Unannounced Standards Review at RHC

28 March 2022

Unannounced Standards Review at RHC

On March 22nd, a team of five surveyors from Manitoba Health and WRHA arrived at 9am to conduct an unannounced review of the personal care home (PCH) units at RHC. Unannounced reviews are being conducted at all Manitoba personal care homes throughout 2022. Our last formal PCH standards review at RHC occurred in 2020.

An unannounced review includes the following:

  • A detailed tour of the personal care home units and support areas (e.g. laundry, food services, etc.)
  • Assessment of room and water temperatures in resident rooms and tub rooms
  • Observations of medication passes, meal service, shift reports and recreation programs
  • Interviews with residents
  • Surveys of staff and families
  • A review of:
    • RHC audits on infection prevention and control, water temperature monitoring, restraint use and care plan documentation
    • The minutes from our Medication Quality and Safety Committee for the past two years
    • Current vacancies for staff in the personal care home program at RHC
    • Any complaints received in the past 6 months and information on how RHC responded to these complaints
    • Eight randomly selected resident health care records to review documentation practices

Kathleen and I had a short debrief with the team of reviewers.  These are the highlights:

  • They thanked us for a great day, and noted our wonderful hospitality and very friendly staff
  • There were a few minor things they noticed regarding maintenance and documentation, and at the same time recognized how tired everyone must be post-outbreaks and that the attention to detail and return to/normalizing post-COVID will address these few things
  • They highlighted our “really good system” that is in place for monitoring our water temperature
  • They were impressed with the cleanliness, “pristine condition” of the facility
  • They made note of our staff and their responsiveness; a resident noted that “the staff make me feel very safe”
  • They highlighted the level of familiarity that staff have with the residents, which is evident in the care plans, and our approach, re-approach, and de-escalating with residents, and that our charting aligns with the care plan
  • They suggested reminders regarding med passes and following processes
  • They suggested documenting “not used” daily if the tub is not used, to be assured that the tub is clean prior to use
  • They asked for our quarterly care plan form to share with other facilities
  • There was quite a bit of discussion about meals and the RDF/more choice/less institutional and daily posting of the meal choices.  The accreditation surveyor for the LTC standard mentioned the same – this is an opportunity for us to advocate for changes in this regard

They met with a number of residents, received feedback from staff and residents and families from the survey that was shared, witnessed mealtimes, programs, med passes, shift report, interactions including “the staff person and the residents speculating on what lunch might be and then turning it into a reminiscence opportunity”.  Overall, they were very positive about all that they saw and heard! 

We will receive a formal report in 4-8 weeks’ time. The findings will be shared with the PCH staff and with Resident Council.

 In the meantime, congratulations!  There was clearly much evidence of our staff living our mission, vision and values. 

Thank you to all of the staff who were actively involved in the review and all those who supported in our preparations. Thank you to our residents who participated in interviews and to our staff and families who completed surveys.

And most especially, thank you to our RCMs and to each of your teams for your commitment to person centred care and improved quality of life and experience for those we support, evidenced today and every day!