Avalon House Nursing Home - Aged Care Quality...Residents living with dementia Street/PO Box: 14-16...

Avalon House Nursing Home RACS ID 0833

14-16 John Street AVALON NSW 2107

Approved provider: Thompson Health Care Pty Ltd

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 17 June 2015.

We made our decision on 1 May 2012.

The audit was conducted on 2 April 2012 to 3 April 2012. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits.

Home name: Avalon House Nursing Home Date/s of audit: 2 April 2012 to 3 April 2012 RACS ID: 0833

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Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome Accreditation Agency

decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

Standard 2: Health and personal care

Principle: Residents' physical and mental health will be promoted and achieved at the optimum level in partnership between each resident (or his or her representative) and the health care team.

Expected outcome Accreditation Agency decision




2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


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Standard 3: Resident lifestyle

Principle:

Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care service and in the community.


decision




3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors.


decision




4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


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Audit Report

Avalon House Nursing Home 0833


Introduction This is the report of a re-accreditation audit from 2 April 2012 to 3 April 2012 submitted to the Accreditation Agency. Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to residents in accordance with the Accreditation Standards. To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards. There are four Standards covering management systems, health and personal care, resident lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment. Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Accreditation Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home. Assessment team’s findings regarding performance against the Accreditation Standards The information obtained through the audit of the home indicates the home meets:

44 expected outcomes


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Audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the re-accreditation audit from 2 April 2012 to 3 April 2012. The audit was conducted in accordance with the Accreditation Grant Principles 2011 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors. The audit was against the Accreditation Standards as set out in the Quality of Care Principles 1997. Assessment team

Team leader: Barbara Knight

Team member/s: Kim Short

Approved provider details


Details of home

Name of home: Avalon House Nursing Home

RACS ID: 0833

Total number of allocated places:

78

Number of residents during audit:

78

Number of high care residents during audit:

71

Special needs catered for:

Residents living with dementia

Street/PO Box: 14-16 John Street State: NSW

City/Town: AVALON Postcode: 2107

Phone number: 02 9973 0900 Facsimile: 02 9973 0950

E-mail address: [email protected]


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Audit trail The assessment team spent two days on-site and gathered information from the following: Interviews

Number Number

Director of nursing (DON) 1 Residents/representatives 10

Deputy director of nursing (DDON)

1 Recreational activities officers 2

Registered nurses 4 Aromatherapist 1

Infection control/occupational health and safety officer (RN)

1 Physiotherapist 1

Care staff 3 Laundry staff 1

Application support 1 Cleaning staff 3

Catering staff 3 Maintenance staff 1

Sampled documents

Number Number

Residents’ files 9 Medication charts 4

Resident agreements 6 Personnel files 8

Other documents reviewed The team also reviewed:

Accident/incident forms and monthly reports

Activities programs

Aromatherapy pain list

Audit and survey records

Bus trip list

Church service dates

Cleaning schedules

Compliments/complaints register

Continuous improvement plan

Criminal record check register

Education calendar, attendance records, questionnaires and competency assessments,

Food safety manual, cleaning, temperature and sanitising records consistent with hazard analysis critical control point (HACCP) requirements

Individual activities attendance sheets

Infection records including incidence of infection, infection rates analysis and summary reports and graphs, audit results and quality improvement activities undertaken

Information handbooks, residents/staff/contractors/volunteers

Mandatory reporting register


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Medication audit results

Meeting minutes including residents/relatives/staff/ infection control and OH&S

Monthly aromatherapy/massage records

Pest control reports

Policies and procedures

Position descriptions/duty statements/staff appraisals

Preventative maintenance schedule, warm water temperature and legionella testing records

Professional registration records

Psychotropic drug totals

Schedule 8 medication register

Service agreements

Skin integrity clinical trend analysis report

Staff rosters and daily allocation sheets

Supplements list

Various assessments

Various observation charts and records

Volunteer documentation Observations The team observed the following:

Activities in progress including dog show and Easter church service

Chemical storage and material safety data sheets appropriately located

Clean and dirty utility rooms including sharps containers, spills kits and, waste disposal

Cleaning in progress and equipment trolleys

Electronic ordering system for continence aids

Equipment and supply storage areas and equipment in use

Equipment to support mobility and transfer of residents

Fire panel, fire equipment, emergency flip charts, evacuation plans and evacuation box

Hand sanitisers, hand washing facilities and posters

Information brochures, noticeboards and suggestion box

Interactions between staff, residents and family members

Living environment internal and external

Lunch time meal service

Medication rounds

Outbreak management box including equipment and documentation

Residents being assisted to eat and mobilise

Residents’ files securely stored


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Shift handovers

Storage of medications


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Assessment information This section covers information about each of the expected outcomes of the Accreditation Standards. Standard 1 – Management systems, staffing and organisational development Principle: Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates. 1.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Interviews, observations and document review demonstrate that Avalon House Nursing Home has systems and processes that underpin the active pursuit of continuous improvement across the four Accreditation Standards. Information is obtained through continuous improvement feedback forms, results of audits and surveys, meetings, incident/accident reports, observation and informal feedback from staff residents and representatives. A continuous improvement plan is developed which documents the issue, actions, timeframes, progress, evaluation and closure of all identified opportunities for improvement. Staff and residents/representatives are aware of the program and the ways in which they can make suggestions and commented that they receive feedback on all suggestions and improvement activities. Improvements relevant to Accreditation Standard One include:

Implementation of the electronic documentation system. This included trial of the system, education for all staff and appointment of “superusers” to assist and support staff across all shifts. Avalon House Nursing Home was one of the trial sites for the organisation and “went live” in December 2010. Since then the system has been upgraded and the latest version implemented in January 2012. As well as resident information the system is used for messaging and maintenance issues. Management and staff are very satisfied with the system and report benefits that include improved access to information, relevant information is more easily located, and time saving.

Development of staff through education and training programs such as Frontline Management, Certificates III and IV in aged care and leisure and lifestyle and in house mentoring. Management is able to undertake succession planning and staff have opportunities to further develop their careers.

In response to staff feedback regarding the increasing acuity of residents and consequent increased workloads, an extra care staff member has been allocated for the morning shift and for night duty. This has been well received by staff.

1.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”. Team’s findings The home meets this expected outcome There are systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. The home receives information


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from the head office regarding legislative changes and any impact they may have at local level. Information is also obtained through peak industry bodies, circulars and bulletins from Department of Health and Ageing and other government and non government departments and professional organisations. Regulatory issues and updates are communicated to staff through memoranda, meetings and education sessions. Staff state they receive regular updates on regulatory issues and that they have access to information in regards to legislative and regulatory requirements. Management monitors compliance through a review of policies and procedures, audits, observation of staff practices and feedback. Examples of the home’s monitoring and compliance with regulatory requirements relevant to Accreditation Standard One are:

A system to ensure criminal history checks for all staff remain current and the maintenance of a criminal history check register

Maintenance of a mandatory reporting register

Maintenance of professional staff registrations

Notification to residents/representatives of the re-accreditation audit and their right to speak with the assessment team.

1.3 Education and staff development: This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Avalon House Nursing Home can demonstrate that systems and processes ensure that management and staff have appropriate knowledge and skills to perform their roles effectively. There is a flexible education program which includes needs identified through performance appraisals, in response to resident care needs, complaints, mandatory requirements, results of audits and surveys and staff requests. An education calendar is developed and in addition to formal training sessions, registered nurses provide education on targeted topics at handover and on the spot training is used to address identified individual issues. Training records are kept and were noted to include education across the four Accreditation Standards. Orientation for all staff includes education on elder abuse, infection control, fire safety and manual handling. Safe food handling is included for relevant staff. Discussions with staff confirm they receive education at orientation and on an ongoing basis to enable them to perform their roles effectively. Education relevant to Accreditation Standard One includes:

Information systems ongoing training and updates on the electronic documentation system

Elder abuse and mandatory reporting

Bullying and harassment.


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1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s findings The home meets this expected outcome There are systems to ensure that residents, their representatives and other interested parties have access to internal and external complaints mechanisms. Internal mechanisms include meetings, internal suggestion/complaints forms and discussions with management. The team noted that information on external complaints mechanisms is displayed at the home and information is detailed in the resident handbook. Review of the compliments/complaints register demonstrated all complaints both written and verbal are documented, actioned and closed off within appropriate timeframes. Interviews with residents/representatives confirm they are aware of internal and external complaints mechanisms, but prefer to go straight to management as they have an open door policy and any issues are promptly dealt with. 1.5 Planning and leadership This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service". Team’s findings The home meets this expected outcome The philosophy, vision and values of the home include the commitment to provide a homelike environment where excellence in care services is provided to each resident. The philosophy and values are displayed throughout the home, documented and published in the resident and staff handbooks. Policies and procedures guide staff practice and the home’s established continuous improvement program monitors and evaluates the ongoing commitment to quality. Management and staff are aware of and understand the philosophy, and their commitment can be observed in the practices, attitudes and interactions between staff and residents/representatives. 1.6 Human resource management This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives". Team’s findings The home meets this expected outcome Avalon House Nursing Home has systems and processes to ensure there are sufficient staff with the appropriate knowledge and skills to provide care and services to the residents. The home is supported by the organisation’s Human Resources department which provides direction and assistance as required. There are recruitment and selection processes, an orientation program including buddy shifts and ongoing education. Staff have a performance appraisal after three months and then annually. Professional development is discussed at the time of appraisal and there is opportunity for further education including Certificates III and IV in aged care and leisure and lifestyle. A master roster is in place and daily staff allocations are managed by the DDON. The roster is responsive to changes in resident profile and acuity. An incentive system includes “Employee of the month” awards with a staff lunch and presentation each three months, an offsite, catered graduation ceremony for those completing education during the year, and gifts at Christmas and for birthdays. Staff confirm


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they receive ongoing education relevant to their roles and have opportunities to undertake further training. Residents/representatives are satisfied there are sufficient, appropriately qualified staff to meet care and service needs. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s findings The home meets this expected outcome The team observed and staff confirmed there are appropriate levels of stock and equipment including medical supplies and equipment, food, chemicals, furniture and linen, to provide quality care and services to residents. Management state head office is responsive to requests for additional equipment and supplies, for example, low/low beds have been purchased to meet identified need in the secure unit. A preventative maintenance schedule is in place and reactive maintenance is requested through the electronic documentation system and noted to be actioned in a timely manner. External contracts are in place for the maintenance of specialised equipment. Staff state there are sufficient supplies of goods and equipment for them to carry out their duties. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome Avalon House Nursing Home has processes which ensure that information, including legislative requirements, care and lifestyle issues, is effectively managed and disseminated to staff, residents and representatives. The electronic documentation system facilitates access to resident care information and dissemination of information to staff through the messaging system. There are resident handbooks and residency agreements, resident and representative meetings, newsletters, information brochures, noticeboards and suggestion forms. Information is provided to staff through the electronic system, staff handbook, orientation and ongoing education, meetings and handover reports. Discussions with residents, representatives and staff indicate that they are satisfied there is an efficient two way flow of information. All staff sign confidentiality agreements on commencement of their employment and staff files are securely stored. The electronic system is password protected, backed up daily and there are contingency plans should there be an interruption to computer services. Discussions with staff and residents/representatives indicate they are satisfied there is an efficient two way flow of information. Particular mention was made of management’s open door policy. 1.9 External services This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals". Team’s findings The home meets this expected outcome All externally sourced services are reviewed regularly to ensure they meet the home’s needs and quality goals. There are contracts/agreements for the supply of goods such as


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pharmaceuticals and continence products, for maintenance of systems such as fire safety and air conditioning and provision of services such as allied health, hairdressing and beautician. Equipment is trialled before purchase. Feedback on contracted services is encouraged through meetings and surveys.


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Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome For details of the continuous improvement system refer to expected outcome 1.1 Continuous improvement in this report. Examples of continuous improvement activities relevant to Accreditation Standard Two include:

Introduction of the “Circle of Care” to support staff in the management of residents with behavioural issues. This is overseen by a clinician from the mental health team and centres on different methods of managing behaviours through review of the whole person rather than focusing on the behaviour. Staff report they now feel more confident in supporting and managing residents with behaviours of concern

Introduction of doll therapy for identified residents with behavioural issues. Staff and family members report residents’ marked decrease in behavioural issues

Provision for a staff member to attend a palliative care course and purchase of a syringe driver for use in palliation. Previously the home had borrowed a syringe from a local hospital and accessed the palliative care team for advice and support.

2.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.2 Regulatory compliance for details about the home’s systems to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards and guidelines. Examples of compliance with regulations relevant to accreditation standard two include:

Maintenance of register of nurses professional registrations

Maintenance of schedule eight drug records 2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.3 Education and staff development and expected outcome 1.6 Human resource management. Examples of education relevant to Accreditation Standard Two include:


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Dementia care workshop for staff working in the secure unit and ongoing behaviour management education for all staff

Continence management and colostomy care

Oral hygiene

Sleep management, use of aromatherapy

Use of newly purchased syringe driver 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome Residents’ accommodated at Avalon House Nursing Home include high and low care residents including those with dementia related illnesses. The staff provide residents with clinical care which is appropriate to their needs and preferences. The home’s processes include collecting information from personal history, initial assessment data, clinical assessments, progress notes, referrals and clinical reports. Care is planned, delivered and evaluated with the input from staff, other health professionals, residents and/or their representatives. Care is generally carried out consistently according to the resident’s care needs. Each resident has a documented care plan which is evaluated every three months. General observations are conducted and appropriate actions taken as required. A resident accident and incident reporting system is in place through which residents’ accidents and incidents are reported, acted upon and reviewed; where necessary referrals are also made. There are clinical policies, procedures and flowcharts to inform and guide staff in aspects of clinical care. Staff interviewed demonstrated knowledge of individual resident care requirements. Information in relation to residents current care needs is reported to staff in written form and verbally through the handover reporting system. Residents/representatives confirm that they are satisfied with the care provided. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s findings The home meets this expected outcome There are systems to identify and meet residents’ specialised care needs; these include educating staff to the appropriate level to deliver specialised care and ensuring that appropriately trained staff are providing the care. The home has registered nurses on both floors of the home. The registered nurses develop and review all care plans for residents. Education has been provided to registered nurses on specific areas of specialised care to develop an internal knowledge base. Specialised care is generally provided according to medical and clinical orders. Staff interviewed demonstrated knowledge and understanding of specific residents’ specialised nursing care needs, for example, wound care, diabetic management and catheter care. Residents/representatives express satisfaction with the management of specialised nursing care needs.


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2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s findings The home meets this expected outcome Processes at the home enable residents to receive timely and appropriate care from health specialists according to individual needs and preferences. There are systems to ensure residents are regularly reviewed by their doctor; documentation demonstrated that doctors are engaged with in emergencies and as needed. Resident incidents and accidents which result in resident injury, are investigated and appropriate clinical care/referral is provided such as contacting the doctor, first aid and/or transfer to hospital. Staff interviewed demonstrated an understanding of the referral system and staff have access to information on resident referral requirements. Information in relation to referral to the appropriate health specialist and follow-up of referrals was viewed in the resident notes; for example; the mental health team, doctors, physiotherapist, and podiatry. Residents/representatives interviewed express satisfaction with the care provided by the home and residents’ access to medical and clinical care. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome There are effective systems to ensure that medication orders are current and resident medication care needs are identified (for example allergies, special alerts and medication administration needs). Consideration is given to residents’ cognitive level and physical requirements. Residents’ medications are regularly reviewed and changes in medications are communicated and supplied in a timely way. The home has a system to ensure medications are ordered, received, stored, administered, documented and discarded safely. Medication is provided to residents by registered nurses. The medication management system is monitored through the continuous improvement system which includes regular audits, pharmacy reviews and medication incident reporting. Staff interviewed demonstrated an understanding of routine monitoring of residents’ response to medications. Residents /representatives reported satisfaction with the home’s monitoring and management of residents’ medication. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s findings The home meets this expected outcome Pain management is provided through the identification, assessment, exploratory investigation and evaluation of pain levels which are completed on admission and as required. Focus assessments include the identification of pain through non-verbal and verbal cues. Interventions to manage and minimise pain levels are documented in the residents’ care plan. Regular and routine evaluation of the effectiveness of pain management strategies is conducted. The home provides a range of treatment options for residents’ pain management including aromatherapy, massage, re-positioning, physical therapy, the use of pain relieving equipment, heat/ice packs and medication management. Staff interviewed demonstrated an understanding of individual resident’s pain management requirements.


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Residents/representatives interviewed report satisfaction with the care and assistance provided to assist in pain management. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s findings The home meets this expected outcome The staff and management at the home can demonstrate that the dignity and comfort of residents who are terminally ill is maintained. Systems are in place to identify and put into practice end of life wishes, and palliative/cultural specific care. Staff interviewed demonstrated knowledge and skills in the management of residents who have a terminal illness including skin care, pain management, cultural and spiritual needs and emotional support. The home has equipment for providing advanced pain management such as a syringe driver. End of life wishes and requirements are documented in resident records. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s findings The home meets this expected outcome Residents’ dietary needs and preferences are obtained on entry to the home and this information is provided to the kitchen. Food of varying consistency and texture is provided based on residents’ individual needs. Staff provide assistance to residents with their meal as needed. Residents are weighed monthly or more often as required. Observation of staff practices demonstrated individual attention to residents’ nutritional and hydration needs. Residents are encouraged to maintain hydration with drinks provided at meal times, together with morning and afternoon tea. Additional drinks and nutritional supplementation of meals is provided based on residents’ identified needs. There is a system for the management of residents hydration needs during hot weather and access for residents who wish to independently access fluids. The home has systems for the identification of ‘at risk’ residents. The home has access to a speech pathologist who will visit to the home to assess residents as required. Residents/representatives reported to the team that residents receive sufficient food and drinks. 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome The home ensures that residents’ skin integrity is consistent with their general health through skin and general health assessments. These are conducted on entry to the home and specific focus assessments are conducted to identify potential risks to residents and individual skin care needs and preferences as required. Care plans detail residents at risk and identify interventions and preventative measures. Monitoring and treating of skin irregularities, wounds, infections, pressure areas and skin integrity incidents by the appropriate staff occurs. External providers such as podiatrists are available and accessible.


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We observed specialised equipment used to assist with maintaining skin integrity such as pressure relieving devices, specific manual handling equipment, limb protectors and the use of skin moisturisers. Skin breakdowns have wound/dressing charts recorded and treatments are provided by registered nurses. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s findings The home meets this expected outcome Residents’ continence is managed effectively through initial and focus continence assessments, care planning and the provision of individual toileting programs, bowel management programs (including documented voiding patterns via bowel charts) and continence products. The home demonstrated an effective system for the management of continence aids, bowel habit recording and catheter care. There are systems for the assessment, usage and distribution of continence pads. Staff interviewed demonstrate an understanding of specific resident’s continence requirements and knowledge of the systems and policies used at the home. The team noted the home was free from odour during the two days of the re-accreditation site audit. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The home has systems to effectively manage the needs of residents with challenging behaviours. Assessment and intervention strategies occur in consultation with residents and/or representatives, doctors and/or other health professionals or teams as required. Referrals for the management of residents with behaviours of concern and challenging behaviours include reviews from medical practitioners, psycho-geriatrician and mental health team. Staff interviewed described general and specific managements of residents’ behaviour. The activity program provides for specific one-to-one and small group programs for residents with identified challenging behaviours. The home has a dementia specific area for residents with dementia and wandering behaviours. The home has a system to manage residents who may try to leave the home and for the management of residents who require restraint. Staff practices observed are consistent with appropriate behaviour management strategies. We noted the dementia specific area to have an environment that was calm and pleasant. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s findings The home meets this expected outcome The home has systems for ensuring that optimum levels of mobility and dexterity are achieved for each resident, including comprehensive assessments, the development of mobility and dexterity plans and mobility programs. A mobility and dexterity program is developed for residents by the physiotherapist. The activity officer provides group exercises which encourage dexterity and maintains mobility. Manual handling assessments are


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conducted and the information is updated and accessible for all staff. An individual walking program is regularly conducted by the physio-aid. The effectiveness of the program is assessed through physiotherapy assessments, in addition to the monitoring and review of incidents and accidents. The staff interviewed discussed and demonstrated how the program has resulted in improvements to and maintenance of residents’ mobility and dexterity and the management of residents who are assessed as ‘at risk’ of falls. Staff are provided with education on manual handling. Residents/resident representatives interviewed express satisfaction with the management of residents’ mobility and dexterity. 2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Staff explained to the team how residents are assisted with their daily oral care and hygiene. Residents with their own teeth are encouraged and supported to maintain their independence in terms of oral hygiene and brushing. The home has a dental care service that visits the home. Residents expressed satisfaction with the support provided to maintain their oral and dental care. Strategies used by the home to maintain dental hygiene include regular dental review and the provision of soft tooth brushes and swabs to alleviate dry mouth. Care staff identify problems such as mouth ulcers, chipped, broken or ill fitting dentures whilst providing care; any problems are reported to the registered nurse who follows up with the dental services. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome The home ensures that residents’ sensory losses are identified through the assessment process that can include examination by vision and audiology specialists as required. Optometry and hearing aid services are accessible and the home can access specialist medical services if necessary. The level of assistance required and management of relevant aids such as reading glasses and/or hearing aids are included on the resident’s care plan that is regularly reviewed. Communication assessments and care planning procedures are in place. Sensory stimulation is also provided through the activities that residents participate in, for example aromatherapy, walks, exercises, bus trips, playing music and massages. Residents/representatives interviewed confirmed residents are referred to appropriate specialists as required and residents indicated satisfaction with their meals. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome The home has systems to ensure that sleep patterns are assessed on entry to the home and at times when sleep difficulties are identified. Individual sleep management strategies are developed depending on residents’ needs and preferences. These include maintaining usual settling and rising times for each resident, pain relief, regular toileting or provision of night


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continence aids. Staff are able to adjust the environment by keeping noise levels to a minimum, regulating heating and lighting to assist residents to have a good night’s sleep. Residents’ sleep patterns are monitored by the staff on night duty and sleep disturbances and interventions are recorded in the residents’ progress notes. Irregular sleep patterns are followed up through assessments and clinical/medical review. Staff reported medication is used as a last resort and that the alternatives include, aromatherapy, massage and warm drinks.


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Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome For details of the continuous improvement system, refer to expected outcome 1.1 Continuous improvement. Examples of continuous improvement activities relevant to Accreditation Standard Three include:

With the introduction of the upgraded electronic system a gap was identified that there was insufficient information to complete the “Life Story” part of the assessment process. All staff were involved in gathering information from residents and family members to complete the life stories. Very positive feedback was received from staff who stated they had increased awareness of residents’ background and more understanding of their individuality.

Introduction of the use of doll therapy as detailed in expected outcome 2.1. Residents are now able to participate more actively in the life of the community.

Ongoing review of activities with feedback from and consultation with residents. 3.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about resident lifestyle”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.1 Regulatory compliance for details about the home’s systems to identify and ensure compliance with all relevant legislation, regulatory requirements and professional standards and guidelines. Examples of compliance with regulations relevant to Accreditation Standard Three include:

Residents/representatives are provided with information on prudential arrangements and sign agreements on or before entry to the home

Residents’ handbook and agreement detail security of tenure arrangements and the Charter residents’ rights and responsibilities, which is also displayed.


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3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.3 Education and staff development and expected outcome 1.6 Human resource management. Examples of education relevant to accreditation standard three include:

Choice and decision making

Privacy and dignity

Cultural awareness with death and dying 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s findings The home meets this expected outcome The home has systems to ensure that each resident is supported when adjusting to life in the home. These include providing information to the residents/representatives prior to entry, careful monitoring in the initial stages and additional one on one time when needed. Residents are assessed on entry into the home and these assessments include depression assessment as well as nursing requirements and likes and dislikes. This information is used to establish care plans and other documentation to assist staff when providing care and support. Residents/resident representatives interviewed by the team expressed a high degree of satisfaction with the staff and individual attention as well as with the emotional support residents receive. 3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s findings The home meets this expected outcome The home assists residents to maintain their independence and encourages family and friends to visit. The home has regular visits from religious ministers. Avalon House Nursing Home has recently upgraded their electronic documentation system which includes the ability to capture information about residents’ life stories. Staff interviews indicated this information is very useful when developing interventions for residents. Residents have access to mobility aids and other assistive devices such as canes, walking frames and wheelchairs to promote their independence. Staff encourage residents to maintain their independence with personal hygiene as well as with their meals. Meals are prepared soft or cut up when needed. We noted residents were very active socially during the re-accreditation audit.


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3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s findings The home meets this expected outcome The home has systems to ensure each resident’s privacy and dignity is respected and their confidentiality maintained. All staff are required to sign confidentially agreements when commencing employment. Staff interviewed confirmed they respect residents’ rights to privacy and dignity at all times. Residents/resident representatives interviewed by the team stated staff always speak nicely to them and treat them well. During the re-accreditation audit we observed staff speaking respectfully to residents and knocking on doors before entering residents’ rooms. We noted privacy curtains being drawn and doors being closed when residents were being attended to by staff. Residents’ files were also noted to be stored securely. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s findings The home meets this expected outcome The home has an activity program providing a wide range of leisure activities available to residents seven days per week. Documentation review confirmed residents are assessed on entry into the home and information including interests, religion, history, likes and dislikes is recorded. Residents are informed of what activities are organised through printed weekly activities programs. Copies of these programs are displayed in a number of locations around the home. Residents interviewed by the team confirmed they have access to weekly programs and they are also prompted verbally by staff to remind and encourage them to participate. We observed many activities in progress throughout the re accreditation audit. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s findings The home meets this expected outcome The home values and fosters individual interests, customs and beliefs of its residents and staff. Information about specific needs, beliefs and customs is recorded on entry into the home and updated as needed. Residents are supported to maintain cultural and spiritual links in the community and the activities program includes regular religious services. A Catholic priest visits the home regularly. While the current resident mix is predominately Anglo-Saxon the home has multicultural resources available if the mix changes. The main cultural celebrations include Christmas, St Patrick’s Day, Easter, ANZAC day, Australia day, Mother’s Day and Father’s Day. We observed a non-denominational Easter service on the second day of the re-accreditation audit which was well attended.


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3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s findings The home meets this expected outcome The home is able to demonstrate that each resident (or their representative) participates in decisions about the services residents receive and are able to exercise choice and control over the residents’ lifestyle while not infringing on the rights of other people. Assessment of residents’ specific needs and preferences is performed on entry to the home and on an ongoing basis. Residents with special dietary needs such as residents with diabetes are provided for. There is a range of allied health professionals available to residents. Residents/representatives interviewed provided examples that demonstrate that residents are given freedom of choice in their daily lives; for instance if a resident does not like a particular meal being offered the kitchen will make them a sandwich. Residents/representatives also stated they are able to participate in decision-making forums such as resident meetings if they wish. 3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s findings The home meets this expected outcome Residents/representatives interviewed state they are satisfied with the information that was provided on entry to the home. Information includes details of tenure as well as fees and charges. A residential aged care service agreement is provided for new residents. The agreement outlines information on security of tenure, the Charter of residents’ rights and responsibilities, fees/bonds, privacy matters and specified care and services. Management advised that residents/representatives are consulted prior to a resident asking or being asked to move rooms; and any re-locations within the home are carefully considered by management. The resident/relative handbook details the services available at the home. Information is provided and displayed in the home for residents/representatives and includes brochures on comments and complaints. Residents interviewed said they feel secure at the home. Residents/representatives interviewed said they understand the information that they receive and have ongoing opportunities to provide feedback to the home


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Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.1 Continuous improvement. The home’s continuous improvement activities include systems to check that the home provides a safe and comfortable environment consistent with residents’ care needs. Examples of continuous improvement activities include:

Introduction of random mock fire drills with observation and debriefing, as a non threatening way of improving staff awareness and identifying any deficiencies.

Following extensive media coverage of an event requiring evacuation of an aged care facility, the home undertook an education program for residents and representatives and brought forward the date of the relatives’ to meeting to reach a wide audience. The program included familiarisation with equipment and evacuation plans, discussion of training provided to staff and gave residents and representatives the opportunity to ask any questions. Residents/representatives interviewed were very appreciative of the prompt response and of the reassurance provided by management and staff.

The home also took the opportunity to review evacuation plans and the evacuation box and demonstrate these to residents/representatives.

4.2 Regulatory compliance This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”. Team’s findings The home meets this expected outcome Refer also in this report to expected outcome 1.2 Regulatory compliance. There are systems to ensure compliance with regulations relevant to residents’ quality of life and provision of a safe environment. Examples of regulatory compliance relevant to Accreditation Standard Four include:

Regular testing of warm water systems

Food Safety Program to ensure compliance with hazard analysis critical control points (HACCP) requirements

Material safety data sheets (MSDS) at point of use for all chemicals

Colour coded equipment to meet infection control requirements

Mandatory fire safety training for all staff

Review of workplace health and safety program consistent with legislatives updates.


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4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s findings The home meets this expected outcome Refer also in this report to Expected outcome 1.3 Education and staff development. The home demonstrates that staff have the knowledge and skills required for effective performance in relation to physical environment and safe systems. Examples of education and training programs relevant to Accreditation Standard Four include:

Infection control training included in orientation and ongoing education

Fire safety training

Chemical handling education

Food safety and food handling 4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with residents’ care needs". Team’s findings The home meets this expected outcome Avalon House Nursing Home provides a safe and comfortable environment consistent with residents’ care needs. There are attractive communal areas on both levels and smaller areas for private family functions. Access via the front and car park entrances is key pad controlled and there is additional controlled entry/exit to the secure unit. There is external security lighting. The coffee shop on the ground floor is well patronised and provides a social hub for residents and family members. Residents are accommodated in single rooms with ensuite bathrooms. There are double rooms which can be occupied by married couples. Rooms and bathrooms are equipped with call bells and hand rails. Preventative and reactive maintenance programs are in place. The home presented a calm and peaceful environment during the re-accreditation audit and residents/representatives state that residents are very happy with their home. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s findings The home meets this expected outcome Avalon House Nursing Home has developed systems and processes which enable it to demonstrate there is a safe working environment that meets regulatory requirements. The home is supported by specialist staff at organisational level who are available for direction and guidance. Education provided at orientation and on an ongoing basis includes manual handling, fire safety awareness, infection control and hazard and accident/incident reporting. Lifting devices, slide sheets and personal protective and other equipment are available for the protection of both staff and residents A combined infection control/ workplace safety committee meets regularly and reviews accident/incident and infection data and results of


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audits and surveys. Preventative and reactive maintenance programs are in place. Staff interviewed are aware of their responsibilities regarding workplace health and safety. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s findings The home meets this expected outcome Avalon House Nursing Home has established practices to provide an environment and safe systems of work that minimise fire, security and emergency risks. There is controlled access to the home and external security lighting. Fire fighting equipment, emergency flip charts and evacuation plans are located throughout the home. An evacuation box with relevant resident information is easily accessible in event of an emergency. All staff undertake training at orientation and on a regular basis thereafter; random mock drills are held. The emergency procedures manual details evacuation procedures and transfer to other facilities within the organisation and there is liaison with the area health service regarding key personnel and notification procedures. Contingency plans are in place for the interruption of services and in the event of a power failure emergency lighting provides ninety minutes of service and a blackout kit is available. See also expected outcome 4.1 for additional details. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome Avalon House Nursing Home has established policies and practices that support an effective infection control program. There is a dedicated registered nurse who oversees the program and chairs the infection control/workplace safety committee. Staff receive training at orientation and on an ongoing basis and undertake regular hand washing competencies. Hand sanitisers and hand washing facilities are located throughout the home and personal protective equipment is available at point of use. The system includes auditing and reporting mechanisms, cleaning, maintenance and food safety programs, linen handling procedures, disposal of waste and use of spills kits. A vaccination program is in place for staff and residents. The home follows State and Federal guidelines for the management of influenza and gastroenteritis outbreaks and an outbreak box with protective equipment, documentation and signage is easily accessible. There is a program for appropriate stock rotation of food in the kitchen and temperature checks are in accordance with regulatory guidelines for food and equipment. All equipment is appropriately colour coded. Data on infections are collected, analysed, discussed with staff and reported at the infection control/workplace safety meetings. All staff interviewed are very aware of their responsibilities regarding infection control generally and extra precautions to be taken in the event of an outbreak.


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4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s findings The home meets this expected outcome The home has policies, processes and working arrangements that ensure that hospitality services are provided that enhances residents’ quality of life and staff working arrangements. Residents/representatives expressed satisfaction with the hospitality services provided at Avalon House Nursing Home. They commented particularly on the cleanliness and freshness of both their personal areas and the community areas and of the friendliness and responsiveness of the cleaning staff. Some residents identified issues with clothing going missing after being sent to the laundry, but this has improved since the home purchased its own labelling machine. Previously the machine had been shared with another home in the group. Residents generally are happy with the variety of meals provided and stated that they have the opportunity to provide feedback through surveys and the resident meetings. Cleaning staff perform their duties guided by daily, weekly and periodic cleaning schedules and the results of inspections/audits. Staff receive regular training in the use of equipment, infection control and outbreak management procedures, manual handling and safe use of chemicals. Staff interviewed demonstrate a sound knowledge of infection control practices and the safe use of equipment. The home presents as clean, fresh and well cared for. The home received an A rating in the NSW food authority audit conducted in March 2011, a further audit is due in May 2012. All food is cooked fresh on site and the rotating menu is dietician approved. Residents have a choice of main meal and alternatives such as salads and sandwiches are available. Residents’ individual requirements such as specialised or modified diets are forwarded to the kitchen and regularly updated and catering staff are aware of any changes. Catering practices and documentation were observed to be consistent with HACCP requirements. There is a commercial standard laundry with designated clean and dirty areas and separate entrances. Chemicals are dispensed automatically into washing machines which are programmed according to the load to be washed. Soiled linen is prewashed in debulking machines located in the dirty utility areas before being sent to the laundry. All linen and personal items are laundered on site. Spring loaded trolleys are provided for the transport of clean and dirty linen within the laundry areas. Personal items sent for laundering are returned to residents on the same afternoon.

Avalon House Nursing Home - Aged Care Quality...Residents living with dementia Street/PO Box: 14-16...

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Transcript of Avalon House Nursing Home - Aged Care Quality...Residents living with dementia Street/PO Box: 14-16...