AGED-CARE & RETIREMENT
August - September 2013 | Vol. 7 Issue 6 | $10.95
WE’VE GOT YOUR INDUSTRY COVERED I www.insitemagazine.co.nz
NEWS
MALVINA MAJOR VILLAGE INCIDENT SPARKS CONCERN REGULARS
ON THE SOAP-BOX:
CONSUMER MAG DEFENDS ITS STANCE
FOCUS ON NUTRITION
THE IMPORTANCE OF CELEBRATING MEAL TIMES GETTING THE DINING ENVIRONMENT RIGHT FOR RESIDENTS
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A Tyco Business
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INsite Magazine Vol.7 Issue 6
Editor: Jude Barback @INsite_NZ T: 07 575 8493 E: editor@insitemagazine.co.nz Advertising: Belle Hanrahan T: 04 915 9783 E: belle@apn-ed.co.nz Production: Barbara la Grange Aaron Morey Editor-in-chief: Shane Cummings @ShaneJCummings General manager/Publisher: Bronwen Wilkins Subscriptions: T: 04 471 1600 F: 04 471 1080 E: subscriptions@apn-ed.co.nz Publisher’s note: © Copyright 2013. No part of this publication can be used or reproduced in any format without express permission in writing from APN Educational Media (NZ) Ltd.
Editorial & business address Level 1, Saatchi & Saatchi Building, 101-103 Courtenay Place, PO Box 200, Wellington 6140, New Zealand T: (04) 471 1600 F: (04) 471 1080 ISSN 2324-4755 INsite is distributed to key decision makers in the aged care sector and its distribution is audited by New Zealand Audit Bureau of Circulation (ABC).
In this issue... Super kitchens - but at what cost? Hubs for hospital food under scrutiny.
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Catering qualifications: training kitchen staff
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Grub’s up: the importance of getting dining environment right for residents
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Nutrition vs food: striking the right balance
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Comfort food: Metlifecare and Selwyn share how they make meal times fun for residents
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Ageing and eating disorders: Sarah Ley discusses a widely misunderstood problem.
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Keeping the wheels a-turning. A closer look at Meals on Wheels and the alternatives.
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Catering for residents with food allergies and intolerances
ED LETTER
GRUB’S UP
I like to think of this as our “foodie issue”, and within its pages, we look at food and nutrition from every angle. Sarah Ley discusses the grim realities behind eating disorders in older people. Jessica Bowden answers questions about dealing with food allergies in an aged are facility. We also look at nutrition in the home and the importance of Meals on Wheels and modern alternatives. In researching the origins of Meals on Wheels in New Zealand, the Red Cross Society kindly delved into the archives and forwarded me some publications from the 1950s and 60s when their Meals on Wheels service, originally a soup delivery service, was in its infancy. It made for good reading; one excerpt describes a volunteer delivering a meal and being asked by the recipient to give her a haircut. With scissors thrust in her hand, the bemused volunteer snipsnipped the older lady’s hair before getting on with the rest of her deliveries. Although this particular story made me smile, it made it clear to me that Meals on Wheels, even in its early days, was not just about delivering food but about human contact, about providing an antidote to loneliness. It pains me that sixty years on, social isolation is still such an issue for older people, particularly those living independently. It just goes to show what a vital role food has to play in the lives of older people. Not just the food itself, which inarguably is very important, but all that goes with it – the daily banter with the Meals on Wheels volunteers, the little touches to make a rest home dining environment pleasant, the effort taken to make special meals memorable. In this issue, we also stir things up a little with Peter Bruce sharing his side of the lengthy double-dipping saga and David Naulls defending his controversial editorial in Consumer magazine about the quality of New Zealand rest homes. We also meet Sandy Quigley, manager of Ocean Shores Village and recent winner of the INsite/RVA Manager of the Year award. By happy coincidence, Ocean Shores is a mere five minutes from my home, so I was able to spend a delightful morning chatting with Sandy and residents in the wake of her success. The RVA conference in the Gold Coast was a great success, and the upcoming NZACA conference looks set to follow suit. Editor, Jude Barback editor@insitemagazine.co.nz Follow us on Twitter: @INsite_NZ www.insitemagazine.co.nz
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SUPER KITCHENS but at what cost?
6 Regulars GRUB’S UP
The importance of getting dining environment
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NEWS Snippets and updates from the industry
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ON THE SOAP-BOX... David Naulls
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SPOTLIGHT ON... muscle degeneration
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CONFERENCE REPORT... RVA 2013
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UP CLOSE AND PERSONAL WITH... Sandy Quigley LAST WORD... Peter Bruce
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CONFERENCE REPORT... RVA 2013
Connect with INsite Magazine on Twitter Follow INsite for breaking news, the latest innovations, and conversations with editor Jude Barback on the professional issues close to your heart. Find us on Twitter@INsite_NZ
www.insitemagazine.co.nz | August/September 2013 1
News MALVINA MAJOR VILLAGE INCIDENT HIGHLIGHTS WIDESPREAD CONCERNS Ryman Healthcare’s Malvina Major Retirement Village in Wellington has come under fire for its poor care of a 69-year-old resident with Alzheimer’s disease. On three occasions since early June, the resident’s daughter, Susan Christian, has found her mother in an appalling state and covered in her own faeces. The news came at the same time as Ryman reported improved first quarter trading and shares at a near record high as well as the purchase of four new sites in New Zealand, prompting critics to question whether the operator’s focus was on profits or providing quality care. Ryman’s general manager Simon Challies expressed concern over the failure of senior staff to respond to
Ms Christian’s complaint but did not believe there was a wider problem with substandard care. According to the Dominion Post, Mr Challies has apologised to the families of the residents at the village, saying it had dropped the ball and new staff and strategies would ensure it did not do so again. A regional manager was to be in charge of the village until a replacement was appointed. However, David Wait, the New Zealand Nurses Organisation’s industrial adviser for the aged care sector, said nurses were being unfairly blamed and the problems facing residential care were widespread. “This is not an isolated incident,” he said. “It is not just a Ryman issue; it is one of many. Residential care is in crisis.”
Indeed, since the Malvina Major incident, others have come forward with similar complaints. Massey University researcher Dr Chrissy Severinsen said there is a need to make aged care providers more accountable. “Inadequate staff numbers, increasing workloads and workplace stress, hurried or delayed care are often explained by agencies or the industry as poor practice and management at individual rest homes, but it is symptomatic of problems across many rest homes,” she said. The NZNO is calling for the Government to introduce enforceable minimum staffing level ratios. Meanwhile low and unfair pay levels for residential aged care workers continue to be a major concern for the sector.
INITIATIVE TO PROVIDE QUALITY CARE FOR LESBIAN, GAY AND BISEXUAL RESIDENTS A new resource kit has been developed to help educate staff in aged care facilities about homophobia. The resource kit, which was launched on Monday 5th August in Auckland, was created by the School of Nursing at The University of Auckland in collaboration with a working group drawn from the aged care sector and the Auckland LGB community. It features a video, workbooks for facilitators and participants, and guidelines on caring for lesbian, gay and bisexual (LGB) residents.
The video which contains a clear and brief story of ‘Chris’ an elderly gay man who is admitted to residential care. The twist at the end evokes reflection on the challenges that can face gay residents like ‘Chris’. The initiative stems from earlier research led by Dr Gary Bellamy at the School of Nursing that explored the attitudes, perceptions and practices of care staff in relation to older LGB residents. INsite’s earlier article, Attitudes towards the gay and grey (http://bit.ly/19xVwXZ ) considers this research and how one of the main challenges for staff was dealing with the homophobic attitudes of other residents. “Our initial research showed that there was some awareness from staff regarding stigma associated with LGB residents and that they may not be aware of their own prejudices regarding caring for this population. Participants stated that at times there was stigma placed on LGB residents by other residents in the facility. The staff expressed a desire
to have more resources and education on the best way to care for LGB residents,” says Dr Michal Boyd, the project’s leader and a senior research fellow in the School of Nursing. Following its launch, the new resource kit, which was funded by the Rule Foundation, will be available in digital form from Gay Line (http://www.gayline.gen.nz) and interested groups will be free to download and use them. Distribution and promotion of the kit to aged care providers is still under discussion. “There are many logistical issues in the distribution of the resource that we will be developing in the future. We plan on working with aged care providers, DHBs and others to develop a promotion and distribution plan. We will not be seeking payment for the resources, but will be looking for funding for the promotion and distribution of the resource,” says Dr Boyd. She says no further research is planned at this point in LGB issues in aged care, but this could change in the future.
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August/September 2013 | www.insitemagazine.co.nz
Retirement village operator Summerset recently listed on Australia’s share market, although the company says it is not about to expand its operations overseas. Chief executive Norah Barlow says Summerset has no plans to build in Australia. “We’re happy that our model works well here in New Zealand and the demographics show that with the ageing population doubling in the next 20 years, we have plenty of room for growth here. However, we may look at it further down the line because you can never say never.” Barlow says the company is not looking to issue new shares to fund growth, as its pipeline of new work is already funded. Australian investors already hold 25 per cent of Summerset’s capital. This includes the remaining 22 per cent shareholding by private equity firm Quadrant and a small number of Australian institutional investors. Summerset expects to increase the number of Australian investors with an ASX listing. The company says the aim of the dual listing is to increase liquidity of the company and enable investors who are mandated to only invest on the ASX to invest in Summerset. Summerset joins an increasing number of New Zealand companies to list on the Australian share market. Australia’s greater capacity for investment, combined with the decreased availability of investor funds in New Zealand in the wake of the Government’s decision to sell equity in several power companies is thought to be driving Kiwi companies to list on the ASX.
FREE DEMENTIA EDUCATION FOR ALL The University of Tasmania has launched the world’s first Massive Open Online Course (MOOC) on dementia. The course, Understanding Dementia has been developed by the Wicking Dementia Research and Education Centre, based at the University’s Faculty of Health Science. Launched in mid-July, the course has already attracted more than 3000 registrants from more than 30 countries. The interest in the course is indicative of the increase in dementia cases throughout the world and the need for dementia education. Deputy Vice-Chancellor Professor David Sadler says the MOOC is likely to have far-reaching appeal. “The MOOC is designed to appeal to and connect a broad range of students, including health professionals, community and residential facility support staff, health policymakers, social scientists, people in the early stages of the condition, their family members and friends, and all those with a general interest in the condition.” The course takes 11 weeks and is divided into three themes: the brain, the diseases, and the person. It includes basic brain anatomy, pathology, dementia research, risk factors, symptoms, diagnosis, medical management, living with dementia, progression and staging, palliation, behaviours, and therapeutic approaches. The material, which is presented online in the form of video clips, activities, scenarios, and so on, is delivered by experts in the field of dementia including neuroscientists, health scientists, clinicians, dementia care professionals, personal carers, and people with dementia.
LANDMARK CASE FOR AGED CARE WORKERS A case brought by the Service and Food Workers’ Union and one of its members, aged care worker Kristine Bartlett, against Terranova Homes and Care Ltd claims that Bartlett’s hourly wage breaches the Equal Pay Act. Gender inequality of pay, a central aspect of this case, is not thought to be a major concern within the sector, and it is hoped the case will draw attention to the more fundamental issue of the disparity in pay between caregivers working in residential care and those in public hospitals. The case has also highlighted the low rates of pay for aged care workers in general. Bartlett, for example, is paid close to the minimum wage, despite being a long-serving caregiver. In addition to the two parties involved in the hearing, a number of parties, including the Council of Trade Unions and the NZACA, were allowed to intervene on the case. New Zealand Nurses Organisation (NZNO) industrial adviser for the aged care sector, David Wait, says that as NZNO sits within the Council of Trade Unions as an ‘intervener’ in the case, the organisation is a primary supporter and provider of evidence. “We are hopeful that our evidence and the work of Kristine and many others will pay off, and the court decides in our favour. When that happens, the work of thousands of other low paid women workers in New Zealand Aotearoa will be valued properly.” The court hearing concluded at the end of June, and the parties are awaiting a finding.
NEWS
SUMMERSET LISTS ON THE ASX
SMOKING BAN
Mid Central District Health Board came under attack from the New Zealand Aged Care Association for pushing onto aged care providers a contract variation that stops residents smoking inside and outside an aged care facility. The contract specifies that all internal areas must be smokefree from December this year and all external areas smoke-free from July 2014. The DHB had been progressively including smoke-free clauses on a voluntary basis, and the next step was to roll the clauses into all future contracts. In a memorandum issued by the DHB on 11 July, it claimed 34 out of 36 providers who had received contracts with the new policy have returned their variations signed and no concerns have been voiced by aged care providers with the DHB. The memorandum also states that they will work with providers to determine “the most appropriate way forward” where there are permanent and private paying residents in facilities who believe they may be adversely affected by the policy. However, NZACA chief executive Martin Taylor says the approach is wrong on a number of levels. “A blanket approach to smoking ignores the rights of the elderly in a setting that is meant to be as homelike as possible.” Taylor suggests the clauses might be in breach of the Smoke Free Environments Act, which allowed for people in residential aged care facilities to smoke. The DHB claims its actions are in line with the Government’s drive for a smoke-free New Zealand by 2025.
www.insitemagazine.co.nz | August/September 2013 3
FOCUS
Super kitchens – BUT AT WHAT COST? The Government’s bid to centralise district health board food services have raised concerns over food quality and job losses.
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he Government’s plans to streamline district health board food services will apparently save more than $10 million a year, money that Health Minister Tony Ryall said would be “reinvested back into the New Zealand public health service”. The proposal to essentially replace some hospital kitchens with centralised hubs that would produce frozen meals to be distributed nationwide was put forward to the Ministry by Health Benefits Limited earlier this year. Health Benefits Limited was established by the Ministry of Health in 2010 to work on initiatives to save money. Catering giant Compass has been flagged as the preferred provider for the new service. Compass already provides about a third of New Zealand’s DHBs with hospital meals, Spotless Services another third, and the rest of the hospitals still create their own meals and deliver them to the wards onsite. Why Compass? Who else was in the running? Spotless, the other obvious contender, declined to comment. Mark Reynolds of Health Benefits said he wasn’t prepared to state which parties might have put forward proposals, other than to confirm that Compass is the preferred respondent. Compass also declined to
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comment until the commercial aspects of the deal were finalised. Indeed, it is still early days, although plans have been growing since Health Benefits held initial workshops with DHBs in May 2011. Since that time, the company has been working with DHBs, clinicians, and advisory groups, including dieticians and infection control experts, to establish the best path to take. “No decisions have been made at this point. It is long-term work that requires careful consideration,” says Reynolds. The next steps involve building a business case to provide an analysis of the costs, benefits, and risks of the options. Reynolds says this will include looking in detail at a range of factors that would need to be managed including local impact assessment, local delivery needs, disaster recovery planning, and so on. It will be several months before a business case is finalised. Ready or not, speculation is rife that a number of hospital kitchens will be downsized and jobs lost. Minister Ryall concedes the centralised kitchen initiative would likely result in a number of other hospital kitchens being downsized. Labour’s Health spokesperson Annette King
said around 1300 jobs could be at risk if the plan goes ahead and Labour’s spokesperson on Labour issues, Darien Fenton, said “such a mass layoff of food service workers would hit hard”. However, Health Benefits have quashed this notion. “The options that we are considering include an approach where a minority of food would be prepared centrally. The majority of food would still be prepared fresh locally. Therefore, reports that 50 hospital kitchens will close and hundreds of jobs will be lost are incorrect,” says Reynolds. Ryall confirmed the interests of the workers who could face job losses were being considered. He said many were currently employed by private contractors. Job losses are certainly to be taken seriously, but there appears to be more focus on this aspect, rather than on the potential gains from the proposal. “For food services, the early indications are that nationally savings of at least $10 million a year could be delivered. All savings from these programmes, should they go ahead, will be available for DHBs to invest in health service delivery. We do not have a view on where it should, or could, be spent.
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Catering qualifications: TRAINING KITCHEN STAFF Where should villages or rest homes look to provide the right sort of training for their catering staff?
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We simply want to help deliver benefits for the health sector,” says Reynolds. It isn’t the first time food services for New Zealand public hospitals have been contracted out to major providers. In the 1990s, outsourcing to a large multinational led to several major problems. The company in question over-extended their business and the collapse left workers and suppliers reeling. Problems around food quality also arose, with food being cooked and chilled and transported long distances in refrigerated trucks. Concerns over food quality have also arisen from the latest proposition. The Service and Food Workers Union said its concern was to “make sure that in the quest for savings that the quality of food delivered to very sick people in public hospitals is not diminished”. However, Health Benefits says that under the new scheme, food quality would be maintained and improved. Ryall agreed that it was imperative they were satisfied with the quality of food before proceeding. So, although any concrete decisions remain in the future, it appears change is lurking close by for public health sector food services.
hat is on the menu plays a very important part for most of us, and it is a focal point of life in a retirement village or rest home. Serving a nutritious, balanced, and interesting daily diet that tempts sometimes jaded or poor appetites is essential and what most catering operators strive to provide. Having skilled staff in the kitchen is vital for developing and delivering a good menu. However, finding and keeping people with the right skills is not always easy. Offering training programmes for new catering staff, or for those who are working in these roles currently, to upskill them will improve their job satisfaction and can impact positively on staff retention rates. Within the aged care qualifications promoted by Careerforce, there are unit standards on eating and drinking that look at supporting a person to eat and drink in an aged care, health, or disability context. Infection control and safe working environments are also covered. However, nutrition and food safety do not fall within Careerforce’s remit. In larger residential facilities, it is not standard practice for care workers and healthcare assistants to prepare food; this is typically the role of kitchen staff. Where should providers look to ensure their kitchen staff members are adequately trained? Programmes to help upskill staff in the food services sector are offered by ServiceIQ, the industry training organisation (ITO) for New Zealand hospitality. Funded by Government and by industry, ServiceIQ – short for service industry qualifications – is
responsible for setting the national skill standards for the hospitality industry and developing arrangements for the delivery of industry training and assessment of trainees, both on and off the job. “The course is the first of its kind to be launched in the aged care sector, and we are pleased with the positive response from the residential care organisations to the programme so far”, says Dean Minchington, Chief Executive of ServiceIQ. Bupa Care Services, Metlifecare, and Radius Residential Care are among those aged care providers that have been working closely with ServiceIQ to develop their staff through training programmes that help them learn new skills or build on the ones they have. The programmes target all levels and recognise that people have different learning abilities. Steven Heesen, manager of property and procurement for Radius Residential Care, comments that his company recognises that food quality, service, and presentation are becoming more and more important with the growth and demands in the aged care industry. “The Food Services Residential course addresses the specific needs of rest homes and we feel it is important to up-skill our staff to be able to deliver more choice and wellpresented meals to our residents”. While there are various factors that contribute to preparing and serving a nutritious, balanced, and interesting daily diet, having skilled staff in the kitchen definitely plays a key part in delivering a good menu each and every day.
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GRUB’S UP: the importance of getting the dining environment right for residents Meal times can be tricky; time constraints, food quality and temperature, and individual resident needs all need to be considered, but JUDE BARBACK discusses why it is important the dining experience itself is not neglected at the expense of getting these aspects right.
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y children, aged three and four, speak with great enthusiasm about the Kereru Café at their preschool. Intrigued, I decided to pop in during afternoon tea time one day to see what had them so captivated. I arrived to find two tables set up on the deck, each with a bright tablecloth and a little vase of flowers in the centre. A dozen three- and four-year-olds sat at the tables chatting happily as the teachers distributed the food – fruit, carrot sticks, and hummus and pikelets the children had made earlier. One of the teachers informs me that if the “café” moves inside, they sometimes light a candle in the middle of the tables instead of flowers. Flowers? Candles? Tablecloths? You would think
the effort, the attention to detail, would be lost on noisy, hungry pre-schoolers. Quite the opposite. The feeling of going to a café, of sitting with friends to enjoy their meal, had them wolfing down all manner of healthy snacks. I watched in amazement as my veg-averse daughter Emily scoffed her carrot sticks, giggling away with her friend Ruby beside her. It just goes to show how important a dining environment is, even from a young age. It is the same reason we make an effort to set the table nicely; why we bother with tablecloths and napkins, matching cutlery, crockery and glassware; why we sometimes put on background music; why we enjoy eating with friends and family. It stands to reason that all this doesn’t change as we age.
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BENEFITS OF ENHANCED DINING EXPERIENCES
usage as well as in laxative and appetite stimulant medication usage. Malnutrition is a complex condition There is a fair amount of and has a strong psycho-social aspect. research to show that the dining Experts believe the dining experience, environment can have an impact in addition to the food itself, has an on a resident’s health and important role to play in keeping wellbeing. residents healthy. A Dutch study in 2006 Tracey Little of Otago University led by K Nijs analysed the conducted a study on the cause and effects of an enhanced dining effect of malnutrition of residents in environment in rest homes. aged care. Her observational study, It found that in homes where based on a cross-sectional survey there was a particular focus on of 50 rest homes in nine centres in table dressings, family-style New Zealand, acknowledged the meals and staff presence at the dining environment and level of staff table, there was a significantly support as contributing factors into increased calorific intake for residents’ nutrition. She found that residents over a six-month rest homes that allowed residents to period. act independently, social interaction Other studies (Bump, 2010; at meal times and a menu providing Bowman, 2010) have indicated familiar foods had a lower rate of improved clinical outcomes, malnutrition among their residents. such as a reduction in weight On the other hand inappropriate loss and a decline in supplement meal temperatures, or portion sizes, a lack of alternatives and little dietitian input, were all said to have a negative effect on residents’ nutrition. found
Some facilities, both here and abroad, have that a good way of incorporating residents into the food selection process is to invite them to contribute a recipe, an old family favourite perhaps.
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DIFFICULTIES WITH DE-INSTITUTIONALISING
For most aged care providers, this is nothing new. You don’t really need to read academic journals to understand the correlation between a homely dining room – with wholesome, familiar food, and supportive staff – and happy, healthy residents. However, it isn’t always that straightforward. The many demands on a provider to ensure meal times run smoothly often mean a task-oriented approach is taken, as opposed to a resident-centred approach. There are time constraints, food quality and temperature to maintain, sometimes multiple seatings to factor in. There are the many and varying needs of residents. Some will need assistance. Some will need food of a consistency that is easy to swallow. Some will have different dietary requirements. Some will need
FOCUS medication. Some will need their food intake monitored. In an effort to meet all that is required at a meal time, it is not surprising that the dining environment is overlooked. After all, surely it is more important that a resident is given the right food and assistance rather than a table centrepiece to look at? But residents can spend up to six hours a day engaged in dining or food-related activities. Having the right ambience is crucial.
HOW TO ENHANCE THE DINING EXPERIENCE
A study led by Otago University investigated the dining environment in a convenience sample of rest homes throughout New Zealand and provided some interesting insights into which factors enhanced the opportunity for a positive dining experience and which did not. A major factor was the attitudes of the staff. Residents appreciated staff members who took care to ensure they had meals they enjoyed, chatted with them, said grace, and read out the menu before the meal was served. It was also found that the ambience of the dining room was important; residents liked their dining environment to be newly refurbished, relaxed, warm, and comfortable. Residents also enjoyed food reminiscent of what they ate when they were younger and appreciated variety and having dining companions. Some facilities, both here and abroad, have found that a good way of incorporating residents into the food selection process is to invite them to contribute a recipe, an old family favourite perhaps. ‘Flo’s Spiced Apple Cake’ or ‘Betty’s Chicken Casserole’ may help give residents a sense of familiarity and homeliness when it comes to food served at their facility. It also allows new residents the opportunity to feel part of ‘the family’ right away. Open dining seating is also good practice, according to many facilities. This allows residents to either sit in the same place each time or mingle with others. Spaces can be reserved for those who need assistance. Those who
‘must’ sit in the same place each time should be encouraged to get to the dining room in good time. Experts agree a homely dining experience is better – lots of smaller tables should be favoured over a few long tables that seat many. Serving residents at the table is preferable to the use of trays. The Otago study also gave some interesting insights into how staff members’ attitudes impacted on residents’ dining experience. The study suggests there needs to be an adequate number of staff to assist with meal times, as inadequate staffing at meal times is a significant contributor to malnutrition and dehydration in aged residential care. It suggests that staff members need to be aware of the importance of offering assistance and positive encouragement to residents. The study found that many residents said they didn’t like to “cause a fuss” if something wasn’t right with their meal. The same mentality was applied to asking for a second helping – although this option was available to them, most did not like to ask. The researchers noticed that this natural reticence in asking for help was often not picked up by the staff, who failed to anticipate or notice the needs of the residents. Observations of this nature included residents who didn’t have the right utensils or those who missed out due to an interruption, such as a hairdresser appointment. Desserts served before the main course was finished meant residents rushed or did not finish their meal. Maintaining a resident’s dignity can sometimes be overlooked in a busy meal sitting. The use of ‘dining scarves’ instead of bibs has been suggested as more subtle and dignified approach for those in need. Medications should ideally be dispensed before the meal, so that medical care is separated from meal times. Food is an important contributor to a resident’s wellbeing – that is a given – but how it is served can make all the difference to both the resident and the overall atmosphere of the facility.
NUTRITION vs FOOD
MARTIN TAYLOR says it is tricky finding the balance between what residents want to eat and what dietitians say they should be eating.
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n the aged care sector, there is a lot said about nutrition, which is defined as the process of providing or obtaining the food necessary for health. The key phrase here is ‘providing’, and as all operators know, food is one of the most, if not the most, important part of meeting consumers’ expectations. However, in aged care, as all health services, there is also the element of choice, which needs to be acknowledged and respected. This can create a situation where the provision of food for nutrition is not acceptable by the resident. For example, a resident may know that they need to have more of certain foods but they refuse because they don’t like them or simply don’t feel like eating them. I often hear of residents who just request a piece of toast and a cup of tea for dinner because they just don’t feel like anything else. Clearly this choice of ‘food’ is not nutritionally sound, but that is irrelevant as the resident has a right to make their choice and the provider has an obligation to facilitate that choice. The basis for this statement is that the resident is compos mentis and the facility has informed them about their nutritional requirements, so they are making an informed choice. Obviously, there has to be some pragmatism around the choice principle – for example, if a resident says, “I want crayfish and whitebait”, this would be outside of what the government subsidy provides. The nutrition vs food tension is often most vividly underlined in some dietitian reports members have passed onto me. One dietitian recommended that a facility took spaghetti on toast off the menu as it doubled up on the carbohydrates. Another recommended providing less mashed potato and replacing it with rice and couscous, and I have also seen recommendations to remove butter from tables as residents were putting too much on their potatoes. While I can absolutely agree with the nutritional logic of these recommendations, they are completely impractical. If someone has managed to get to the age of 84 (average age of entry into aged care), then what does it matter if they choose to have spaghetti on toast or lather their potatoes with butter (the more the better!). Older Kiwis, from what I have seen, don’t really like rice (unless it is in a pudding) and have no knowledge or experience of couscous, so following these recommendations would likely cause a riot. From my perspective, if you are elderly, food needs to not only provide nutrition but also be familiar and comforting. To achieve this, food needs to support resident choice and expectations, which may not always achieve the best nutritional outcomes. As with anything undertaken in the aged residential care sector, everything must be done to maximise the quality of a resident’s life at this very difficult stage of life and food is a very big part of achieving that goal. www.insitemagazine.co.nz | August/September 2013 7
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COMFORT FOOD:
the friendships formed at meal times Meals occur with such regularity that it is easy to forget what an important opportunity they are for allowing residents to socialise. Here, two providers share how their innovative approaches to meal times have made all the difference for their residents.
Left: Staff and resident chat at breakfast buffet; Right: Jenny McIsaac and resident.
A BREAKFAST TALK-FEST The breakfast buffet at Selwyn Village has helped turn the first meal of the day into a relaxed, sociable experience for residents.
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he busy buffet breakfast service at Caswell House, the rest home at Selwyn Village in Point Chevalier, Auckland provides a real talking shop for residents and offers an ideal forum for people to socialise and to get to know each other across the breakfast table. A departure from the traditional ‘room service’ delivery (where breakfast was delivered on a tray to each resident’s room at 7.30am every morning), this new approach enables residents to serve themselves in the dining room any time from 7.30am until 9.00am. They can choose what – and how much – they wish to eat and can enjoy a chat over breakfast, making for an altogether more sociable experience. Jenny McIsaac, Caswell manager, says, “It’s a very informal, relaxed affair. You can come for breakfast in your own time – if you want to sleep in and then come in your dressing gown, it’s entirely up to you! We have background music playing, and you can sit for as long as you wish over numerous cups of hot tea and warm toast, chatting to other residents and the staff. From time-to-time, staff will also sit and have a slice of toast or cup of tea with the residents, and the residents really enjoy the banter. We always share lots of laughs and jokes over the breakfast table! “As residents come to breakfast whenever they want, we only set up six
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August/September 2013 | www.insitemagazine.co.nz
tables, so they may choose to sit somewhere different every day. This means they get to meet and talk with other residents whom they might not otherwise have had the chance to speak to. “Simply by having the toast in toast racks and teapots on the tables means that almost all residents are able to pass the various breakfast items and condiments to each other. They feel good because they’re helping someone else. They look out for each other, pour drinks for those who cannot, call staff if a new pot of tea is needed, and generally make sure that everyone has everything they need. “After the launch of the new service, one male resident who had never previously mixed in was completely transformed – watching out for other residents, walking them to their rooms if they got lost, and telling staff if there was a concern. We were quite amazed at the change in this particular gentleman. “There have been so many other positive outcomes from this change of routine and from doing things differently. Our buffet breakfast is also a great time to monitor exactly how much residents are eating and to encourage those who may need to gain some weight to eat more. We’re able to add fresh cream to the porridge, where necessary, and having brown sugar available next to the crockpot also encourages more
people to eat porridge (this idea was at one particular resident’s request and now everyone enjoys it!). A number of residents have put on quite a few kilos since we introduced the new service!” says McIsaac, who has been manager of Caswell House since 1999. The breakfast initiative is part of The Selwyn Foundation’s ‘At home at Selwyn’ approach to caring. This concept, based on the Eden Alternative, focuses on a more personalised approach to the care of the individual and on the creation of an environment that promotes residents’ independence. It seeks to eliminate loneliness, helplessness, and boredom from the lives of those in residential care, by reintroducing companionship and a sense of purpose, moving away from the institutional model of care to one that creates an environment where people feel truly at home. “Of course, whilst gently encouraging our residents to do as much as they can for themselves, we still continue to care for and support them as much as we did before. But it’s about building a community, a human habitat where relationships are valued most, where people feel involved in the life of their immediate community and where there’s always someone around who cares and who will listen, so no-one need ever feel lonely again.”
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COME DINE WITH ME KIM BROOKS and KAREN SCHNELLER discuss how a fun dining programme has done wonders for a group of Metlifecare residents.
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the old china, tablecloths, glasses, music, and flowers. We support with the clean up and settling. The social interaction is often repetitive. However, the residents appear to enjoy the time together and look forward to the event. The level of satisfaction and enjoyment of social events has increased. ‘Come Dine With Me’ is one of a number of groups that have been established at Metlifecare villages to support resident independence. The groups help to increase participation in daily activities and willingness to seek out social activities. They have also helped decrease levels of agitation for residents due to the frustration that can result from trying to do things without some helpful, supportive guidance. Memory clinic support programmes are also incorporated into the activities thereby supporting memory loss. An interesting observation we have found was that once you are in the group, the environment becomes very safe and protective,
which means that often the family members and staff are the outsiders. It all feeds into Metlilfecare’s restorative model for delivering Home Based Support Services (HBSS), aimed at helping residents age in place. In the initial process of engagement with a resident and their family, identified goals and outcomes to be achieved are discussed and a lifestyle plan is agreed. The care planning focus is on assisting the resident to obtain and maintain their overall health, wellness, and function in daily life. From the outset, the HBSS is to provide long-term or episodic support, enabling the resident to live as independently as in their own home. This reduces the need for specialist services and also provides an environment where residents, families, and staff are all working towards the goal of independent living for the individual. Kim C. Brooks is director of nursing and Karen Schneller is care services manager at Metlifecare.
Residents socialise over breakfast
he ‘Come Dine With Me’ programme evolved out of a need to support a small group of residents who historically enjoyed social events and happy hour in the village but are now struggling to participate in large social groups. We noted that they were becoming isolated and no longer going to village events, such as Friday Night Dinner and Happy Hour, and those that did were often left out of the group. We created a small club based on the principle that residents take turns hosting an evening in their apartments. We support the hostess with setup and arrange happy hour and meal delivery service to the apartment. Guests are supported to get to the hostess’s apartment – often wanting to take a small gift or contribution. We have observed a significant shift in residents’ social behaviour. The resident in the hostess role will draw on past experiences and welcome and care for guests. They enjoy the support for the set-up and want to utilise
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Ageing and EATING DISORDERS SARAH LEY confronts the complex and sensitive topic of eating disorders in older people and suggests that more awareness is needed.
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o older people, especially women, really worry about their body image? Are they affected by the values so often promoted by the media in our Western culture (i.e. youthfulness + beauty = happiness)? Overseas research would suggest that eating disorders are prevalent. In addition, New Zealand is fast becoming a mix of different cultures and ethnic groups who do not espouse Western culture and will bring their own values related to body image and eating into the mix. For health professionals and others who have daily interaction with older adults, it will pay to keep in mind that unusual and unhealthy attitudes to food and/or body image may be developing and should be acknowledged and treated accordingly. There are three categories of eating disorders classified by the Diagnostic and Statistical Manual of Mental Disorders: anorexia 10
nervosa (AN), bulimia nervosa (BN), and eating disorders not otherwise specified (NOS), including binge eating disorder. Characteristics of older adults with AN can be a low body weight with an intense fear of gaining weight or becoming fat or a disturbed attitude to their own body weight. BN sufferers may have recurrent episodes of binge eating and inappropriate compensatory weight loss behaviours such as self-induced vomiting, laxative misuse, diuretics, enemas, fasting or excessive exercise. People with eating disorders NOS can have the same characteristics as for AN and BN as well as other inappropriate behaviours such as repeatedly chewing and spitting out, but not swallowing large amounts of food and employing inappropriate behaviours after eating small amounts of food. Thoughts and beliefs around food, eating, and body image
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are clearly a very important part of the spectrum of disordered eating behaviours. Distinct discrepancies between what is perceived to be ideal and what actually is a healthy body weight are repeatedly seen. It is worth bearing in mind that an ideal body mass index (BMI) for older people can be higher (up to 27 rather than 25) than for younger adults. It is also much more difficult for older adults to gain weight than younger adults and a higher BMI is known to reduce the risk and injuries from falls. Some researchers have proposed that psychological and physical changes associated with ageing and menopause may parallel changes associated with puberty and menarche. However, when body size, eating, and weight related attitudes and behaviours have been compared in middle aged and older women, similar body dissatisfaction levels were found in both groups. Thin
figures were considered ideal and attractive to men across the age spectrum.
LOSS OF CONTROL
The topic of disordered eating in older adults is not widely studied, and therefore, reasons why eating disorders appear or reappear in older age are unclear. Certainly large numbers of younger women are affected by the value Western society places on slenderness and youthfulness. It may follow that this is true for increasing numbers of older women as well. Also to be considered is older women’s loss of status in Western countries, which some researchers have associated with a tendency towards an unconscious development of envy, loss, and preoccupation with body image. Other proposed causes for the development of disorder eating are an older person’s loss of control and power in her/his life. The eating disorder provides a
FOCUS sense of regaining control and drawing the family’s attention to her/his feelings of discontent. These outlooks or attitudes are extremely important to be aware of particularly when older people are living in residential care facilities. Those residents who feel they have been forced to give up many of life’s important choices, may only feel in control of what, how much, and when to eat and drink.
STRESS AS CATALYST
It is important to think about what factors or events may precipitate an eating disorder in older people. A recent review article listed the following: a fall followed by hip surgery, widowed, bereaved, family member moved, domestic crisis, health problems of husband, re-marriage of exhusband, retirement, marriage of daughter, prisoner during WW2, stressful life events, cholecystectomy, stomach operation, immigration, marital dissatisfaction, stress from child rearing, pneumonia, residential move and facial surgery. Widowhood and bereavement were the most common precipitating factors. This is a long list of events, most of which are not direct health issues and do not include the factors that can precipitate or increase the risk of an eating disorder in younger adults. However, it shows how social circumstances may have a huge negative impact on an older person’s attitudes to their own body if they are so predisposed. Once again, the theme of loss of control of many of life’s choices rears its ugly head. Online surveys with questions about disordered eating, eating related beliefs, and dissatisfaction with appearance have turned up some interesting information in Americans living at home. It seems that all age groups from adolescence, emerging adults, midlife, and older adults had similar views that would be suggestive of a high rate of AN, BN or eating disorder NOS. There were high rates in men also. These sorts of results are likely to be similar in New Zealand. One only has to listen to groups of people talking about food,
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New Zealand is fast becoming a mix of different cultures and ethnic groups who do not espouse Western culture and will bring their own values related to body image and eating into the mix. discussing their latest diets, and how it affects their bodies to understand that unusual eating related ideas are rife in New Zealand. The impact of stress and the way individuals deal with stressful situations are important factors in eating disorders. In response to continued or perceived stress, the part of the brain responsible for the “flight or fight mechanism” (hypothalamic pituitary adrenal axis) becomes over stimulated and chronically ready for action. Many people learn to deal with these situations in a positive way, such as using physical activity to channel the excess energy produced from the body’s response to stress. Others, however, may struggle to cope and use anxiety and obsessive-compulsive behaviours to release this extra energy, which causes further stress and a vicious cycle to develop. Researchers have proposed that this is one of the main origins of altered eating behaviour. Another biological/ brain reaction affecting eating is the increased levels of opiates such as endorphins which are released in response to either successfully restricting food or bingeing. This habit forming positive feedback then acts as a reward encouraging the restricting or bingeing behaviour to be repeated.
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out about body dissatisfaction of a group of women in their 60s living at home. Of those with a normal height to weight ratio, over a third felt moderately fat and only 15 per cent said they actually liked their body! The questionnaire also showed that four per cent would be classified as having an eating disorder and four per cent to have single symptoms of eating disorders such as binge eating, use of laxatives or diuretics, and vomiting.
RAISING AWARENESS
There needs to be more awareness around eating disorders in older adults. A high percentage of deaths from AN occur in the elderly. Figures given by one group are 12 per cent in the 65– 74 years age group and increasing to more than double this number in the 85+ years age group.
In my clinical practice, I have come across a number of people, mostly women, who appear to fit a diagnosis of having an eating disorder. For example, women who have gradually narrowed the range of foods that they consider to “agree” with them so that they eat a very limited and unbalanced range of foods. Or perhaps women, having recently suffered loss of a long-term spouse, start restricting their food intake and having unusual, perhaps obsessive thoughts about the effects of food on their body. As a consequence, family members may be frequently requested to bring in special foods to the residential facility. The preparation and/or cooking of these may not be the way the resident is used to and thus everyone from cook to family to resident is disappointed. It makes good sense that counselling is recommended as a foundation of eating disorder treatment. Sarah Ley is the founding director and senior dietitian of Consulting Dietitians Ltd.
SKEWED SENSE OF SELF
Body dissatisfaction appears to be so prevalent in Western society that it has been described by some researchers as a normal discontent with self. Does the effect of a negative body image on a person’s self esteem lessen with age? When body dissatisfaction was studied across the age groups, researchers found that there was no difference but the impact appeared to be less amongst older people and thus formed somewhat of a protective mechanism. Other researchers used a questionnaire to find www.insitemagazine.co.nz | August/September 2013 11
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Keeping the wheels a-turning Meals on Wheels has been around since the 1950s. Given the changing tastes and preferences of older people and the changing political agenda, does the service still have a place in New Zealand? JUDE BARBACK finds out that some things don’t change over time.
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ome 1.2 million Meals on Wheels are prepared and delivered to New Zealanders each year. For many older people, the delivery of their meal is a highlight of their day. But can a service that has been around for over sixty years still be relevant?
THEN...
1961 & 1951
In June 1951, the North Canterbury Red Cross Centre began a ‘soup scheme’ in order to assist the elderly during a shortage of gas, coal, and electricity. Gas rings were lent by the local gas company, large saucepans from the Christchurch Hospital, and three cartons of pint bottles were purchased at a discount. Mr Fail of Fail’s Fish Café offered to cook stock twice a week, which arrived at the Centre cold in a jelly, and the M. M. M. Butchery supplied the bones and meat for free. The soup was prepared at the ‘sub-centres’, bottled in the milk bottles, covered a by a cellophane cover with a red cross in the centre, and delivered cold. By 28 August, 2029 pints had been made and delivered. By this stage, the North Canterbury Centre decided dinners should be cooked and
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delivered hot. At first, these were just stew and potatoes, then vegetables were added, and then milk puddings. A lack of containers and transportation meant that only 18 meals a day could be delivered and delivery took two hours due to the widespread locations of the recipients. By December, four aluminium containers were ordered through the British Red Cross to greatly help with delivery. Approximately 650 dinners were distributed by the North Canterbury Centre between August 1951 and March 1952. A decade later, Meals on Wheels had really taken off. By August 1961, the North Canterbury Centre was churning out an average of 170 meals on each of the three delivery days. It wasn’t just happening in Canterbury; Meals on Wheels services began popping up all over the country in the 1950s and played an important role in keeping people independent in their own homes for longer.
...AND NOW
Meals on Wheels is now on a big scale and part of our culture. The service is provided by a number of agencies throughout New Zealand, as well as a number of private companies. Hot meals, often including a dessert, are delivered on weekday lunchtimes to people who are unable to cook for themselves because of illness, injury, or disability. Older people are often referred to a Meals on Wheels provider through their doctor or as a result of a Needs Assessment Service Coordination assessment. The cost is approximately $4 to $8 per meal. Meals on Wheels services are typically provided by district health boards, often through hospital food services. National service specifications set standards to ensure the quality of the food delivered. Part of this means providing clear information on handling the meal once received,
August/September 2013 | www.insitemagazine.co.nz
about how to reheat, store in the freezer, defrost and cook, for example. This is important as many people keep their meals for later or divide them into several portions. Meals on Wheels are usually delivered by volunteers from community organisations such as Age Concern. An interesting study by University of Otago’s Amanda Wilson revealed that 79 per cent of health professionals thought that Meals on Wheels did not meet the needs of different cultures in New Zealand. Over 80 per cent of nonNew Zealand Europeans knew little or nothing of Meals on Wheels. Wilson recommended some changes around standardising the information given to health professionals and expanding the service to better encompass different ethnicities.
CHANGE IS AFOOT
Whether these changes were heeded is unclear, but it appears the fundamental aspects of the food preparation of Meals on Wheels could be set to change. The Health Benefits Limited proposal to centralise some aspects of district health board food services has repercussions for Meals on Wheels. Labour’s spokesperson for health, Annette King, says that in a document outlining its new business case, Health Benefits notes that the 1.2 million meals provided annually through the Meals on Wheels service will be prepped, plated, chilled, frozen, and stored at the two sites before being transported to regional hubs for storage, then sent on to hospitals for re-heating, and finally delivered to clients. “There are already concerns that recipients are not receiving standard information about reheating, freezing and defrosting.
Transporting these frozen, prepackaged meals halfway across the country before they are finally delivered raises even more questions about quality and safety.” Health Benefits Limited says that while no hard and fast decisions have been made yet, the focus is on maintaining and improving quality of food, and any option would include the continued provision of the Meals on Wheels service. “The priority is to improve the overall quality of food to ensure good nutritional value for all,” says Mark Reynolds of Health Benefits Limited. However, Annette King’s concerns extend beyond food quality to the economic aspects of the scheme. She criticises the intent to reduce the cost of preparing Meals on Wheels servings, which currently cost clients around $5 to $8, yet fail to pass on the savings to the clients, most of whom are on low, fixed incomes.
WHAT ARE THE ALTERNATIVES?
At this stage, it appears to be a case of “wait and see” for how the changes proposed by Health Benefits will affect Meals on Wheels recipients. However, it may
FOCUS prompt some to consider other alternatives. Meals on Wheels is not for everyone and there are now food delivery companies that provide a similar, arguably better, but typically more expensive service than the traditional Meals on Wheels. Food delivery business Eat is one example. It has been around since 2001, making and delivering meals for people all over New Zealand when time or circumstance makes it difficult to prepare meals for themselves. Older people are a key market, but not their only market. Eat’s service involves cooking fresh meals that are then blasted cold to retain the flavour and freshness, then served out into individual meals and vacuum sealed. More recently, the company has also started producing frozen meals. It is a little more expensive than Meals on Wheels; most main meals are just under $10. Customers can order one meal or many meals at a time, although a delivery fee will apply regardless of how much is ordered. Farmhouse Foods is another company that specialises in delivering frozen food to customers in Auckland and Wellington. Small portions are around $6, medium around $8, and large around $9. A minimum of $40 per order is required and delivery charge is from $8 to $15, depending on where the customer is based. Like Eat, Farmhouse Foods appears to be taking a more modern approach to food preparation and delivery. The food itself is said to be more contemporary, and also has low-calorie, gluten-free and dairy-free options available. They can place orders by telephone or online – something that is bound to appeal to kitchenshy baby boomers. The ‘heat and eat’ concept is certainly reminiscent of Meals on
Back in New Zealand, a series The New Zealand Red Cross of cooking classes is popular with 1951–52 annual report stated: older people in various parts of the “Members felt that it was not country. Senior Chef is an eight only the meals that were needed, week cooking class for people aged but interest, and this they were 65 and over who want to improve able to give. During winter they Wheels, but the staff at Eat their cooking skills, confidence, or found some who were in need of dismiss this notion. motivation around cooking for one extra warmth, and were able to “If it is, then it is the ultimate or two people. The classes are three provide blankets, hot water bags, meals on wheels. It is proper hours long and run once a week bed socks, and shawls, all of which food, delivered fresh or frozen during the daytime, with around had been donated to the Good and only heated when you want eight to ten people per class. In Neighbour Scheme, as well as it. It tastes like you just graduated books and papers. One helper has addition to some nutrition education, from culinary school and tips on menu planning, budgeting, taken her old ladies out for motor cooked it yourself, as opposed to rides – another reads to hers.” and shopping, the class learns to lukewarm, sitting around all day, prepare and cook a meal in pairs and and each meal tasting the same then shares the meal with the group. SHARED DINING ... you know there is a problem Of course such incentives are EXPERIENCES when you can’t work out if you In some parts of the United States, great for those older people able are eating chicken or pork!” to get out and about. However, community initiatives are proving this is not always a given for many to be successful in combating this BEYOND FOOD older people living independently, problem of social isolation. However, the one thing lacking especially if they are particularly The Cloverdale Senior Dining from such services tends to be the Café, one of ten such cafés frail. In a University of Waikato daily human contact. Farmhouse operated throughout the Sonoma study headed by Patrick Barrett, Foods is proud of its delivery many older people said problems county by the Council on Aging’s person; “those who are home with their health meant they were Meals on Wheels programme, is enjoy her personal touch with one such example. Up to 30 guests, not very mobile, however, many also putting their dinners into their reported the cost, unavailability and aged 60 and older, enjoy lunch freezers,” claims its website. inconvenience of suitable transport as together on weekdays. barriers to getting out of the house. Similarly, Eat’s website also The idea is that beyond a It is good to see alternatives to makes mention of the interaction delicious, nutritious lunch, Meals on Wheels, and initiatives with couriers: “If you do have an the recipients also have the to get older people dining together. exceptional courier ... patient, opportunity to socialise. Shared However, for many older kind, helpful ... let us know and dining experiences are often New Zealanders, the Meals on we will pop some brownies or a something older people have Wheels service continues to be cake in your box for you to gift to to miss out on if they wish to exactly what they require. It is sad your favourite delivery guy/gal.” continue living independently in to think the same observations of The occasional visit from the community. Residential care, those volunteers delivering the very a courier or delivery service, and to a lesser extent, retirement first Meals on Wheels services are however, is not going to provide villages, give the opportunity for the same daily social interaction social dining experiences that older the same as those delivering meals today. Social isolation remains a that is provided with Meals on people in the community may not key concern, and if the necessity of Wheels. have access to. food being delivered or shared helps Trevor Hitchcock, who lives Senior dining cafés suggest a alleviate this, even if for a brief time in Matamata, receives Meals donation of $4 per guest. No one each day, then that can only be a on Wheels five days a week and is turned away for lack of money good thing. looks forward to the daily visit and there is no means test. from the volunteer making the delivery. He lays the table well before 1pm in expectation of the meal. He has come to know the volunteers, and often recounts shared jokes or small interchanges with his family. It is a talking point, a visit to break up the Is English the second language for some of your staff? day. The stark truth is that it is a respite from inevitable loneliness. Experience amazing improvement in your workplace! Social isolation of older people, Call us now for more information and a free needs appraisal. a problem we are all well aware of, has been around a long, long LITERACY NORTH SHORE INC time. The advent of Meals on Wheels in North Canterbury Auckland-wide Affiliates. Ph 09 444 0420 revealed that people delivering Email: admin@literacynorthshore.org the meals soon realised that the Member of Literacy Aotearoa Inc recipients were just as grateful for the visit as they were for the www.literacynorthshore.org meal.
FREE! ImpROvE YOuR wORkpLACE EFFICIENCY ANd SERvICE wITH OuR pROvEN ENgLISH LANguAgE pROgRAmmE!
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Catering for residents with food allergies and intolerances INsite asks dietitian Jessica Bowden about the ins and outs of handling special and changing dietary requirements of older people. INsite: Have you noticed an increase of residents with gluten sensitivity or food allergies in recent years? Why are such food intolerances becoming more prevalent? Bowden: Prevalence data is limited in New Zealand, so it is difficult to quantify the increase. However, with the increase in awareness and medical testing, we will definitely see an increase in those coming into aged care sites with a diagnosed allergy. A potential reason for increase is the wider range and increased availability of products, which means people may be more likely to consume a food that they then develop an unfavourable response to. It is essential that accurate diagnosis of the food allergy is done to specify the allergen(s) placing the person at risk. This is important as some residents have self-imposed restrictions due to a perceived allergy, which may not exist or be linked to another food or even to an environmental allergy. I have a family member who had been incorrectly told to eliminate gluten from her diet due to intolerances experienced after eating bread. Results from allergy testing came back that she was actually allergic to yeast, not gluten. If she had followed a gluten-restriction then she would have unnecessarily limited food options whilst still consuming the actual allergen that was the root to her discomfort. INsite: Are New Zealand rest homes required to provide meals for residents with food allergies or intolerances? Bowden: It is required that those with additional or modified dietary needs are having nutritional needs met under Health and Disability Sector Standard 1.3.13. Therefore any allergy or intolerance needs to have a safe and nutritious menu offered to meet their needs. If it is self-diagnosed with no medical backing, then I would consider that a dietary preference that the facility should try to cater for within the cost and functional constraints. The way I interpret the standards is that the full nutritional requirements need to be offered that are safe for the residents. Therefore if a safe and nutritious alternative is offered, but a different brand/product is requested by the family, then it is up to the facility if they will supply this or to request the family to purchase. For example, someone with a milk allergy will need to have sufficient dairy replacement so that 14
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calcium requirements can be met. This could be achieved though using soy milk in tea/coffee, making puddings with rice milk and offering soy yoghurt as snacks. However, if the rest home were to purchase Brand A soy milk and the resident wants Brand B, which costs an extra $1/litre, it would be at the facility’s discretion if they were to increase the food costs for that one resident who is already consuming a product that is double the price of standard milk. INsite: Are all rest homes required to have a dietitian on staff? Bowden: Under the Health and Disability Sector Standards, aged care providers are required to provide appropriate specialist services when required. This includes dietitian assessments for nutritional/clinical need. Having access to a consulting dietitian
PROVIDING AN APPROPRIATE MENU
Providing a specialised diet will increase cost as specialised products are understandably more expensive. Therefore whenever possible, use the same menu and just replace the items that are not appropriate for your resident with the specialised need. HERE IS A SAMPLE FOR WHAT YOU MIGHT SERVE SOMEONE WITH A GLUTEN-FREE AND NUT-FREE DIET. BREAKFAST
MORNING TEA
LUNCH
LUNCH DESSERT AFTERNOON TEA EVENING MEAL SUPPER
Gluten-free nut-free cereal, milk,canned or fresh fruit Note: Recommendations are now that those with Coeliac Disease can eat 1 serve of pure uncontaminated oats per day. Gluten-free slice Note: All baking and desserts will need to be made separate using gluten-free flour or brought-in or milk-based pudding with no flour e.g. mousse. Roast chicken with potatoes and vegetables with a gluten-free gravy Note: The majority of main items should be able to be easily made gluten-free by either using gluten-free products (corn flour) for all residents or by separating a portion when it comes to adding the glutencontaining product. Pre-made items typically contain gluten so would need to ensure a suitable replacement for the likes of crumbed fish and sausages. Pavlova with fresh fruit and whipped cream topping Plain rice crackers with sliced tomato and cheese Home-made soup (without flour), scrambled eggs on buttered gluten-free toast, fresh fruit dessert Gluten-free biscuits
FOCUS to contact when the need arises will generally suffice. To find a dietitian in your area visit the Dietitians New Zealand website www.dietitians.org.nz . Alternatively, contact your local hospital or look in the Yellow Pages. INsite: How should family members go about trying to arrange special dietary requirement meals for a resident from the outset? Bowden: I would recommend taking the following steps: »» Talk to the manager about the specific requirements for their loved one. »» See the menu and ask what provisions will be given for the meals that cannot be eaten. »» Determine from the outset what ‘extra’ items the facility will expect the family to purchase. »» Asking if/when training will be given to staff to ensure adequate management of the allergy. INsite: What type of medical information should be brought to the rest home on behalf of a resident with an allergy? Bowden: The rest home needs to know: 1. The allergy type. 2. Severity: For example, do they require epipens to be on hand at meal times? Can the resident sit on the same table as someone else eating the food ? 3. Tolerance level: can small amounts be safely consumed or is total avoidance needed? INsite: What recommendations do you have for educating kitchen staff to help ensure that food provided meets specified dietary requirements? Bowden: I would recommend the following: Risk Prevention: Create of HACCP (Hazard Analysis and Critical Control Points)plans specific to the allergen and the kitchen environment. These allow clear identification where areas of potential contamination with the allergen may occur and allow for risk management. For more information check out http://www.foodsafety.govt.nz/industry/ general/haccp/
Training: Regular in-services and education to kitchen and care staff about the requirements, including what the risks are if the allergen is given to the resident. Preferably these would be conducted by a registered nurse, clinical leader or dietitian. Storage: purchase a separate container to store the specialised food in – e.g. gluten-free foods – so that cross-contamination can be prevented. Storage of the allergen needs to be contained as well – e.g. sealed and labelled containers for peanuts, food bins for flour with excess wiped up. This is to prevent the spread of the allergen into ‘safe foods’. Preparation/Production: When moving from preparing menu items containing the allergen, kitchen staff need to wash hands before starting production of the menu items without the allergen that will be given to the resident. This is to prevent crosscontamination. Equipment: Separate equipment may need to be purchased to prevent cross-contamination depending on the severity and tolerance level of the allergy, for example separate toasters for toasting gluten-free bread. When preparing the special meal, equipment needs to be washed and sanitised before use to prevent cross contamination. If using the deep-fryer for cooking a product containing the allergen, then any other product cooked in that oil would carry risk to the resident developing a reaction. Service: It is important that all kitchen and serving staff know which residents have allergies and that measures are in place to prevent the incorrect meal being given. For example, having a separate plate dished up by kitchen by the same staff when possible and labelled with the resident’s name. Label reading: Look for the key allergen in the ingredient, if they are a common allergen they will be bolded in the ingredient list. Often manufactures give a safety warning of ‘may contain traces of nuts’ and this is usually to protect themselves. If it is an intolerance, you will most likely be safe to provide that item, however allergies can be severe.
AGED-CARE & RETIREMENT
NEXT ISSUE:
OCTOBER/NOVEMBER FOCUS ON: INFECTION CONTROL AND WOUND CARE INsite homes in on the in-depth topics of infection control and wound care in this issue. Medical research and expert opinions are given alongside practical case studies and advice. We look closely at new research emerging in this field to bring readers up-to-date information on providing the best possible care in all areas of the aged-care sector. PLUS: THE REGULARS: ‘SPOTLIGHT ON ... ’ A section dedicated to relevant issues including education and training, therapies, falls prevention, infection control, palliative care, dementia and more. ‘A DAY IN THE LIFE ...’ An insight into the lives of everyone from caregivers to chief executives, residents to retirement village managers. ‘LET’S SNOOP AROUND...’ An insight into the operation of a village or aged care facility. ‘LAST WORD’ Giving sector leaders the chance to air their views on the current status and direction of aged care in New Zealand.
Jessica Bowden is a dietitian for the Oceania Group.
USEFUL RESOURCES
INFORMATION
Nestle Professionals nutrition magazine Number 5: Food Allergies www.nestleprofessional.com
Summary of the main food allergies including cooking tips for caterers for each allergen.
Coeliac NZ http://www.coeliac.org.nz/
Information about coeliac disease, gluten-free food suppliers in New Zealand, gluten-free recipe books.
Grocery supplier
Ask for lists of gluten-free, dairy-free items available for purchase.
Allergy NZ http://www.allergy.org.nz/
Information including a food allergen labelling guide.
Your consulting dietitian
Assessment of dietary intake – nutrition plans to ensure adequate nutritional provisions through replacements for the restricted items.
UDE: THE WEBSITE’S NEW FEATURES INCL
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www.insitemagazine.co.nz | August/September 2013 15
INTERVIEW
On the Soap box ... David Naulls DAVID NAULLS, editor-in-chief of Consumer, defends the magazine’s controversial review of New Zealand rest homes in a recent issue.
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oo few staff. No registered nurse on duty. Residents not receiving adequate care. Poor cleaning. Dinner consisting of tinned baked beans or spaghetti. That’s a brief list of some of the disturbing problems uncovered by unannounced inspections of rest homes in the past year. How serious are shortfalls in the industry? Deficiencies in rest home monitoring make it difficult to find out. To shed some light on the question, Consumer recently reviewed the summary audit reports for 634 rest homes. These summaries, published by the Ministry of Health, remain one of the few publicly available sources of information on rest home care. Our review, reported in this month’s Consumer, found less than 10 per cent of homes fully met all required healthcare criteria. Around 28 per cent of facilities had minor shortfalls; 61 per cent had more-thanminor shortfalls; and three per cent had major shortfalls. The highest rate of failings was in meeting the criteria in the core “continuum of service delivery” standards. Fifty-five per cent of homes only partially met criteria in these standards that the ministry considers to be medium, high, or critical risk or failed to attain some criteria at all. A further 26 per cent partially met criteria considered to be low risk. Summary audit reports don’t detail the specific shortfalls found at these homes. But there’s other evidence of fundamental failings. In her 2012 report on rest home
we “misunderstood” healthcare regulations and expressed the view that 10 per cent compliance was “exceptionally good”. This was more than disappointing. Rather than acknowledge evidence of shortcomings and look at how to fix them, it decided to shoot the messenger. The association seems to be praising mediocrity – why race for the top when we can sit comfortably at the bottom?
WHAT CONSUMERS NEED
monitoring, Auditor General Lyn Provost cited a ministry review of compliance with the standards. It found basic deficiencies, including incomplete care plans, timeframes for GP reviews not being met, care plans not being updated to reflect changes in residents’ needs, and documented interventions that were insufficient to meet these needs. The New Zealand Aged Care Association, which represents the industry, responded to our report by going on the attack. It claimed
We continue to hear from people who tell us their relative – often their mother or father – has been in a home where there have been failings in care. We also hear from people who have experienced good care and are full of praise for the home. Unfortunately, there are more of the former than the latter. More than the bare statistics, it’s these experiences – good and bad – that the aged care industry needs to listen to and learn from. Not so many years ago, one of my aunts and her husband were looking for a rest home for her older sister, who – after a life of fierce independence – needed more care than could be provided by the family. In the absence of more objective information, they relied on what they called the “smell” test – if they could smell boiled cabbage or urine in the general areas of the rest home during their daytime visits, they knew they didn’t have to waste time inspecting the rest of the facility. We can surely do better than this in helping consumers choose rest homes for themselves or other family members.
RESPONSE: MARTIN TAYLOR, CHIEF EXECUTIVE NZACA Consumer claims we have shot the messenger, and they are right because the message is wrong. It follows that the opinions their readers will form based on their mixed-up messages will also be wrong. Consumer has failed to understand the certification system that regulates the entire health sector. They still believe that only facilities who achieve 100 per cent compliance against the Health and Disability standards are good, which means everyone else has somehow ‘failed’. This is why they shout, “less than 10 per cent of homes fully met all required healthcare criteria”. Consumer’s fundamental flaw is they see the certification system as binary – you either pass or fail. If you follow Consumer’s logic, if someone gets 90 per cent in a maths test, they have failed. However, certification is about a progressive grading system – much like A, B, C school grades. Consumer needs to ask themselves questions such as: how many nonaged care private health care providers have ever achieved 100 per cent attainment with the Health and Disability standards? The answer is none. Or how many DHB hospitals have ever achieved 100 per cent attainment with the Health and Disability standards? Again, the answer is none. Perhaps Consumer could ask themselves the question: so why is it that 10 per cent of aged care providers can achieve 100 per cent attainment
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with the Health and Disability standards when all DHBs and all other private health providers cannot? These revelations may result in Consumer writing another misleading headline such as, “No DHB hospital has ever fully met all required healthcare criteria” followed presumably by a demand for more regulation, monitoring, auditing, investigations, and transparency. Despite the opinions in Consumer’s piece that we are ignoring reality, like all New Zealanders, we believe one case of poor care is one too many and we have to do all we can to ensure every one of the 40,000 aged care residents who receive care each year in 693 aged care facilities from 35,000 care givers and nurses all have the best possible experience. However, just like every other health service in New Zealand, some people make mistakes, which means a resident does not receive the care they should. We all wish this was not the case, but that’s the reality of human frailty and we have to do all we can to make sure this does not happen. That is why the aged care sector is the most closely monitored of any health service in New Zealand – and rightly so, as the care of the elderly is very important. It is also why the aged care sector has the highest number of providers with exceptional outcomes under the national certification system; outcomes that other, better funded and better supported public health providers can only dream of.
The focus of our work on rest homes is twofold. Firstly, we’re pushing for improvements in quality of care, and secondly, we’re pushing for improvements in the quality of information available to consumers. Robust auditing and monitoring is essential to both endeavours. Audit processes are improving but more work needs to be done. Unannounced inspections continue to find problems that routine audits should have picked up. Consumers also need much better access to information. The summary reports currently being published don’t provide sufficient details of homes’ shortfalls or the actions required to fix them. Unhelpfully, only the most recent report for each home is usually available. This means it’s difficult to tell whether the facility has a history of problems. Information about substantiated complaints is also not being routinely disclosed either by the ministry or by district health boards. While unannounced inspection reports are being published, these reports are usually removed under the ministry’s “clean slate” policy when the home has its next audit. To fill the gap, we’ve been publishing the reports on our website instead. There’s a strong public interest in this information – and no good reason why it shouldn’t be available. Rest homes receive significant public funding of close to $1 billion a year and consumers have the right to know whether they’re doing their job well. Transparency is also vital for lifting standards in the industry. We’ve previously had to go the Ombudsman to get information released that’s been withheld on the grounds of commercial confidentiality. Should rest homes that are performing poorly be protected from public scrutiny? There’s only one answer to this question: no. The rest home industry could have taken the initiative and published audit and other reports itself – but that hasn’t happened. Full information is fundamental to the efficient operation of markets, yet consumers are being denied the information that allows them to make an informed choice about the respective quality of rest homes. This must end. Associate Minister of Health Jo Goodhew has indicated the ministry may start publishing full audit reports. We’ve been calling for this for years– and are encouraged by the associate minister’s reported response. It should be easy to do and a small step towards increasing transparency. If the ministry isn’t able to do it, Consumer will consider publishing these audits itself on behalf of the public.
HEALTH
Spotlight on … MUSCLE DEGENERATION
Liggins Institute Research Director, Professor DAVID CAMERON-SMITH is leading ground-breaking research on how exercise and nutrition can potentially aid muscle regeneration in older people. MUSCLING IN ON A STRONG FUTURE
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ne of the many great mysteries about growing old is why muscles slowly disappear. From our mid-thirties, there is a slow and inevitable loss of muscle size and strength. The secrets behind this have remained elusive despite many years of research. Along the way, some major discoveries have been made. Muscles are themselves made up of long cells that bundle together to form muscle fibre. Each muscle fibre is able to contract and so there are fast contracting muscles (fast twitch) and more slowly contracting (slow twitch) muscles. Both types of muscle cells are lost with age, but it is mostly the fast twitch and more powerful muscles that deteriorate the most rapidly. This is where exercise becomes important. All forms of exercise are important, whether it is to maintain heart health, improve brain function, or improve sleeping. But it is lifting weights, known as strength exercise training, which is most important for maintaining the all important fast twitch muscle cells. Lifting weights or any form of activity that uses strength is the best medicine for building
stronger and bigger muscles. It is not until you have stopped, relaxed, and have a rest after exercise that the muscles themselves start to get on with the job of repairing and adapting. Recovery is just as important as the exercise itself in helping repair. Recovery is best with some light activity. With ‘all or nothing’ exercise, muscles and tendons become damaged and that repair process can leave you with sore and stiff muscles for days. If you keep moving, particularly the morning after exercise, then the muscle pain will be reduced. Just as important as light exercise in recovery is nutrition. Muscles are made largely from protein. Traditional dietary advice is that everyone generally eats enough protein throughout the day to meet the needs of the muscle cells. New research from the Liggins Institute is examining how protein-rich foods, consumed after exercise, can provide an extra boost in the recovery and rebuilding process of making bigger and stronger muscles. In studies targeting men over the age of 65 years, we have shown that a protein boost, taken after exercise, powers the repair process. This new research highlights that protein rich foods, not only supply the amino acid building blocks, but that these amino acids are also effective in driving the repair process. My advice for strong healthy muscles is to do three things. Carefully start and maintain regular exercise that involves lifting weights. Recover well by going for a walk or light exercise like swimming or cycling between strength exercise sessions. But importantly, feed your muscles the protein-rich foods in the first two hours after exercise to bolster the speed of repair. I recommend a variety of protein-rich foods including selecting high protein dairy (including yoghurt), lean meat, and protein-rich legumes. If a snack or a drink is what you are after, the many protein-rich snack foods and drinks are just right for all ages.
www.insitemagazine.co.nz | August/September 2013 17
CONFERENCES
Pioneer Club
“AMAZING SPEAKERS” help make RVA conference a success CONFERENCE REPORT
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INsite/RVA Manager of the Year 2013, Sandy Quigley, Manager of Ocean Shores
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ver 200 delegates, exhibitors, and partners took over the Marriott Gold Coast Resort from 24–27 June for the Retirement Villages Association’s 2013 conference. At the opening cocktail party, the local MP welcomed delegates; the following days were jam-packed with thought-provoking, stimulating sessions and opportunities to make and strengthen industry connections. MC Jim Hopkins, in his inimitable way, pulled all the strands together while keeping the programme on time and everyone’s energy levels high. RVA President Margaret Owens opened Tuesday’s sessions with an overview of the industry, neatly leading into the first keynote speaker, Australian of the Year, Ita Buttrose. Ita shared the insights she’s gained as Patron of the Alzheimer’s Association. The audience also enjoyed her anecdotes about working for the Packer and Murdoch publishing empires. From there, the diverse programme traversed employment law, the economy, aged care contracts, using social media strategically, marketing, demographic and social trends and change, the political scene, insurance updates, and the formation of the new Retirement Living Council in Australia. Some key highlights were Amanda Stevens’ session on marketing to women, which also provided some useful insights into men for all the women in the room! We learned that 60 per cent of New Zealand start-ups are run by women, and a high proportion of these are older women – ‘the rise of the olderpreneur’ – and
that women constitute 80–85 per cent of spending decision-makers. Jill Walker built on this with more detailed insights into marketing to mature audiences, and how to make your brand consistent and prominent. Bernard Salt explored the profile of future retiree demographics as the baby boomers age, and gave us some unforgettable new acronyms: for our industry, KIPPERs (Kids in Parents Pockets Eroding Retirement Savings) are a key challenge. Mike Williams provided invaluable political insight against a backdrop of Australian political leadership change almost as he spoke, which complemented Cameron Bagrie’s economic insights. The speed-dating session proved both popular and useful again, as trade exhibitors honed their elevator pitches and focused on RVA members’ needs in the five minutes allotted to each speed date. The day after the conference closed, delegates had the option of attending an in-depth master-class with Amanda Stevens, followed by the customary village tour to a range of local Gold Coast retirement villages. Outside formal sessions, delegates caught up with each other in the ANZ lounge, trawled the trade stands, honoured their industry’s growing Pioneer Club, enjoyed a superb formal dinner, danced their socks off to the Monroes, played some serious golf, or took a local tour. Feedback forms featured comments such as “Some really, really AMAZING speakers this year – well done!” and “Speed dating sessions were fantastic; the leads obtained were genuine and of good quality.” Conference presentations are available online at the RVA website.
CONFERENCES
SURVEY SHOWS
VILLAGE SECTOR IS UPBEAT At the 2013 Retirement Village Association (RVA) Conference in June, ANZ surveyed retirement village owners about the industry. A useful temperature gauge, the survey delivers insights into the challenges and opportunities affecting this sector. Performance expectations for the New Zealand economy in the next 12 months are strong, with 97 per cent of respondents expecting growth and opportunity. Not unexpectedly, owners expect to see their villages benefit from a sound economy. Only eight per cent of retirement village owners were pessimistic about their businesses over the next 12 months. Overall, this optimism is carried through to performance expectations for the next three years. The 2011 RVA conference survey showed that the housing market was the key issue for village managers. However, this year it fell to fifth-equal. In 2013, the number one issue identified by retirement village owners is ‘Competition’ closely followed ‘Finding good employees’. The concerns around competition appear to be forward-looking and perhaps signal a significant number of new villages currently in development and coming to market. Interestingly, finding good land ranked among the lowest areas of concern. The biggest surprise was that owners who ranked this in their top three were located around the country and not just in the property hotspot of Auckland. The New Zealand housing market is having a positive impact on the retirement village sector. However, some parts of New Zealand are recording higher prices than other areas and this mixed price experience is shown in our survey with 21 per cent of respondents expecting house prices to be flat. Interestingly, only 21 per cent of people expect price rises of more than three per cent. There appears to be an expectation of a slow-down in house price increases. Will owners be increasing the price of villas and apartments? The answer is a clear yes. The final question was, ‘is your village worth more today than two years ago?’ An overwhelming number of respondents believe their villages are now worth more, and this corresponds almost exactly with the percentage intending to increase villa and apartment prices within the next 12 months. The 2013 survey reflects continued optimism in the sector and a positive outlook on the New Zealand economy. Looking forward, we will see increased development, villa/apartment price rises and higher valuations. The only clouds on the horizon are the top three issues of competition, funding and paying good people and compliance. Good management, investment in brand, and a quality product will help business owners meet these challenges.
Golf day
Party time!
>> CONFERENCE CORNER
DATES FOR THE DIARY: NZACA 2013 conference, ‘Moving with the Times’: 28th to 30th August 2013, SKYCITY Convention Centre, Auckland. Ageing and Spirituality one-day conference: Friday 6 September 2013, 9.30 am-4 pm, Tamaki Campus, University of Auckland. Selwyn Foundation’s gerontology nurses’ professional development conference, 14 August 2013, Waipuna Conference Centre, Auckland.
Committed to the Retirement Villages Industry. We understand how access to knowledge and expertise can make all the difference. Don’t wait until the conference to talk to us about your plans. If you currently have a Retirement Village, are planning new stages or are considering a new Village altogether, give one of our Healthcare Relationship Managers a call today. Find out how we can help make your vision a reality. Auckland: Richard Hinchliffe, Head of Healthcare 09 252 2952. Reuban Dalzell 09 252 3095. Wellington: Chaitanya Cherukumilli 04 436 4134. Christchurch: Brent Crisp 03 368 2414.
anz.co.nz ANZ Bank New Zealand Limited 05/13
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www.insitemagazine.co.nz | August/September 2013 19
INTERVIEW
Up Close and Personal with ... Sandy
Quigley
JUDE BARBACK catches up with INsite/RVA Manager of the Year 2013, Sandy Quigley, Manager of Ocean Shores, Mount Maunganui.
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he residents at Ocean Shores village are buzzing. Today, their manager, Sandy Quigley, is giving the presentation she gave at the RVA conference the week before. They are thrilled for her, and I sense they take some ownership for the fact she won. I take the opportunity to quiz several residents on what they think of Sandy. “Fantastic”, “Very deserving”, and “Couldn’t be beaten” were the first three responses I got. “I’ve been here 15 years; she’s the third [manager] and the best,” was another. The Ocean Shores residents’ committee was responsible for nominating Sandy for the award, and the RVA’s resident survey and visit to the village, after Sandy was declared a semi-finalist, was essentially what saw her take home the title. Industry outsiders might be surprised that the person at the helm of Ocean Shores has been awarded Manager of the Year. The village is a building site. The entrance way is cluttered with construction and warning signs, orange cones, workmen in high-vis vests having their smoko. But behind the construction site is the story which helps explain, in part, why Sandy is manager of the year. Ocean Shores was built in 1996, a time which will cause anybody remotely familiar with the New Zealand building scene to raise their eyebrows – the leaky building era. Sure enough, the main apartment complex began to show signs of water impingement. Individual leaks were dealt with on an ad hoc basis over the years, until it reached a head last year. During the refurb of an apartment, some of the gib board was removed to see if it revealed any problems. “We didn’t like what we found,” says Sandy, “so in April last year, we did some environmental and air sample testing.” The results of the testing “weren’t great” according to Sandy. Very conscious of the health of their ageing and vulnerable residents, a complete sanitisation of the apartments was undertaken while construction people and other experts did more investigation. By July 2012, it was apparent Ocean Shores had a “big problem”. The decision was made to redevelop the main apartment complex to put an end to the leaky nightmare once and for all. Fortunately, the village’s owner, Australian company Lend Lease, specialises in construction, and while New Zealand construction firms were used, the Lend Lease asset team were able to provide the necessary resources. And so it began, the big redevelopment – not remediation, Sandy claims – of Ocean 20
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Shores. From the outset of the project, Sandy’s biggest priority has been the residents’ welfare. A great deal of consultation followed in which Sandy informed residents that a major disruption was inevitable, but that they would do everything possible to minimise that disruption. The consultation process, which Sandy says they had stepped up in recent years anyway, proved to be invaluable for getting a sense of the residents’ concerns and for reassuring residents that their care would not be compromised and they would not be out of pocket as a result of the change. The pre-fabrication was all done off-site, an innovative approach to minimise the build time. However, it was still necessary to move residents. The more vulnerable residents were moved to another wing within the village, while others were moved to the Anchorage apartments on Pilot Bay. This move in itself took a huge amount of organisation. The health and safety aspects
of the apartments had to be brought up to scratch to comply with the retirement village standards. Residents’ belongings had to be stored and insured. Telephone and internet providers for each resident needed to be informed of the change. Staffing had to be increased to provide 24/7 care provision, and Anchorage staff even had to undergo some induction training on residents’ rights. Every effort has been made to make the Anchorage residents comfortable with the change. A welcome barbeque was thrown, welcome baskets were gifted, a daily bus service was laid on to shuttle them back and forth to the village. Their main meal is provided at Ocean Shores for free, an incentive to keep them involved in village life. However, despite all best intentions, April this year brought torrential rain to Mount Maunganui and several of the ground floor resident apartments were flooded. Sandy took this set-back in her stride, as appears to be her way. She describes her leadership style as “participative”. “I work long hours. I muck in and do anything that’s required,” she says. I spot a pair of gumboots in the corner of her office and I believe her. Sandy isn’t willing to take all the credit herself and says she wouldn’t have won the award without the support of a good team alongside her. Like the residents, staff members are clearly thrilled for her. Her office is littered with congratulatory items: banners, flowers, cards, balloons. While Sandy appears to be enjoying the moment, she is already focused ahead on the next six weeks, which will be extremely busy for the village. There will be a change-over of apartments, involving the relocation of approximately 70 residents, some in their mid-nineties. I’ve visited Ocean Shores before, and while I enjoyed my last visit, I feel I’ve had a chance to glimpse the real heart and soul of the village this time, construction site and all. I’m catching them – the residents, the staff – all mid-journey, but what is so refreshing is that rather than hiding behind the change, they are embracing it and even enjoying it. I look forward to returning when the village is all pretty and new again. However, I feel privileged to witness change in action. The way it has all been managed is a credit to Sandy, and it is nice to see, as evidenced by the staff and residents’ applause at the end of her presentation, that her efforts have not gone unnoticed or unrewarded.
PROFILE
PETER BRUCE shares his “double dipping story”.
Last Word ... Peter Bruce
J
ust like so many other busy people, I was confronted with organising aged care for my increasingly frail, forgetful, and demented parents. For a few years, we had been getting more and more assistance in their home and it began to get a bit messy – in retrospect, it’s kind of funny to hear that they would frequently call an ambulance and when it arrived wonder who had called it and what it had come for. I paid many times for these false calls. Eventually the day came and both my parents went into a rest home – in separate rooms. Mum in the rest home and Dad into an apartment (in a Licence to Occupy arrangement) in the same home. This worked for a while until Mum deteriorated into Alzheimer’s disease and we moved her into the dementia wing of the same home, where she eventually passed away. Dad was also deteriorating. He was assessed by a geriatrician to be in need of greater care – rest home level care. The good news was that he could receive it in his apartment. This was in August 2010. The tariff, I was informed, was the same as for residents in the rest home part of the complex. But hang on – in the rest home, the accommodation is included as part of the care provided. We should be charged a little less, as Dad provided his own accommodation. A casual meeting with the operators in the supermarket one day confirmed this and they informed me that a nationwide chain had independently assessed this portion of the fee at $27 per day. After a two month stand-off, they offered $10 per day rebate. I accepted this as I did not want to compromise Dad’s care – but to everyone (except the rest home operators) this is a blatant rip off. Something is independently valued at $27 per day but we will pay you $10 per day for it. This is double dipping; I resolved to take it further. It seemed easy to begin with; an exchange of letters to the Minister of Health and our local district health board (DHB) agreed that this was happening and it was illegal under the contracts that all rest homes in New Zealand have with the DHBs. Consequently, a letter was written by the Nelson/Marlborough
DHB to every rest home in the region requiring refunds to be made to every resident in this situation. This letter was dated 2 May 2011 and has been universally ignored by rest home operators in the NMDHB’s region. Then it became difficult – the NMDHB did not know what to do. I began an unrelenting campaign to “put this right”. Numerous letters to the Minister of Health, the Associate Minister of Health, the NMDHB, the confederation of 20 DHBs, newspapers, three complaints to the Commerce Commission, two complaints to the Ombudsman’s office, personally addressing the NMDHB twice and much, much more. In the middle of all this, Dad died in January 2012. On 29 May 2012, the NMDHB announced that it was solved and they forwarded me the solution. I rejected it as unacceptable and even the Associate Minister of Health concurred with me, saying that, and I quote, “the solution could have been clearer”.
This is a blatant rip off. Something is independently valued at $27 per day but we will pay you $10 per day for it.
A senior member of the Minister of Health’s staff agreed that this anomaly was obvious and ridiculously overdue time and took a personal interest in moving this along. On 20 February 2013, I received a message from this senior staff member saying all had been agreed to and the final wording would be along soon. This has never happened. In the first week of March 2013, I met with Chris Fleming, the new chief executive of the NMBHB, who informed me that a solution had been found and it would be incorporated in the new contracts with every rest home in New Zealand and would come into force on 1 July 2013. It was forwarded to me, and on my initiative, re-litigated and then found to be satisfactory.
It was breath-taking in its simplicity. 1. Rest homes pay 12.3 per cent GST instead of 15 per cent; this is an 18 per cent reduction in GST. Because rent doesn’t attract GST, this is the negotiated percentage between all the rest homes in New Zealand and the IRD, and quite simply, is the accommodation component of rest home care. 2. This would apply to all residents in this situation – both subsidised and not subsidised. 3. There would be no retrospective reach – residents or residents’ families are free to pursue this by any other means they wish. So in dollar terms, in each DHB these vary a little. At NMDHB, the current maximum rate of subsidy is $830.49 per week or $118.64 per day. Eighteen per cent of that is $21.35 per day or $7792.75 per year to be refunded to each resident in this situation. A senior executive of the NMDHB informed me that about 20 residents in this region were in this situation and that the DHB has three per cent of New Zealand’s population. So that means the NMDHB rest homes have been double dipping to the tune of $155,000 each year, and nationally, this figure is over $5 million annually.
LESSONS LEARNED
To achieve anything in this situation, a bit of pit bull is required. Soft lobbying does not work. Results-driven process in the DHBs is hard to find. Process-driven process is the status quo with DHBs. The rest homes’ advocate groups promote and protect their interests very tenaciously, sometimes to the disadvantage of their frail, confused, and occasionally demented residents. Advice to give: An issue like this can easily dominate your life. It will take much longer that you perceive it at the beginning and a high level of commitment is required. If you have the luxury to think about this before you begin, then take a moment to consider if this is what you really want to do.
Got an opinion? Have your say online at www.insitemagazine.co.nz
edward@activerehabequipment.co.nz
www.insitemagazine.co.nz | August/September 2013 21
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