is contributing to the room’s warm, relaxed atmosphere.
In the same way, the home maker – “we don’t call them cleaners,” Woodward informs me – is clearly a vital part of the household, ensuring it is a nice place to be.
Woodward sees the home maker role maturing into eventually assisting residents to do their own laundry if they wish.
It seems the model of anchoring care partners and home makers to households has not only enabled the relationships between staff and residents to really blossom, but has empowered the care partners to be more proactive, to use their initiative more, and feel more confident about making decisions.
That is not to say the model is without its challenges. Woodward says anchoring care partner teams to households has been “jolly difficult”, mainly due to unforeseen things like staff illness or parental leave.
Staffing can be a complex issue, particularly in this sector. The aged care workforce, in general terms, remains burdened by low wages, a lack of mandatory training, and in many cases, high turnover. Consequently, many facilities find their staff stretched, with nurses and caregivers overseeing large numbers of residents. A facility might have every intention of personalised care, yet finds itself operating most days in survival mode. The goal changes from finding out what a resident needs or wants or feels that morning, to simply getting them up and dressed in time for breakfast.
Woodward says it is difficult to completely avoid operating in an institutionalised way.
“The tyranny of the clock exists all the time,” she says. The point of difference at Elizabeth Knox, she feels, is that there is a pressure to help get residents up as early as the residents want to be up, such is the residents’ desire to get stuck into each day.
Woodward tells me it is “positively frenetic” during the week, but even on the Saturday I am there, the place is humming. There are people coming and going to vote, families visiting, a movie in progress, (a resident-run activity every Saturday), volunteers making drinks and chatting with residents.
The volunteers also play an important part in the Knox environment. There are a staggering 600 volunteers in the programme. The youngest is 12 and the eldest in their 80s.
Woodward shares with me a beautiful card from a volunteer given to a resident with advanced dementia. It describes how much her friendship with the older lady has come to mean to her and helped her to come to grips with living in a new place.
Knox has a strong relationship with Languages International, and many of the volunteers come from there. Like the author of the card, many are a long way from home, and Knox offers a respite from their loneliness and a chance to improve their English in a safe environment.
Girls from nearby St Cuthbert’s College are frequent after-school volunteers, too, often making biscuits in the kitchens with the residents.
It is very difficult to imagine a resident being bored or lonely here – especially when there is the opportunity to alleviate another person’s loneliness. The principles of the Eden Alternative hinge on combating loneliness, helplessness, and boredom, and I am not surprised to learn that Knox is the first care provider in New Zealand to achieve full Eden Alternative Registration.
Woodward says they have trained over 135 team members as Eden Associates, and for the past two years have held weekly Eden sessions for residents, family, and staff, which have helped the whole Knox community engage in decision-making, not only in terms of care delivery, but in the strategic decisions related to the ongoing site redevelopment.
Woodward gives the example of how one resident suggested the kitchen bench tops and appliances were lower to accommodate those in wheelchairs, which has been a very practical modification to the plans.
I’ve often heard caregivers, nurses, and managers say they aim to treat their residents how they, the carer, would like to be treated – which is certainly admirable – but really, the emphasis should be on treating residents how they, the residents, like to be treated. No one has the same needs and wants.
As I leave Knox, I think about how I would like my life as a resident to be. I like to cook. I like to read and write. I like to exercise. I like to be social sometimes, but reclusive at others. While my capacity to cook, write, and exercise may wane, I can’t envisage a day when I won’t want to do any of these things. So when the time comes for me to go into a care facility, if it is to be truly person-centred, it is going to need to accommodate these things.
I see Knox residents returning from casting their vote. They look happy. Indeed, there is something satisfying about choosing your preferred party and candidate from a list of options. Choice and flexibility are fundamental to their lives at Knox, thanks to a person-centred approach that hasn’t been achieved by a single change or variable but a raft of factors stemming from a common vision.