Elderbloom Community Care Centres

Drawing on research evidence and findings from earlier project phases, the team developed a three-part approach involving staff education, Skin Champions to support practice improvement, and a care bundle designed to strengthen pressure injury prevention for residents at risk. The care bundle approach was adapted from the University of Manchester INTACT protocol.

The implementation phase began with a co-design workshop involving carers, nurses, facility managers, clinical and quality staff, and members of the project team. During these discussions, carers and nurses raised concerns that the proposed pressure injury prevention activities could add to an already busy workload. The original care bundle required staff to complete multiple documentation steps at every repositioning interval, which participants felt could create an additional administrative burden.

Staff also expressed concern that the information collected through the project could be used to monitor performance or identify non-compliance, rather than support learning and improvement. This feedback highlighted the importance of presenting the initiative as a quality improvement project focused on resident outcomes, rather than a compliance exercise. 

Following the co-design process, the care bundle and implementation approach were refined and trialled across all three Elderbloom sites. The three-month bedside care bundle trial was introduced for residents identified as being at risk of pressure injuries, initially involving 31 residents. Registered nurses completed assessments to determine each resident's repositioning requirements and any individual considerations that needed to be taken into account. 

Regular audits were used throughout the trial to monitor implementation, track whether repositioning activities were being completed within the required timeframe, and identify opportunities for improvement. Compliance results were reviewed fortnightly by service managers and the project team, allowing targeted follow-up support when required. During the second half of the trial, the Clinical Lead also undertook Skin Champion responsibilities, providing additional oversight and support to frontline staff.

At the start of the project, two of three Elderbloom sites were sitting at pressure injury levels more than double the national benchmark. The project achieved meaningful improvements in pressure injury prevention, with all three Elderbloom sites approximately at or below the national benchmark by the Jan–Mar 2026 quarter. Compliance with the Pressure Injury Prevention Checklist reached 75% overall. While compliance was initially variable and later impacted by expanded at-risk criteria, sites were able to recover and achieve rates above 80% following adjustment and change management.  

The introduction of Skin Champion responsibilities into existing clinical leadership roles supported ongoing focus on wound prevention and management, while data dashboards improved visibility of pressure injury trends and prevention activities across the organisation. Together, these initiatives strengthened Elderbloom's ability to identify risks early and take preventative action before harm occurred. 

In aged care, pressure injuries are a visible marker of whether basic care systems are working: skin assessment, mobility, repositioning, nutrition, continence care, documentation, escalation and clinical oversight. They are also part of Australia’s residential aged care Quality Indicator Program, which is used by providers to monitor performance and compare trends.  

Given the strengthened Quality Standards now place a stronger emphasis on clinical governance and clinical care, the project shows that providers can improve care quality by focussing on the care process before harm occurs, not just investigating incidents after a pressure injury has developed.  

As Elderbloom is a small aged care provider, this project also has implications for small aged care providers where workforce capacity is often stretched and staff may need to cover multiple roles across clinical care, operations and quality. This project demonstrates that even in a smaller organisation, meaningful improvement is possible when prevention activities are embedded as part of everyday routines rather than added as another separate compliance task.  

The project highlighted the importance of involving frontline staff in the design of new initiatives and adapting approaches based on feedback during implementation. A digital compliance process, such as QR or barcode scanning at the point of care, would likely have improved efficiency, reduced manual audit burden, and enabled broader 24/7 compliance monitoring. 

Co-design with frontline staff was critical to gaining buy-in and ensuring solutions were practical for day-to-day care delivery. The project team made several adjustments in response to feedback and audit findings, including laminated checklists, clipboards, attached whiteboard markers, clearer colour-coding based on repositioning frequency, and flexibility in whether checklists were kept bedside or centralised at nurse stations. 

A key project pivot was the broadening of at-risk resident identification criteria beyond the Braden Risk Assessment. This expanded the cohort from 31 to 58 residents, covering more than 40% of Elderbloom’s occupied beds, and improved the project’s ability to capture residents at genuine risk, although it also increased audit workload. 

Overall, the project demonstrated that successful pressure injury prevention requires practical tools, frontline ownership, responsive change management and systems that support sustainable compliance monitoring. Future improvements could include digital capture and recording the resident’s repositioning side or position to strengthen clinical documentation.