Narrative for Health Care Organizations in Ontario - Quality Improvement Plan (QIP)
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Quality Improvement Plan (QIP) Narrative for Health Care Organizations in Ontario February 23, 2023
2 NARRATIVE QIP 2023/24 Org ID 54400 | Chartwell Wynfield LTC Residence
OVERVIEW
Chartwell Wynfield is home to 172 residents in Oshawa Ontario.
We strive to be the best place to work and live. In order to do this,
we are committed to improving the quality of life and overall
experience by providing care and service that align with our mission
and corporate Values of RESPECT. Our Mission is to provide a
happier, healthier, and more fulfilling life experience for seniors.
The Home’s Continuous Quality Improvement Committee, led by
the Home’s Administrator, includes representatives from all
disciplines, as well as a resident and a family member, as well as the
Home’s Medical Director, Dietitian, and other community partners.
This committee meets quarterly, and will bring forward any
concerns from other committees, including Residents and Family
Councils. This Committee currently meets in a hybrid model, some
members live and some virtually. This allows everyone to
participate in reviewing quality indicators and initiatives, and allows
members to share their ideas, input and feedback. This Committee
determines priorities for the year, including quality improvement
activities for indicators, Resident and Employee Satisfaction, and
does so by participating in annual program evaluations. The
Committee communicates with the Home via postings on a Quality
Improvement Board, as well as during town hall and department
meetings, and Residents and Family Councils.
The Home provides long term care services to residents with a
variety of complex medical and nursing needs. As an early adopter
for the BSO program with dedicated funding, we will continue our
work in spread and sustainability both within the home and the
community as part of our agreement. In addition, Chartwell’s
IMAGINE program, has led to additional education for team3 NARRATIVE QIP 2023/24 Org ID 54400 | Chartwell Wynfield LTC Residence
members, continuing to increase resident engagement in life at the REFLECTIONS SINCE YOUR LAST QIP SUBMISSION
Home. Chartwell Wynfield LTC Residence is dedicated to the
Since submission of the last QIP, the Home has continued to
provision of excellent care and services for its residents, utilizing the
experienced challenges based on the COVID-19 pandemic. Now
Home's staff, volunteers and community resources. During the
that the pandemic is ultimately transitioning to more endemic in
pandemic, the Home had to become experts in Infection Prevention
nature in Ontario and Canada, the Home had been able to refocus
and Control, and as part of the Home’s 2022-2023 plan, has
on the quality initiatives in the Home. Part of this including
demonstrated significant improvements in this area during 2022-
expanding membership of our Continuous Quality Improvement
2023. Additionally, as seen in progress report, Falls Prevention
Committee to include a resident and family member, and all
program has shown great improvement in 2022-2023 based on
internal and external partners. Action plans from Resident and Staff
work done by the Home. As per the Home’s dedication to quality
Satisfaction surveys rendered action plans to assist in overall quality
improvement, the Home continues to maintain 3 year accreditation
improvement at the Home. The Home implemented requirements
status with CARF, Commission on Accreditation of Rehabilitation
for new Fixing Long Term Care Act and found successful solutions
Facilities.
for ongoing human resource challenges. As evident by the
indicators, the Home did see improvement in two areas of focus in
The Home prides itself on being accessible for residents, families,
the plan from 2022-2023. Exceeding the goal set for Falls
and team members, ultimately creating a safe environment for
Prevention was a major success for the team and residents.
everyone.
Although the Home did not meet the goal set for worsened
pressure ulcers, we acknowledge there was improvement noted
Our Values incorporate
from initiation of our plan, and with focus on this area in 2023-
2024, we are confident that the Home will realign quality indicators
Respect - We honor and celebrate seniors
with provincial and Chartwell averages.
Empathy – We believe compassion is contagious
Service Excellence – We Believe in providing excellence in customer PATIENT/CLIENT/RESIDENT ENGAGEMENT AND
service PARTNERING
Performance – We believe in delivering and rewarding results
Education – We believe in lifelong learning The Home works with it’s Residents and Family Councils each year
Commitment – We value commitment to the Chartwell Family to review a satisfaction survey to be provided to everyone for
Trust – We believe in keeping our promises and doing the right feedback. Both Councils review the proposed survey for any
thing. additions or changes. Our Survey was available for completion in a
paper copy, or online from June 6-24, 2022. Team members were
available to assist residents to complete their survey as requested.
Clarification provided only as needed. Once results are received4 NARRATIVE QIP 2023/24 Org ID 54400 | Chartwell Wynfield LTC Residence
back, they are reviewed by both Councils. Overall satisfaction for 2022. Both Councils were very pleased with the plan and focus on
residents was 31%, a slight decline from 35% the previous year. improvement for residents in the Home. This process will continue
Our Residents Council reviewed on November 23, 2022, Family into 2023, providing the Home with valuable feedback to continue
Council reviewed results and action plans January 18, 2023 (based to focus on resident and family satisfaction.
on their meeting schedule) and was reviewed by the Continuous
Quality Improvement Committee on December 8, 2023. PROVIDER EXPERIENCE
Additionally, the Quality Improvement lead (Administrator) of the The Home is as dedicated to employee satisfaction as it is Resident
Home held focus groups with residents to gain further feedback, and Family Satisfaction. This is demonstrated by completing annual
which were completed on November 6 and 8, 2022. This feedback satisfaction survey, solicitation of feedback and input into action
was used to complete action plans for 2023 year. The Home also plans, and execution of the plans. The employee satisfaction survey
met and communicated results with the team on October 25, also was completed from June 6th-June 24th, 2022. Results were
gaining team input for their satisfaction survey action plans. received and communicated October 26, 2023, and feedback into
development of an action plan solicited. The Home did implement
The Home and residents celebrated some successes from the some of the action items from previous year’s survey including
previous year’s survey, despite seeing an overall decline in improving daily provision of information at team up meetings.
satisfaction. The team saw an increase in team members providing Additionally, schedule for reception team was adjusted to have
care in both nursing and recreation teams. This improved more coverage time to address inquiries from visitors. Staffing
timeliness of care provision for the residents and feedback was compliment was increased, and new job routines created for new
positive during focus groups. The recreation team also re- roles, to assist with provision of excellent care for our residents.
implemented outings and completed a specific request for a Also, job shadowing was encouraged to increase knowledge of
breakfast outing which was enjoyed by many. Additionally, the other roles, and improve teamwork. Chartwell corporate team has
Home highlighted resident choice meals, themed meals, special initiated Lifespeak, a resource with many videos, education and
meals (BBQs, Corn Roasts) and also reeducated cooks regarding support resources available to all team members. Team members
recipe provision, all to help improve satisfaction of food at the also have onsite support from the Home’s Social Service Worker
Home. The Home also implemented a continental style breakfast and external supports through an Employee and Family Assistance
for those residents who prefer to rise later in the morning, Program. The Home provides appreciation events throughout the
therefore missing the seated breakfast meal. year including themed events with games and prizes, or special
meals, and snacks. To support retention efforts the home actively
The Home’s Quality Improvement plan has also been shared with participated in administering pandemic premiums for PSW staff
both Councils for input and feedback. The Residents Council through government initiatives which are now permanent in
reviewed on July 20, 2022 and the Family Council on September 18, nature, and retention funding was provided for the RNs/RPNs in the5 NARRATIVE QIP 2023/24 Org ID 54400 | Chartwell Wynfield LTC Residence
Home. The Home has focused on human resources, implementing completes practice exercises to grow confidence in responding to
a corporate recruitment strategy, providing a referral bonus to Code White incidents. The Home ensures mandatory reporting of
current team members. The Home maintains contracts with agency critical incidents based on the current regulations.
partners, utilizing their services where required. However, we
focus on student learning and mentoring, and encourage student The Joint Health and Safety Committee, a group made up of both
applicants. The Home has participated in Supervised Practice leadership and front-line team members, complete a risk
Experience Partnership with College of Nurses of Ontario, assisting assessment annually, reviewing and sharing any feedback with the
internally trained nurses reach their goal to nurse in Canada. Home’s leadership team to address. Individual concerns brought
forward following requirements of the Occupational Health and
WORKPLACE VIOLENCE PREVENTION Safety Act. Supports for our team members include onsite access
The Home reviews the Workplace Violence Prevention policy to the Home’s Social Service Worker, Employee and Family
annually, posting a signed copy in the Home. Additionally, posters Assistance Programs, WSIB for any workplace injuries and
reminding all visitors, team and residents that this is a respectful Chartwell’s corporate Health and Safety team.
environment are spread throughout the Home. These note that
disrespectful behaviour will not be tolerated. Upon hire, each team PATIENT SAFETY
member receives education on Workplace Violence Prevention The Home uses various methods to monitor and analyze patient
policy, and all team members review annually thereafter. In 2022, safety. One of which is our internal reporting process. Any incident
the home hosted sessions on diversity, dangers of biases, is documented in our internal documentation system, Point Click
inclusiveness, and respectful workplace from the Home’s Care, and shared through report to alert members of the team. If
Administrator and Human Resource Managers. The Home also required, these incidences would be reported through Mandatory
educates team members on Whistleblower protection and policy, Reporting or Critical Incident reporting system. These Critical
which prevents any retaliation to someone bringing forward a incidents are tracked and analyzed by the Home. Critical incidents
complaint. Any breaches of this policy are addressed. are reviewed at the Professional Advisory Committee, as well as
with the newly revitalized Continuous Quality Improvement
Team members receive education on Responsive Committee. This team also reviews annual Program Evaluations
behaviours/personal expressions, Dementia, Mental Health, and which often include discussions regarding critical incident
many have attended the IMAGINE program. This program focuses occurrences and trends. The Home also tracks, reviews, and
on supporting residents to live their lives to their full potential by analyzes complaints received. This is helpful to identify if a concern
examining staff approach, expressions having meaning, and how to is repeating or focused on one neighbourhood in the Home. The
engage residents into meaningful activity. Team members received Continuous Quality Improvement Committee and Leadership
education on Code White, and how to respond. The Home also Committee review these at every meeting, to track trends, and6 NARRATIVE QIP 2023/24 Org ID 54400 | Chartwell Wynfield LTC Residence discuss plans for improvement. 5%. In addition to tracking and analyzing data from critical incidents and HEALTH EQUITY complaints, the home reviews other indicators regarding resident Chartwell Wynfield LTC is dedicated to an inclusive environment for safety including; medication errors, resident falls, and infection all residents, families, visitors and team members. The Home has rates. All of these are reviewed at monthly Leadership meetings, as focused on diversity and inclusion training in 2022 for its team well as at Continuous Quality Improvement Committee meetings. members and has focused on celebrating cultural events as well. In Discussions and feedback are always incorporated back into the 2022, the team hosted a Caribbean festival celebration for residents improvement plan for the Home. Annual program evaluations for and team members, as well as Chinese New Year, Diwali, Truth and each program, are also completed and reviewed by the Continuous Reconciliation Day, and many other cultural celebrations. The Quality Improvement Committee. Continuous Quality Improvement Committee and Leadership As a result of these evaluations and reviews of trends as previously Committees, review Strategic Panning annually, and part of this discussed the Home develops action plans which may result in plan is completing a Cultural Competency and Diversity Plan. Using education for team members, revisions of resident care plans, data collected for residents; Point Click Care assessments, our communication to team through memos, and team up meetings or Recreation Assessments, All-About-Me posters, conversations with huddles. For instance, Infection Prevention and Control was a residents and care conferences, the Home revises and updates its major focus for our Home in 2022, and while working to improve plan accordingly. Additionally, Chartwell corporate team has this program, additional education for families was also provided, to started to include gathering of more focused demographic data on ensure they understood proper hand hygiene and donning and annual staff surveys, to assist in focusing on creating a more doffing for isolation purposes. inclusive organization. The Home shows dedication to resident safety by conducting an Through gathering of this data, the Home can connect with annual Medication Safety Self-Assessment, guiding the home’s community organizations for supportive programming for residents. focus with regards to safe medication management. Additionally, This may include finding a companion or friend that a resident can the Home is making improvements including implementing speak to in their preferred language. The Home maintains a list of Medication Safety Technology. The Home now has an Automatic team members who speak languages other than English, who can Drug Cabinet, which dispenses medications safely and securely. support residents and families as a result. The Home supports The Home uses Falls Prevention funding to provide individualized resident programs centred on cultural diversity and inclusion. The falls and injury prevention interventions to its residents. The efforts Home has hosted PRIDE week for several years now, highlighting made in the Falls prevention program at the Wynfield LTC in 2022, that the Home is accepting of all people; race, gender and culture. have demonstrated a significant improvement, decreasing falls by At a corporate level, Chartwell has formed a Diversity and Inclusion
7 NARRATIVE QIP 2023/24 Org ID 54400 | Chartwell Wynfield LTC Residence
Committee, with resources available to all of our Homes, the
Wynfield LTC included. SIGN-OFF
It is recommended that the following individuals review and sign-off on your
CONTACT INFORMATION/DESIGNATED LEAD organization’s Quality Improvement Plan (where applicable):
Debbie McCance I have reviewed and approved our organization’s Quality Improvement Plan on
Administrator/Quality Lead February 23, 2023
Chartwell Wynfield LTC Residence
451 Woodmount Drive
Oshawa, ON L1G 8E3
Christine Maragh-DRO, Board Chair / Licensee or delegate
Email: dmccance@chartwell.com
Phone: (905) 571-0065 Ext. 502
Debbie McCance-Administrator, Administrator /Executive Director
Debbie McCance-Quality Program Lead, Quality Committee Chair or
delegate
Barb Murphy-Director Quality Chartwell, Other leadership as
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