Published_decision_(SA_and_RA) - agedcarequality.gov.au€¦ · Web viewStaff performance...

Andrina Aged CareRACS ID: 4525

Approved provider: Kwok Nominees Pty Ltd

Home address: 80 William Road CARRUM DOWNS VIC 3201

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards. This home remains accredited until 31 May 2018.

We made our decision on 22 December 2017.

The audit was conducted on 04 December 2017 to 11 December 2017. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple:Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

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 carePrinciple:Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.




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 MetHome name: Andrina Aged Care Dates of audit: 04 December 2017 to 11 December 2017RACS ID: 4525 2

Standard 3: Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services and in the community.




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 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors




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

Home name: Andrina Aged Care Dates of audit: 04 December 2017 to 11 December 2017RACS ID: 4525 3

Audit ReportName of home: Andrina Aged Care

RACS ID: 4525

Approved provider: Kwok Nominees Pty Ltd

IntroductionThis is the report of a Review Audit from 04 December 2017 to 11 December 2017 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients 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, care recipient 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 Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Review Audit from 04 December 2017 to 11 December 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. 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 2014.

Details of homeTotal number of allocated places: 50

Number of care recipients during audit: 43

Number of care recipients receiving high care during audit: 40

Special needs catered for: Care recipients living with dementia


Audit trailThe assessment team spent two days on site and gathered information from the following:

Interviews

Position title Number

Director of Nursing 1

Aged care consultants 2

Clinical care coordinator 1

Registered nurse 2

Care staff 4

Lifestyle coordinator 1

Administration staff 1

Catering staff 1

Care recipients 13

Representatives 4

Laundry staff 1

Cleaning staff 1

Maintenance staff 1

Sampled documents

Document type Number

Care recipients’ files 11

Summary and/or quick reference care plans 11

Medication charts 6

Personnel files 5

Other documents reviewedThe team also reviewed:

Activity calendars and electronic attendance records

Allied health checklist

Audits

Care recipient agreement sample


Care recipients’ information package, handbook

Clinical indicators and associated reports

Compliments, complaints, suggestion forms

Compulsory reporting folder

Education and training records

Electronic clinical documentation system, including charting and specialised nursing documentation

Emergency evacuation lighting test records

Emergency planning and response process map documentation, instructions

Essential safety measures register

Fire instructions

Food safety certifications

Food safety program and associated documentation

Human resource management documentation, position description sample

Incident reports (electronic) and related documentation

Laundry documentation

Medication registers

Meeting documentation and memoranda

Menu and care recipient dietary choices documentation

Nursing registration documentation

Organisation chart

Pest control records

Police certificate and statutory declaration information

Preventative and corrective maintenance documentation

Priority actions plans

Process maps (procedures)

Progress note entries

Restraint data records

Room transfer documentation

Rosters

Social activity charts

Specialised nursing care folder and contents

Staff handbook

Staff orientation checklist, induction checklist for nursing agency staff

Staff satisfaction survey 2017

Weight charts

Work log history.


ObservationsThe team observed the following:

Activities in progress

Displayed ‘Charter of care recipients’ rights and responsibilities’.

Equipment and supply storage areas

Evacuation bags

Fire exits, egress routes, equipment and assembly areas

Information noticeboards

Interactions between staff and care recipients

Meal and refreshment service

Medication round (observed)

Laundry operations, clothing labelling and ironing systems

Living environment-internal and external

Palliative care kit

Personal protective equipment

Short group observation in East communal lounge

Storage of medications

Suggestion box.


Assessment informationThis section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational developmentPrinciple:Within the philosophy and level of care offered in the residential care services, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The organisation actively pursues continuous improvement across the Accreditation Standards and shows improvements in management, staffing and organisational development. Management use a recently refined system to identify opportunities for improvement from sources including ‘Compliments, suggestions, complaints’ forms, verbal feedback from stakeholders, meetings, audits, focused care recipient interviews and staff satisfaction surveys. Management maintain new priority action plans to achieve objectives. Processes for collating, reporting and actioning clinical indicator data are developing. Management monitor and evaluate improvement processes and outcomes through stakeholder feedback and meetings. Care recipients said they are encouraged to have their say about matters affecting them. Staff and representatives described ways the home has recently improved.

Examples of recent improvement initiatives in relation to Standard 1 Management systems, staffing and organisation include:

As part of a review of human resource management, management has considered staffing needs in relation to planned and unplanned leave and recruited two enrolled nurses and one registered nurse to supplement the casual staff bank. Management is satisfied staffing options are now more flexible and responsive.

Management positions have increased and are now stable. The former acting director of nursing is now appointed to the ongoing position. The care coordinator role, formerly seven shifts per fortnight, is now a full time position. Stakeholders are satisfied with increased management support.

Management identified information issues including email limitations with only two positions able to access email services and a memoranda system that not all staff could access online. Management is improving information systems by arranging more email addresses and implementing a memoranda folder that is accessible to all staff.

1.2 Regulatory complianceThis 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”.



The organisation’s management has recently refined systems to identify and promote compliance with relevant legislation, regulatory requirements, professional standards and guidelines. The organisation is informed of legislative changes through membership of a legislative update service, peak body membership, government communications and regional network meetings. Management inform staff of regulatory changes through a legislative update resource folder, meetings, memoranda, electronic care system messaging and individual contact as appropriate. The monitoring of regulatory compliance occurs through audits, database reviews, observation of practice and stakeholder feedback. Staff are satisfied management inform them of regulatory requirements. Care recipients and representatives are satisfied management provide them with information updates.

Examples of responsiveness to regulatory compliance relating to Standard 1 Management systems, staffing and organisational development include:

Management maintains an action plan for continuous improvement across the Accreditation Standards.

Management has a system for maintaining current police certificates and applicable statutory declarations for staff, any volunteers and external contractors as appropriate.

Confidential documents are stored, archived and disposed of securely.

1.3 Education and staff developmentThis expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.


Management and staff have the appropriate knowledge and skills to meet role requirements and the organisation’s objectives. The education program is increasingly responsive to the training needs of management and staff and includes training across the Accreditation Standards. Education and staff development opportunities include self-directed learning packages, toolbox training and learning sessions by external providers. Topics are identified through internal and external audits, staff feedback, observation of practice and identification of care recipient needs. Monitoring of attendance at education and follow up of non-attendance at mandatory training sessions is in the early stages of development. Staff are satisfied with the education opportunities provided. When asked about staff knowledge and skills, a small proportion of care recipients and representatives said there were opportunities to improve staff and management performance. The majority of care recipients and representatives expressed satisfaction with management and staff abilities. Management said they are taking steps to improve the education system and strengthen performance monitoring processes.

Recent training and development opportunities relevant to Standard 1 Management systems, staffing and organisational development include: equal opportunity/bullying and harassment

continuous improvement and compliance

risk management

1.4 Comments and complaintsThis expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".



Internal and external comments and complaints mechanisms are accessible to care recipients, representatives and other interested parties. The system includes ‘Compliments, suggestions, complaints’ forms, meetings and an ‘open door’ policy of access to key staff and management. Management ensures external complaint information is accessible and conveys information about ways to comment and complain in information handbooks for care recipients and representatives, through prominently displayed signage inviting feedback, at meetings and during informal contact. Newly refined complaints management processes guide complaint response to ensure timeliness, progressive feedback to the initiator and evaluation of the complainant’s satisfaction with resolution outcomes. Staff and care recipients and representatives with one exception said they would be comfortable to comment or complain if the need arose. Management said they encourage all stakeholders to provide feedback and matters are treated confidentially.

1.5 Planning and leadershipThis expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".


The organisation has a documented mission, vision, values and philosophy, with objectives and commitment to quality inherent in the leadership statements. This documentation is displayed on the home’s website and in documentation throughout the service.

1.6 Human resource managementThis 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".


There are sufficient, appropriately skilled and qualified staff to ensure the delivery of services in accordance with the Accreditation Standards and service philosophy and objectives. While a review of the human resource management system including staff roles, responsibilities, work practices, accountabilities and human resource processes is currently in progress, staff recruitment has continued. The recruitment process includes, interviews, credential and referee checks and staff induction. Management reviews staffing levels and skill mix through consideration of care recipient needs, observation of practice, feedback and review of clinical indicators. Management seek to replace staff on planned and unplanned leave and use casual bank or nursing agency staff as required.

Staff performance management processes are being refined and enacted and management plans to re-introduce a performance appraisal system. Staff said there have been recent changes in the way they deliver services, the changes have been challenging and they work harder than before to provide a higher level of care and services to care recipients. Staff, care recipients and representatives said there are enough staff and all except one care recipient were satisfied with call bell response times. The majority of care recipients and representatives were complimentary of the care and services provided by staff and feedback included comments that care has recently been more thorough and attentive. `A small proportion of care recipients and representatives were not satisfied with staff attitudes and a small number said staff do not always wear pagers. Management said they have been working with staff to improve call bell response times and they are reviewing human resource management, including staff performance to ensure responsive service delivery.


1.7 Inventory and equipmentThis expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".


Established procurement systems ensure appropriate goods and equipment are available for quality service provision. Designated staff organise the purchase of inventory and equipment through established ordering and supply processes, compliance with instruments of delegation and the use of preferred suppliers and contractors. Management and staff identify equipment needs through mechanisms such as electronic stock lists of products and frequently ordered items, identification of care recipient need, observation and stakeholder feedback. Systems including new chemical storage and continence aid storage processes ensure goods are secured in clean areas. New linen supplies were recently purchased. Maintenance programs and regular electrical testing and tagging processes operate. Staff said recent linen purchases ensured sufficiency for care recipient need. When asked about equipment availability, care recipients and representatives were satisfied with the availability of equipment and supplies.

1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".


The home has systems to provide all stakeholders with access to current and accurate information. Management and staff have access to information that assists them in providing care and services. Electronic and hard copy information is stored securely and processes are in place for backup, archive and destruction of obsolete records, in keeping with legislative requirements. Key information is collected, analysed, revised and updated on an ongoing basis. Data obtained through information management systems is used to identify opportunities for improvement. Management continue to review policies and process maps but were unable to advise of a completion date. Staff are generally satisfied they have access to current and accurate information. Care recipients and representatives are generally satisfied the information provided is appropriate to their needs, and supports them in their decision-making.

1.9 External servicesThis 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".


Management ensures externally sourced services meet service needs and quality goals. External services include allied health services, pharmacy and fire services. Contracted services and suppliers are selected through interview processes. External service agreements and credential checks apply. External service providers receive an informal induction to the home. Management monitor the quality of services provided through consideration of service outcomes, stakeholder feedback and observation of quality and timeliness. Care recipients, representatives and staff are satisfied with external services.


Standard 2 – Health and personal carePrinciple:Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.



The organisation actively pursues continuous improvement in care recipients’ health and personal care. New processes that enable clinical indicator data to be collated, reviewed, reported and actioned were recently implemented and are in the initial stage of development. Care recipients and staff are satisfied the home is improving in Standard 2 Health and personal care. Please refer to expected outcome 1.1 Continuous improvement for a description of the continuous improvement system.

Examples of recent improvement initiatives in relation to Standard 2 Health and personal care include: To better coordinate care recipient access to optometry, audiology and dental services, a

new allied health folder has been initiated. A checklist identifies the date the care recipient was last seen and specifies whether the care recipient wishes to have an appointment arranged. Staff are satisfied the folder assists with allied health visit coordination and referral.

An external audit identified incomplete clinical assessments. To support consistent assessment processes, management implemented a 28 day assessment schedule. Staff are satisfied the planner enables assessment progress to be tracked and supports assessment completion.

A handover sheet has been implemented with care recipients’ diagnoses, hygiene and skin needs, mobility, diet and fluids, continence needs, complex health care needs and a ‘comments’ section for specific needs. Staff are satisfied the new handover sheet supports clinical care provision.

To support specialised nursing care provision, each wing now has a specialised nursing care folder with forms and charts. Staff are satisfied the folder supports the provision of complex health care.

To strengthen the assessment of care recipient capacity to self-medicate, a new process that takes into account the care recipient’s cognitive score was recently introduced. Management and staff are satisfied the new ‘self-administration of medication’ assessment supports the safe administration of medication for care recipients wishing to take medications or apply prescribed creams independently

2.2 Regulatory complianceThis 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”.



Management has systems to identify and promote compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care. Please refer to expected outcome 1.2 Regulatory compliance for details of the regulatory compliance system.

Examples of responsiveness to regulatory compliance relating to Standard 2 Health andpersonal care include the following: A process enables documentation in relation to nursing registrations to be maintained.

A documented process map guides staff practices in the event of the unexplained absence of a care recipient.

Appropriately qualified staff plan, supervise and undertake the provision of specialised nursing care.

Medications are securely stored.



A recently refined education and staff development system supports management and staff to have the knowledge and skills to effectively meet role requirements for the provision of health and personal care. Staff are satisfied with the increasing education and staff development opportunities provided and said the education supported their roles. When asked about staff knowledge and skills in relation to clinical care, care recipients and representatives are satisfied staff meet health and personal care needs most of the time or always.

Please refer to expected outcome 1.3 Education and staff development for a description of the education and staff development system.

Recent training opportunities in relation to Standard 2 Health and personal care include: behaviours and charting

continence care

dysphagia

medication management

oral and dental care

skin integrity

specialised nursing care needs

wound management.

2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.


Whilst the previous review audit conducted in August 2017 indicated several concerns regarding clinical care, review of those files and interviews of the remaining care recipients/representatives confirm they are now satisfied with clinical care provided. Care recipients receive appropriate clinical care. Staff now have access to assessments to determine care recipient’s clinical care needs on entry to the home and annually thereafter


unless more frequently as required. The development of a new 28-day assessment guide helps staff keep track of the assessment process. There is a newly established care review process to ensure effective care is provided. Management now monitor the clinical care system and any deficits are identified and actioned. All care recipients have care plans and respite care recipients have interim care plans. Clinical documentation includes an enhanced handover document to guide staff in the care of care recipients, which includes infection control information, hygiene requirements, mobility requirements, dietary, continence and toileting times and complex health care needs. Staff say this improvement has made a positive impact. Whilst a small number of care recipients and representatives described opportunities to improve clinical care, most care recipients are satisfied with the care received. Nursing and care staff say they have sufficient time to complete their work.

2.5 Specialised nursing care needsThis expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”.


Management continue to implement new systems and processes to assist with the management of specialised nursing care needs. Care recipients who have specialised nursing care needs have care plans that provide guidance and directives for staff to meet care recipients’ needs. There are clear instructions from medical officers and other health professionals documented in progress notes and care plans. Staff have access to equipment, information and resources to ensure care recipients’ needs are met. Staff practices continue to be monitored. Care recipients and representatives are satisfied with the specialised nursing care provided.

2.6 Other health and related servicesThis expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”.


The home has systems to ensure care recipients are referred to appropriate health specialists in accordance with their needs and preferences. Care recipients have access through regular or referral processes to a range of services including medical, nursing and allied health specialists, including physiotherapy, podiatry, dietitian, speech pathology, optometry, audiology, mobile dental service and mental health care. Directives and instructions are communicated to staff and documented in care plans and care is generally consistent with these instructions. Staff practices are monitored to ensure care is in accordance with care recipients' needs and preferences. Staff support care recipients to attend external appointments with health specialists. Care recipients and representatives are satisfied referrals are made to appropriate health specialists of their choice and staff generally carry out their instructions.

2.7 Medication managementThis expected outcome requires that “care recipients’ medication is managed safely and correctly”.


There are systems to ensure care recipients' medication is generally managed safely and correctly. Processes ensure adequate supplies of medication are available and medication is


stored securely and correctly. Medical officers prescribe and review medication orders and these are dispensed by the pharmacy service. Medication orders provide guidance to staff when administering or assisting with medications. Policies, procedures and guidelines provide clarification around safe medication practices. The home's monitoring processes include analysis of medication incident data. The medication advisory committee provides advice on the home's medication management system and a pharmacist regularly conducts medication reviews for individual care recipients. Nursing staff receive education in relation to this. Care recipients who manage their own medications have risk assessments and authorities completed. While one care recipient said a medication incident has resulted in a lack of confidence in the safety of medication administration, other care recipients and representatives are satisfied care recipients' medications are provided as prescribed and in a timely manner. Management said they provided medication management training and they are addressing medication incidents.

2.8 Pain managementThis expected outcome requires that “all care recipients are as free as possible from pain”.


All care recipients are assessed for pain upon entry to the home. Care plans are then developed, either interim or long term. New pain assessments are completed when there is a changed in pain medication, upon return from hospital or when additional pain complaints are made. Nursing staff use a range of pain assessments to ensure those care recipients who are unable to voice their pain are identified. Care plans describe the kind of pain and treatment options identified. Administration of pain medication is usually followed through with the documentation of the results of administration. Care recipients and representatives are satisfied pain is managed effectively at the home.

2.9 Palliative careThis expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”.


Care recipients who have reached the end of their life and prefer to spend what time they have left at the home, are supported to stay. Staff endeavour to complete an advanced care directive and when the time is right, staff ensure an end of life pathway is commenced. This pathway includes guidance and directives to ensure care recipients’ pain, skin, diet and other care issues are attended. Families are encouraged to stay and spiritual and cultural preferences are honoured. Referrals are made to medical officers, palliative care specialist teams and other health specialist services as required. Management and staff said they ensure the comfort and dignity of terminally ill care recipients.

2.10 Nutrition and hydrationThis expected outcome requires that “care recipients receive adequate nourishment and hydration”.


Care recipients receive adequate nutrition and hydration. Staff assess care recipients’ nutrition and hydration needs when they move into the home and then care plans are developed to meet specific needs. Staff monitor care recipients’ nutrition and hydration to identify those care recipients who are at risk and refer care recipients to other health


specialists such as a dietitian, speech pathologist and dental when required. Care recipients are provided with texture modified diets or special equipment as required. Alternative meals, extra drinks and snacks are available at all times. While two care recipients or representatives were not satisfied with the adequacy of nourishment in the evening meals, the majority of care recipients and representatives are satisfied with the adequacy of meals and drinks provided to care recipients. Management demonstrated the nutritional content of the menu was recently reviewed by a dietitian.

2.11 Skin careThis expected outcome requires that “care recipients’ skin integrity is consistent with their general health”.


Processes ensure care recipients' skin integrity is consistent with their general health. Care recipients' skin care requirements, preferences and special needs are assessed and identified in consultation with care recipients and/or representatives. Care plans reflect strategies to maintain or improve care recipients' skin integrity and are reviewed regularly. Skin care needs are monitored, evaluated and reviewed as required. Registered nurses assess and manage care recipients' skin tears and other issues related to skin integrity. Referral processes to other health specialists are available if a need is identified.

Monitoring processes now include documenting and analysing incidents relating to skin integrity. The home now use pressure risk assessments on all care recipients. Additional equipment has been purchased. Staff have been provided with education relating to skin care and wound management and the revised handover sheet indicates the skin care requirements of care recipients who need pressure area care. Staff have access to moisturisers, pressure relieving devices, pressure area care and safe manual handling techniques. Documentation indicates staff undertake positional changes on a regular basis and we observed care recipients who require supportive garments such as leg protectors, were wearing these aids. Most care recipients and representatives are satisfied with the assistance provided to maintain skin integrity. One care recipient or representative said staff do not always attend to pressure area care to ensure no pressure injuries occur. Management said they will monitor skin care and remind staff about pressure care.

2.12 Continence managementThis expected outcome requires that “care recipients’ continence is managed effectively”.


Processes ensure care recipients' continence is generally managed effectively. Continence needs and preferences are identified and strategies to manage care recipients' continence are documented in care plans. Care staff manage individual care recipients' continence needs and promote privacy when providing care. Changes in continence patterns are identified, reported and reassessed to identify alternative management strategies. Equipment and supplies such as continence aids are available to support continence management. The home's monitoring processes include the collection and analysis of data relating to infections. Staff are conscious of care recipients' dignity while assisting with continence needs. The newly revised handover sheet documents care recipients’ continence requirements. While one care recipient is not satisfied with continence care, other care recipients and representatives are satisfied with the support provided to care recipients in relation to continence management. Management said they would continue to monitor continence management.


2.13 Behavioural managementThis expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”.


Processes ensure the needs of care recipients with challenging behaviours are effectively managed. Needs are identified through assessment processes and in consultation with care recipients, their representatives and/or allied health professionals. Individual strategies to manage challenging behaviours are identified and documented in care plans and are regularly evaluated to ensure they remain effective. Strategies include one-on-one and group activities. The environment supports the comfort of care recipients and care recipients were observed to be calm and relaxed. Monitoring processes include the collection and analysis of behavioural incident data. Staff manage individual care recipients' challenging behaviours, including those care recipients who are at risk of wandering. Although a small number of care recipients or representatives said a few staff needed training in behaviour management and dementia care the majority of care recipients and representatives are satisfied with the way staff manage care recipients’ responsive behaviours.

2.14 Mobility, dexterity and rehabilitationThis expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.


Optimum levels of care recipients’ mobility and dexterity are achieved. Care recipients' mobility, dexterity and rehabilitation needs are identified through assessment processes and in consultation with care recipients and/or their representatives. Where a need is identified, referrals are made to medical officers and other health specialists. Strategies to manage care recipients' mobility and dexterity are generally documented in care plans and are regularly evaluated and reviewed to ensure care recipients' needs are met. Management review incident reports and make monthly reports on causes of falls. Care recipients and staff have access to a variety of equipment to assist with care recipients' mobility, dexterity and rehabilitation needs. Care recipients and representatives are satisfied with the support provided for achieving optimum levels of mobility and dexterity.

2.15 Oral and dental careThis expected outcome requires that “care recipients’ oral and dental health is maintained”.


Care recipients oral and dental care is maintained. There are systems to guide staff with assessment and development of an individualised oral and dental care plan for each care recipient. Aids required, equipment and the level of staff assistance is recorded in care plans. Staff assist care recipients with maintaining their oral and dental hygiene regimes. Care recipients and representatives are satisfied with how staff maintain care recipients’ oral and dental health.

2.16 Sensory lossThis expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”.



The home has a system to identify and manage sensory loss for care recipients. Staff assess care recipients who first enter the home and on a regular basis. Care plans record identified strategies and required aids to support care recipients with known sensory loss. The development of an improved handover sheet has identified care recipients who have specific sensory losses to guide staff practices. Care recipients and representatives are satisfied care recipients sensory losses are adequately managed.

2.17 SleepThis expected outcome requires that “care recipients are able to achieve natural sleep patterns”.


The system for ensuring and assisting care recipients to achieve natural sleep involves initial assessments when care recipients first enter the home. A care plan is developed and regularly reviewed. Staff capture information about bed time and rising preferences and this is documented, along with comfort strategies. Care recipients and representatives are satisfied care recipients are adequately supported to achieve natural sleep patterns.


Standard 3 – Care recipient lifestylePrinciple:Care recipients 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.



The organisation actively pursues continuous improvement in care recipient lifestyle. Care recipients, representatives and staff described recent changes occurring in care recipient lifestyle. They said lifestyle staff change was difficult and impacted lifestyle staff who were familiar to them, the program was different and while a small number of care recipients said good ideas were being introduced, other care recipients and representatives said they preferred the way things used to be. Management said they were aware of this situation and were encouraging staff support for the new lifestyle personnel and program. Please refer to expected outcome 1.1 Continuous improvement for a description of the continuous improvement system.

Examples of recent improvement initiatives in relation to Standard 3 Care recipient lifestyle include:

A new, qualified lifestyle coordinator commenced in November 2017 and is implementing a new lifestyle program after consultation with care recipients. The monthly program is documented and care recipients have a choice of program formats to keep in their room. Activities and events now have starting times displayed to support care recipient attendance. The program is new and not yet evaluated for effectiveness.

The lifestyle program is now to include a wider variety of group activities such as a literature circle and word games using a newly purchased whiteboard. Sensory videos are being introduced. Full implementation and evaluation for effectiveness has not yet occurred.

3.2 Regulatory complianceThis 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 care recipient lifestyle”.


Management has systems to identify and promote compliance with relevant legislation, regulatory requirements, professional standards and guidelines in the area of care recipient lifestyle. Please refer to expected outcome 1.2 Regulatory compliance for details of the regulatory compliance system.

Examples of responsiveness to regulatory compliance relating to Standard 3 Care recipient lifestyle include the following:

A compulsory reporting register is accessible.

Care recipients or their representatives receive information on care recipients’ rights and responsibilities and security of tenure.


Staff receive information to guide the maintenance of care recipients’ privacy and confidentiality at orientation and ongoing.



An education and staff development system supports management and staff to have the knowledge and skills to meet role requirements for the support for care recipient lifestyle. Staff are satisfied with care recipient lifestyle education and development opportunities. When asked about staff knowledge and skills in relation to resident lifestyle, care recipients and representatives said lifestyle is changing and they did not know whether management and staff have the appropriate skills and knowledge to support care recipient lifestyle.

Please refer to expected outcome 1.3 Education and staff development for a description of the education and staff development system.

Recent training opportunities include:

cultural diversity

elder abuse/compulsory reporting

emotional support

privacy and dignity.

3.4 Emotional support This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis".


There are systems to ensure care recipients are supported in adjusting to the new environment. Care recipient’s emotional needs are identified on entry and on an ongoing basis. There are processes to assist care recipients include the provision of information to care recipients and representatives prior to entering the home. Family involvement is encouraged for further support of care recipients. Most care recipients and/or representatives are satisfied with the level of emotional support shown by staff.

3.5 IndependenceThis expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service".


Management and staff encourage independence and to maintain connection to community, friendships and ties. All care recipients are assessed on entry to the home and identification of care recipient’s needs and preferences for maintaining independence are made. Friends and family are welcomed to the home throughout the day and evening with a range of internal and external areas throughout the home that can host social gatherings with friends and family. There is equipment available to assist in maintaining independence, such as mobility aids and specialised cutlery. Care recipients and representatives are satisfied with how the home encourages independence.


3.6 Privacy and dignityThis expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".


Care recipients’ preferences in relation to privacy, dignity and confidentiality are recognised and respected. Strategies for ensuring privacy and dignity are planned and implemented. The living environment supports care recipients’ need for personal space and provides areas for receiving guests. Feedback, meetings and care reviews identify opportunities for improvement in relation to the home’s privacy, dignity and confidentiality systems and processes. While a small proportion of care recipients and representatives indicated there were opportunities to improve the approach to privacy and dignity, the majority of care recipients and representatives said staff maintain their privacy, dignity and confidentiality. Management said they will reinforce the home’s expectations with staff.

3.7 Leisure interests and activitiesThis expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them".


Care recipients and representatives are encouraged and supported to participate in a wide range of interests and activities of interest to them. The activities program appears to meet the needs of all care recipients. Care recipients isolated in their rooms due to need or choice, are visited and encouraged to participate in activities that match their interest. The newly appointed activities coordinator has renovated the activities program. All care recipients are assessed for their interests when they first enter the home and a detailed care plan is developed and regularly reviewed. While two care recipients or representatives were not satisfied with weekend lifestyle options, other care recipients and representatives are satisfied with the activities program. Management said lifestyle staff do not work on Sundays and they encourage staff to support care recipient lifestyle.

3.8 Cultural and spiritual lifeThis expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".


There are processes to ensure care recipients’ individual customs, beliefs and cultural backgrounds are valued. Staff establish care recipients’ cultural and spiritual preferences. Activities are organised to reflect cultural preferences, for example multicultural dancing and celebrations of specific cultural and religious days with food to enhance the experience. There are regular church services at the home and access to other religious personnel ensure religious needs of care recipients are met. Care recipients and representatives are satisfied with the cultural and spiritual life provided for care recipients.


3.9 Choice and decision-makingThis expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people".


There are processes to demonstrate care recipients are aware of processes to exercise choice and decision making over lifestyle while not infringing on the rights of others. Care recipients have input into the services received and have choice about preferred rising and settling times, food and dining preferences and preferred title and name. Care recipients are encouraged to give feedback through improvement forms, satisfaction surveys and meetings. There are noticeboard displays advertising the process to follow regarding elections. Care recipients and representatives are satisfied care recipients have choice and these choices to not infringe on other care recipients’ rights.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


The organisation has a system to ensure care recipients have security of tenure within the home and understand their rights and responsibilities. An information handbook and displayed ‘Charter of care recipients’ rights and responsibilities’ inform care recipients and representatives about security of tenure and responsibilities. Agreements include information about security of tenure, rights and responsibilities. Management and staff assist care recipients to understand their rights and responsibilities through responding to individual queries, meetings and information displays. Management said consultation with the care recipient and representative occurs as appropriate prior to any room change. Management and staff monitor security of tenure through agreement management processes and stakeholder feedback. Care recipients said they felt secure within the home.


Standard 4 – Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



The organisation actively pursues continuous improvement in the physical environment and safe systems. Care recipients and staff are satisfied with improvements to the physical environment and safe systems. Please refer to expected outcome 1.1 Continuous improvement for a description of the continuous improvement system.

Examples of recent improvement initiatives in relation to Standard 4 Physical environment and safe systems include:

To improve the comfort of the external living environment, management recently purchased four new outdoor tables and eight chairs and are ordering padded cushions to ensure comfortable seating. Staff, care recipients and representatives are satisfied the furniture will be well used when the weather permits.

Staff were formerly required to share pagers. Management purchased seven new pagers and now there is a pager for each staff member. Management and staff are satisfied the new pagers promote care recipient safety.

To improve chemical safety, management organised a new, secure chemical store with new metal shelving. Management and staff are satisfied the new storage arrangements promote chemical safety.

To identify care recipients with contagious infections, management placed small flower pictures above the door of affected care recipients. Management and staff are satisfied the pictures inform staff in a subtle way that they need to take additional precautions to promote infection control.

4.2 Regulatory complianceThis 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”.


Management has systems to identify and promote compliance with relevant legislation, regulatory requirements, professional standards and guidelines, about the physical environment and safe systems. Please refer to expected outcome 1.2 Regulatory compliance for details of the regulatory compliance system.

Examples of responsiveness to regulatory compliance relating to Standard 4 Physical environment and safe systems include the following:

Management supports workplace health and safety.

Safety data sheets are available where chemicals are stored.

The catering service complies with a food safety program.




An education and staff development system supports management and staff to have the knowledge and skills to effectively meet role requirements for the physical environment and safe systems. Management and staff are satisfied with education in relation to safe systems. When asked about staff knowledge and skills in relation to the physical environment and safe systems, care recipients and representatives expressed satisfaction with management and staff abilities. Please refer to expected outcome 1.3 Education and staff development for a description of the education and staff development system.

Recent training opportunities in relation to Standard 4 Physical environment and safe systems include:

chemical management

fire training, emergency management plan exercise

infection control

restraint.

4.4 Living environmentThis expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs".


Management is actively working to provide a safe and comfortable living environment. Care recipients are accommodated in air conditioned private rooms with ensuite bathrooms and a small number of shared rooms are available if required. There are clutter free communal lounge and dining areas, with access to well-maintained surrounds. Management and staff maintain the living environment through service provision arrangements, an electrical test and tag program and through maintenance programs. Call bells and security arrangements promote environmental safety. Management monitor the safety and comfort of the environment through observation, inspections and risk assessments as appropriate. The home now has a minimal restraint approach. Staff described ways they ensure care recipients are safe and comfortable. All care recipients interviewed said they felt safe and comfortable.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


Management actively work to provide a safe work environment that meets work health and safety regulatory requirements. The organisation provides education and resources that promote occupational health and safety. Management inform staff of their responsibilities in relation to safe work practices through induction programs, staff information handbooks initial and ongoing manual handling training, process maps and meetings. Processes to monitor work health and safety are being strengthened and include audits and inspections, risk


assessments, maintenance requests, incident reports and data review. Staff are satisfied management works to provide a safe environment.

4.6 Fire, security and other emergenciesThis 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".


Management and staff actively work to provide a safe environment and systems of work that minimise fire, security and emergency risks. The home’s fire protection system includes alarms, fire panel, sprinklers, smoke detectors and firefighting equipment. Fire services personnel check emergency equipment and emergency lighting checks regularly occur. Initial and ongoing fire and other emergencies training and emergency process maps guide staff response to fire and emergencies such as heatwaves, disruption to power, gas leaks and building damage. Evacuation lists and evacuation kits are maintained. Established security systems operate. Fire, security and other emergency risks are monitored through internal and external audits and inspections and incident reporting processes. Staff said they participate in mandatory fire and emergency training. Care recipients are not sure of what to do in an emergency but they are satisfied staff would assist them.

4.7 Infection controlThis expected outcome requires that there is "an effective infection control program".


The home has an effective infection control program. Staff have access to information to guide staff in the care of care recipients with ongoing contagious infections. Practices to control the spread of infections are implemented. Management generally monitor the infection control system and action deficits. Staff practices and equipment promote an effective infection control practice. Infectious waste containers and personal protective equipment is available for staff to manage infections. Care recipients identified as having an infection, management create alerts for staff to see when they logon to the home’s electronic care planning system as well as signage in private areas of care recipients’ bathrooms as well as personal protective equipment, which include gloves, aprons, masks and booties. Care recipients, representatives and staff are satisfied with the prevention and management of infections.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


Hospitality services are provided to enhance care recipients’ quality of life and the staff working environment. Food is prepared onsite according to a seasonal rotating menu. Care recipients are offered menu alternatives and specialised dietary needs and preferences are catered for. Staff compliance with a food safety program ensures food is stored, prepared and served according to recommended guidelines. Cleaning programs are established and staff ensure the environment is clean, and uncluttered. Linen and care recipients’ personal clothing are laundered on site and labelling processes are accessible. Management monitor hospitality services through stakeholder feedback and observation. While a small proportion of care recipients or representatives say the meals could improve, the majority of care


recipients land representatives are satisfied with catering services most or all of the time. Staff, care recipients and representatives are satisfied with the cleaning and laundry services provided however, we received feedback that items of clothing are sometimes lost. Management said they are currently reviewing the dietitian’s recommendations in relation to the menu and they will review clothing labelling processes.


Published_decision_(SA_and_RA) - agedcarequality.gov.au€¦ · Web viewStaff performance...

Documents

Transcript of Published_decision_(SA_and_RA) - agedcarequality.gov.au€¦ · Web viewStaff performance...