Provincial Recognition for Tilbury Manor

Sara Le, Director of Nursing at Tilbury Manor, aspired to enhance the quality of life for residents, their families, and staff. Partnering with Beverley Faubert, RNAO LTC Best Practice Co-ordinator, Sara reviewed the best practice performances at Tilbury Manor.

Positive results, with sustainability one year later, were achieved within less than six months by modelling nursing care practices after the RNAO Best Practices Guidelines (BPG) (see right). As a result of her team’s exceptional successes, Sara has been mentoring other LTC homes to help them achieve sustainable success in a short timeframe. The types of changes introduced often take 18 months to implement and are frequently challenged with questions like ‘why do we have to change?’ or ‘this will just add to our workload by adding another documentation step’. So why was Tilbury Manor so successful?

Empowerment of front line staff was key to the success of the initiative. Multi-disciplinary teams, each led by a registered staff, were formed to align with each of the best practices guidelines. With the results of a gap analysis in hand, teams created an action plan for achieving better outcomes in resident care which included: practice changes, policy review, and education and training for staff, residents and their families. Team leaders were responsible for implementing changes and ensuring the effectiveness of those changes. Scheduled audits and a review of the quarterly quality indicators reports showed that set goals had been achieved. Throughout the process, Dr. Colin Bryan, Tilbury Manor physician, was fully supportive of the changes.

Sara states that in her experience the gap analysis was easily completed in collaboration with the LTC BPG Coordinator. Front-line staff provided input and defined an organizational and inter-professional approach to filling identified gaps. There was minimal impact on workload as teams met weekly for one hour. In some areas, such as pain management, documentation was reduced.

Staff at Tilbury Manor
Kerri Taylor RPN, Megan Drummond RPN, Deborah Robert RN, Colette Berg RN,
Cheryl Labonte-McFeggan RN, Sara Le RN, Jovanna Klassen RPN


After one year of the great leadership provided by Sara and her team of champions, Tilbury Manor was one of three finalists for the Leadership Excellence Award at the November OLTCA Conference held in Toronto.

How can such a small long term care home achieve such big results? Beverly says “by keeping weekly meetings to one hour, we ensured there was little impact on workload. However, the most important enabler to success is ongoing support to empower staff with the clinical knowledge and leadership skills to create a positive, healthy work environment where they are the leaders from the beginning and become advocates for enhanced resident care.”

Interested in knowing how YOUR organization can achieve this level of success? Beverley or Sara would be happy to speak with you. You can reach both Beverly and Sara by email or phone at: bfaubert@rnao.ca or call 519-401-8485 and Sara at: DRC.Tilbury@Diversicare.ca or call 519 -682-0243.


Positive outcomes achieved by Sara and her team:

  • 0% newly acquired pressure ulcers
  • 0% worsened pressure ulcers
  • Falls decreased to below provincial averages
  • Restraints from 17% to 9%
  • Decrease in UTIs
  • Increase in bladder continence
  • Decrease in pain scores
  • Increase resident/ family satisfaction surveys
  • Increase in staff satisfaction