Wingham Court Nursing Home - Aged Care Quality€¦ · Wingham Court Nursing Home RACS ID 2632...

Wingham Court Nursing Home RACS ID 2632 Primrose Street

WINGHAM NSW 2429

Approved provider: The Frank Whiddon Masonic Homes of New South Wales

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 5 February 2015.

We made our decision on 16 December 2011.

The audit was conducted on 21 November 2011 to 25 November 2011. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits. This home is a 2014 Better Practice Award winner. Click here to find out more about their award.

Home name: Wingham Court Nursing Home Date/s of audit: 21 November 2011 to 25 November 2011 RACS ID: 2632

2

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


3

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


25

Site Audit Report

Wingham Court Nursing Home 2632


Introduction This is the report of a site audit from 21 November 2011 to 25 November 2011 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 a site 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


25

Site audit report Scope of audit An assessment team appointed by the Accreditation Agency conducted the site audit from 21 November 2011 to 25 November 2011 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: Sandra Heathcote

Team member/s: Patricia Affleck-Mooney

Approved provider details


Details of home

Name of home: Wingham Court Nursing Home

RACS ID: 2632

Total number of allocated places:

49

Number of residents during site audit:

42

Number of high care residents during site audit:

42

Special needs catered for:

nil

Street/PO Box: Primrose Street State: NSW

City/Town: WINGHAM Postcode: 2429

Phone number: 02 6553 4855 Facsimile: 02 6557 0336

E-mail address: [email protected]


25

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

Number Number

Director of care services 1 Residents 16

Deputy director of care services

1 Representatives 5

Registered nurses/endorsed enrolled nurses

4 Catering staff 1

Care staff 3 Laundry staff 1

Physiotherapist 1 Cleaning staff 1

Physiotherapy aide 1 Maintenance staff 1

Administration assistant 1 Leisure and lifestyle staff 2

Sampled documents

Number Number

Residents’ files 30 Medication charts 22

Summary/quick reference care plans

30 Personnel files 6

Other documents reviewed The team also reviewed: Accident and incident reports, database, summaries and trend data, hazard reports forms Activities program: monthly schedule and participation reports; daily program and

attendance records, leisure assessments, social and human needs assessments, resident scrapbooks

Admission documents: checklist for entry, medical information and care needs, application for residency, admission form, financials, privacy, electoral enrolment, activity authority forms, authority and review of restraint, client agreement and specified care services

Clinical assessments and care plans Aromatherapy assessments and care plans Authorisation and review of restraint Care plans – ‘Plan of Care’; plan of care review forms Charts on computer: wound charts, observation charts Communication book, diary of appointments Continuous improvement plan, logs, action plans, surveys and audit results; annual audit

schedule Contractor service agreements and other documentation Dietary needs and preference sheets Education documentation including attendance records, staff training database, training

records, annual calendar, training needs analysis and skills audit, competencies External audit results and benchmarking Fire safety documentation and annual fire safety statement Gentle exercise and walking program Handover sheets


25

Human resource documentation Intranet communication and information systems Job descriptions and duty statements Kitchen documentation including temperature monitoring records for food and equipment,

resident meal surveys, approved suppliers certification and other documents, food safety program manual, cleaning schedules, material safety data sheets, resident nutrition sheets, lists for modified and special diets, menus and dietary requirements/preferences documentation

Laundry cleaning checklist, schedules Mandatory reporting register Manual handling instructions Medication incidents, medication management review reports nurse initiated medication

list (NIM), pharmacy notification form and schedule eight drug registers Memo folder for staff Memorandum Minutes of meetings; meetings’ schedule Mission, values and commitment to quality statements Monthly infections report, monthly skin tear reports Newsletters Occupational health and safety documentation including hazard and incident report

forms, policies, meeting minutes, audits, risk assessments, first aid register, workers compensation reports, fire safety audits, injury management

Physiotherapy exercises folder Policies and procedures Property services, preventative maintenance programs, maintenance request books,

asset register, pest control service book Purchasing documentation including order forms, preferred providers, agreements,

insurance Resident ‘welcome’ pack and corporate information handbook Staff handbook Therapy tracking sheets Visitors and contractors ‘sign-in’ books Observations The team observed the following: Activities in progress Archiving system Carer support education information (flyers) Catering: dietary and nutrition assessments available Charter of resident rights and responsibilities’ on display Chemical and oxygen storage Cleaners’ rooms and trolleys, colour coded equipment, wet floor signage Comment/complaint forms and suggestion box on display Communication systems including staff phone/pager system, email, memorandum, and

information noticeboards. Contaminated waste disposal Electrical equipment tagged for safety Equipment, supply storage and delivery areas Fire fighting equipment, sprinkler system, emergency exits and signs, evacuation box and

black out box, emergency flip charts, emergency pouches carried by staff Flyer displayed for visitors regarding food brought into the home Fridge temperature monitoring records Gardens and courtyards Hairdressing salon


25

Hand washing sinks and gel hand sanitiser Hospitality services in operation Interactions between staff and clients Kitchen work and food storage areas Laundry separate dirty and clean areas, automatic fed chemical into machines Living environment – internal and external Material safety data sheets, spill kits, sharps containers, waste disposal systems, out of

order tags Medication management process including ordering, storage and administration.

Electronic medication data available through corporate license via the website. Menu and activities on whiteboard (large print) Mobility aids including walkers, wheelchairs and lifters Personal protective equipment in all areas, colour coded equipment in the kitchen and

cleaning areas, hand washing signs, sinks, wall mounted soap dispensers and waterless sanitisation liquid for hand washing, infection control resource information, outbreak management kit

Security of documents and computers Staff serving/supervising/assisting residents with meals Staff work practices The organisation’s philosophy and mission statement on display Video surveillance camera and screen display


25

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 The home actively pursues continuous improvement across the four Accreditation Standards. The quality systems utilise a variety of qualitative and quantitative methods to identify opportunities for improvement within the home including audits, surveys, meetings, comments and complaints, accident/incident reporting and “I have an idea” forms,. Areas identified as requiring improvement are actioned, monitored and evaluated. Feedback is provided to interested persons verbally, through discussions at meetings, the receipt of meeting minutes, reports, education, memoranda, notices and action plans. The home has an organisational committee which monitors and encourages continuous improvement. Staff told the team about the systems for continuous improvement and improvements made through out the home. Residents/representatives confirm that they have input into the improvements and are aware of improvements being made. Recent improvements relating to Accreditation Standard One include:

As a result of feedback from a resident the home now displays the photographs of the

management team so residents and their representatives’ may easily identify who is a part of the management team.

The management team have redesigned the roster as staff were having difficultly

following the roster at a glance. The roster now has the departments divided into separate sections and the shift times have been colour coded for ease of viewing. The management team said this has reduced confusion and errors occurring.

The home observed an increase in the number of residents becoming frailer and

spending more time in bed. They have purchased six additional pressure relieving mattresses’ to provide more comfort for residents while they are resting in bed. Management said and incident data shows there has been a decrease in skin tears and wounds occurring and no residents have sustained pressure areas.

The residents suggested that they would like to show appreciation to staff by choosing a

staff member once a month to be recognised for the good work they are doing. Residents’ vote each month and the staff member chosen is recognised with an award and a lottery ticket.

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 The home has systems in place to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. Regulatory information is


25

sourced through subscription to peak bodies, Department of Health and Aging updates, industry related newsletters and through the checking of websites by the management team. Received information may be communicated within the home through memos and meetings. Staff education is implemented as appropriate and orientation/induction procedures are updated as needed. Policies and flow charts are updated when needed. Staff interviewed displayed knowledge and understanding of a number of regulatory requirements. Examples of the home’s monitoring and compliance with legislation and guidelines relevant to Accreditation Standard One, Management systems, staffing and organisational development include: Documentation and dissemination of information to staff, residents and their

representatives prior to the accreditation site audit. The home provides information to residents/representatives and staff about internal and

external complaints mechanisms. All staff, volunteers, community visitors and external service providers undergo criminal

record checks and a register is in place to monitor ongoing compliance. 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 The home has a range of mechanisms in place to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. Each position within the home has a documented position description which is used to identify the skills and qualifications required during the recruitment and selection processes. New employees undergo an orientation as well as induction to the home and are buddied with an experienced member of staff to provide support and guidance. Regulatory required education is mandatory for staff and management have a system for monitoring staff compliance. Staff development needs are identified through performance appraisals, audit results, competency assessments, observation and feedback from residents and staff. All staff interviewed stated they participated in and were supported to attend education within the home and externally.

Examples of education that has occurred relevant to Standard one include: Leadership training First aid training Information technology Elder Abuse 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 Residents and their representatives and other stakeholders have access to an effective


25

complaints mechanism both internally and externally to the organisation. Residents and their representative are advised of the internal compliments and complaints processes and external complaints mechanisms and advocacy services on entry to the home. Relevant information, including the charter of resident rights and responsibilities is included in the resident agreement and the resident handbook and is on display within the home. Residents and their representatives are encouraged, through an open door policy, to approach management with their issues and concerns. Management maintains a centralised register of complaints which includes details of actions taken, feedback provided to the complainant, and complaint outcomes. Residents and their representatives and staff indicate they are confident in using the home’s complaints mechanisms and that complaints are addressed promptly and appropriately. 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 corporate vision, mission, and philosophy are clearly documented and included in both the resident and staff handbooks. They are also displayed in the entry foyer and common areas of the home. The home has effective mechanisms for communication, planning and review, and integration of services. For example, there are high levels of stakeholder consultation, robust committee and reporting systems, as well as strategic planning and budget processes that underpin the provision of services. Interviews with residents and their representatives and the assessment team’s observations indicate that management and staff model behaviours consistent with the home’s values and hold a strong culture of care for residents. 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 Management has effective systems in place to ensure there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with the Accreditation Standards and the home’s philosophy and objectives. All staff are provided with duty statements and position descriptions and are supported to undertake ongoing training and professional development relevant to their roles. New staff undertake formal orientation and are buddied with experienced staff for mentoring and on the job training. Staffing and skill levels are monitored regularly and adjusted in response to changing resident care needs. Registered nurses are employed to work over the 24 hour period to supervise and direct care. They are supported by enrolled nurses and certificate four care service employees who work in the role of team leader. Staff interviewed indicated they are confident that they have the relevant knowledge and skills to do their jobs. Residents and their representatives interviewed by the team said that generally response times by staff are satisfactory and that staff provide good care.


25

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 home has adequate stocks of equipment and goods to provide quality service delivery to residents. Equipment needs are identified through monitoring of maintenance systems to identify replacement needs, changing resident needs, feedback from staff and relatives, occupational health and safety aspects and regulatory compliance requirements. New equipment is assessed for occupational health and safety aspects and may be trialled prior to purchase. Preventative and reactive maintenance of equipment is implemented by the home’s maintenance officer, and by external contractors. The home uses preferred suppliers, and responsibilities for ordering medical, catering and other supplies are clearly allocated within the home. Staff interviewed by the team said that the home has adequate levels of equipment and supplies to provide quality resident care and that maintenance and repairs are completed promptly. 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 Interviews, documentation review and observation confirm that the home has effective information systems in place to provide access to current information to all stakeholders. Information for residents is provided on entry to the home in a comprehensive information pack that contains the resident’s handbook and resident agreement. Information systems within the home for residents’ include resident meetings, case conferencing, newsletters and information placed on the noticeboards. Staff have access to policies, procedures, job descriptions and duty lists and sign a privacy statement on employment. Care staff report updated information is available from the communication book, progress notes, handover, emails, staff memos, verbal discussion, and staff meetings. The home routinely collects information through audits, surveys, documentation of incidents/accidents, medication incidents and infection rates. The information is analysed, actioned and communicated within the framework of relevant meetings. The home maintains the confidentiality of information by securely storing resident files which are only accessible by staff. Key staff have password protected access to the computer system. 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 The home ensures that external services are provided in a way that meets the home’s needs and quality standards by having an approved list of suppliers of external services, and maintaining service agreements with the majority of the external providers. Details of licences, insurances, and chemicals used where appropriate are maintained. Food product suppliers have agreements which specify quality, freshness and transportation requirements to meet the food safety standards. Contractors’ visitor book and badges are in place. Records of service calls and service reports are maintained. Performance of external service providers in the home is monitored. A comprehensive ‘resource manual’ is in place


25

containing contact details of external providers and services, and procedures are in place for after hours contact. Residents and their representatives and staff interviewed by the team are satisfied with services offered by external contractors.


25

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 Refer to expected outcome 1.1 Continuous improvement for further information including a description of the overall system of continuous improvement. Management demonstrated results that show improvements in health and personal care and their responsiveness to the needs of residents, representatives and stakeholders. Some results achieved relating to Accreditation Standard Two includes: In August 2011, the home commenced the introduction of an electronic care planning

system. The benefits of this system include a reduced environmental impact, decreased staff time on paperwork, streamlined documentation, information recorded closer to the time events occur so it is not forgotten, and staff always using the current forms. The home has computer work stations which can be taken to the bedside to record information. All residents’ care requirements are documented in one place so registered nurses and team leaders are able to monitor residents’ clinical care more easily. Messages can be generated for all staff to keep them informed about any changes and tasks can be allocated to staff so that required care is reliably provided.

An audit identified that the medication system was not meeting the home’s needs.

Management researched alternate medication systems and identified a company with whom they have entered into a contract. This supplier provides the services included in their contract including providing colour coded medication blister packs, sign sheets, conduct of routine audits, monitoring the use of psychotropic medications and providing regular staff education. Management report and medication incident data shows medication errors have reduced since the introduction of the new medication system.

The home has implemented a therapeutic massage program for residents who are

experiencing pain. Residents who would benefit from the treatment have been assessed and programs have been documented and treatments provided. A resident interviewed by the team said the massage treatment provided does relieve their pain.

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 The home has systems in place to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s systems. Examples of regulatory compliance with Accreditation Standard Two include:


25

The home monitors registrations and authority to practice for registered and enrolled nurses working within the home and other health and related service personnel.

The home has a system in place to ensure it meets the regulatory requirements for the

reporting of unexplained absences of residents. 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 to expected outcome 1.3 Education and staff development for a description of how the home provides education and monitors the results to ensure staff have appropriate skills and knowledge to effectively perform their roles. Examples of education and training related to Accreditation Standard Two include: Wound management Managing challenging behaviours Continence Pain management Palliative care Oral and dental care 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s findings The home meets this expected outcome The home has a system in place to ensure that residents receive appropriate clinical care that is specific to their individual needs. Documentation reviewed demonstrated that initial and ongoing assessments of the residents’ clinical care needs are conducted and documented and include consultation with residents, their representatives and health professionals. Care plans are developed in consultation with the resident to reflect their individual requirements. All care plans are prepared by an endorsed enrolled nurse (EEN) and are reviewed by a registered nurse (RN) at least three monthly to reflect the care needs of the clients at all times. Residents are referred to allied health and medical professionals to promote optimal clinical outcomes. The team observed staff providing care consistent with residents’ care plans and recording routine observations in their progress notes. Residents and their representatives interviewed expressed satisfaction that appropriate clinical and personal care staff are available to meet their needs and their preferences are taken into account. Residents and their representatives comments included statements such as ‘staff are fantastic’ and ‘beyond that’.


25

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 The need for specialised nursing care is identified on entry to the home and on an ongoing basis with details documented in residents’ care plans. The home currently cares for residents with specialised nursing care needs such as diabetes management, anti-coagulant therapy and continuous oxygen therapy. Staff interviews and documentation review confirmed that assessments of residents’ specialised care needs are undertaken as required by a registered nurse or other appropriately qualified staff in consultation with residents and their representatives and medical specialists. Staff are provided with education and appropriate equipment for specialised nursing care. Interviews conducted with residents and their representatives and staff confirm residents’ specialised nursing care needs are appropriately met. 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 The residents are able to access medical officers, allied health professionals and appropriate health specialists in accordance with their needs and preferences. A number of health care specialists visit the home on a regular basis and as required, including a physiotherapist, podiatrist, aromatherapist, optometrist, dietician and mental health consultant. Other specialist health services can be accessed through the local area health service. Records of visits to specialists are kept in resident files and relevant advice from these specialists is included in residents’ care plans. Staff advised, and residents and their representatives confirm, the home assists in the arrangement of appointments to health specialists and transportation to appointments as necessary. 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 The home has clear policies and procedures for the safe and correct management of medications and a medication advisory committee considers and advises on policy. There is a system to ensure medication incidents are documented, reported and appropriately addressed. The medication needs of each resident are assessed when they first move into the home in consultation with their representative and medical officer. Documentation reviewed demonstrated information on residents’ individual medication administration needs, such as methods of altering the form of medications, swallowing difficulties or allergies, is readily accessible and clearly written. All staff responsible for administering medications are appropriately trained and participate in annual competency assessments. A multi-dose blister medication pack system is used and all packs are checked against medical officers’ orders upon delivery from the pharmacist. The team observed staff administering medication in a safe and correct method in accordance with the plan of care. A pharmacist is contracted to conduct routine audits and all files reviewed included a comprehensive medication review. Medications no longer required, those out-of-date, or damaged medications are disposed of


25

appropriately. Residents and their representatives interviewed expressed satisfaction with the management of residents’ medications. 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 An individual pain management plan is prepared for all residents identified as experiencing pain in consultation with the residents and their representatives and the resident’s medical officer. The home has clear policies and procedures regarding pain management. Pain assessments including verbal and nonverbal indicators’ occur when residents move into the home and on an ongoing basis. Strategies to manage pain experienced by residents are determined according to the abilities, needs and preferences of the individual. The team noted that staff administered pain medication as prescribed and recorded any change in the behaviour of residents that may be due to pain. Feedback is sought from residents and their representatives as to the effectiveness of pain management strategies. The home provides a range of alternatives to medication such as aromatherapy, heat packs, massage, music and one-to-one reassurance and diversion. Residents and their representatives interviewed confirmed that residents are maintained as free from pain as possible and that pain relief can be accessed as required. 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 home has clear policies and procedures for the provision of palliative care. A dining/lounge room that is rarely used can be converted into a palliative care room during the end stages of palliation, to ensure privacy and dignity for the resident and their family. The team observed staff interacting with residents and their representatives in a supportive, consultative manner, while respecting the resident’s privacy and dignity. Staff interviews and documentation reviewed confirmed a multidisciplinary approach to palliative care, with consideration given to complementary therapies. Referrals to specialists, environmental aspects and the provision of any specialised equipment or materials is made by staff as required. The local ministers of religion regularly visit the home and are contacted on the request of residents and/or their families to provide spiritual support if needed. 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 are assessed on entering the home for their dietary needs and preferences using oral, dental, and dietary and nutrition assessments. Strategies are developed to address any issues identified and these are documented in a care plan that is reviewed at least every three months. Residents are weighed three monthly as part of routine observations or more frequently if necessary, and a weight loss assessment is conducted if required. Residents are offered a varied, healthy and well balanced diet, which was developed in consultation with a dietician. The home has access to a speech therapist to assess the swallowing ability of residents as required, and special diets and dietary supplements are available as needed.


25

Staff assist residents with their meals when needed and are able to monitor the intake of foods and fluids through special care charts when required. Residents and their representatives expressed satisfaction with the home’s approach to meeting residents’ nutrition, hydration and associated support needs. 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 Clinical documentation reviewed confirms that residents have a skin assessment completed on entry to the home, which includes the identification of those residents at risk of skin impairment. Staff interviewed gave examples of strategies and interventions used in accordance with plans of care to maintain or improve residents’ skin integrity. Staff monitor clients’ skin integrity daily, provide moisturiser for each resident after showering and encourage residents to keep up their fluid intake. Incidents of skin tears are monitored and appropriate action taken. Wound care is carried out by qualified staff and treatment/progress is documented in wound care charts. Nurses provide routine nail care for residents, with specialist foot and skin care for diabetic residents provided through a podiatrist. Residents and their representatives interviewed confirm they are happy with the care provided. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s findings The home meets this expected outcome Residents interviewed stated that they are consulted in regards to the ways in which their continence needs are managed and were satisfied with the manner and timeliness of staff assistance with their continence management. All residents have a continence assessment on entry to the home. A continence care plan and toileting program is developed if required and is regularly reviewed and evaluated. Residents have ample access to toilets throughout the home and access to a call bell system when physical assistance is required. Staff interviews and documentation confirmed strategies and interventions in related aspects of care such as skin integrity and fluid intake, are monitored and carried out as needed. The team observed there are adequate supplies of disposable continence aids of varying sizes available for residents, and staff are trained in the use of these products. Residents and their representatives interviewed confirm they are happy with the care provided and that residents’ continence is managed effectively. 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 demonstrates that the needs of residents with challenging behaviours are managed effectively. Review of clinical documentation shows that specific behavioural assessments are conducted on moving into the home, annually and when necessary. Challenging behaviours, triggers and management strategies are documented in care plans and challenging behaviours are monitored. Residents are referred to specialist medical officers as necessary and reports from referrals were noted in resident’s clinical records. The home has access to a psycho-geriatrician, clinical pharmacologist and a behavioural


25

consultant. The use of psychotropic medication is monitored and alternate strategies are identified and implemented as appropriate. Where restraint is used documentation demonstrated the need for this has been assessed and its use is monitored and regularly reassessed. Staff interviews confirmed the various strategies used to assist in modifying residents’ behaviours, and also stated they are provided with education in behavioural management. Residents and their representatives interviewed by the team stated that they are satisfied with the way the needs of residents with challenging behaviours are managed. 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 mobility and dexterity of residents is assessed on entry to the home and on an ongoing basis by a consultant physiotherapist who provides a care plan and individual exercise programs for residents. A physiotherapy aide assists residents with these individual exercises, balance and strengthening programs and the team noted details of this in the residents’ files reviewed. The recreational activity officer also holds a weekly exercise class for residents. Equipment and assistive devices are available and a comprehensive falls program is in place. Residents and their representatives interviewed state they are happy with the assistance and rehabilitation program provided to residents to achieve optimum levels of 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 The home demonstrates that residents’ oral and dental health is maintained. Residents’ oral and dental care needs and preferences are identified on entry to the home through a variety of assessments. Care plans are developed and a monitoring program implemented to update the plans for any changes required in an ongoing manner. Staff provide assistance to residents with oral hygiene daily as outlined in the resident’s care plan, and any needs or problems are noted in the progress notes and communication book. There is a local dentist who is available for routine appointments. Residents interviewed advised the team they are assisted with oral hygiene when necessary and are satisfied with the care provided. 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 Assessments of residents’ sensory loss are undertaken on entry to the home and strategies to cater for sensory needs are documented in residents’ care plans. Staff assist residents with cleaning glasses and hearing aids as required as part of the residents’ daily hygiene routine and the team observed the patience and sensitivity of staff interacting with residents with sensory loss. The home accesses the services of Australian Hearing Services. The activities program includes a sensory stimulation program that engages all the senses and has proved very popular with residents. A ‘tactile touch trolley’ has been set up as part of this program and contains interesting items for residents to touch which provides a stimulating and varied touch experience. A sensory garden has been established in a secured garden


25

area for all residents and visitors to enjoy. The home provides a safe hazard free environment and aids to assist those with sensory loss such as large print books and magnifiers. Residents and their representatives interviewed by the team indicated satisfaction with the management of sensory loss. 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 Residents’ sleep needs and preferences are assessed on entry to the home and strategies to ensure residents are able to achieve natural sleep patterns are documented in the residents’ care plans. Night staff conduct regular rounds during the night to ensure residents are not unnecessarily disturbed during their sleeping hours. Strategies to assist residents achieve a natural sleep pattern include pain and continence management, heat packs, aromatherapy, warm drinks and medication where prescribed. Residents and their representatives interviewed confirm that the environment is quiet at night and that staff use a range of strategies to assist residents if they have difficulty in sleeping.


25

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 Refer to expected outcome 1.1 Continuous improvement for further information including a description of the overall system of continuous improvement. Management demonstrated results that show improvements in health and personal care and their responsiveness to the needs of residents, representatives and stakeholders. Some results achieved relating to Accreditation Standard Three includes: The staff have laminated a map of Australia which they use during activities to reminisce

with residents about the places they have been and where they would like to see. Staff said the residents enjoy discussing their travels with them and other residents.

A fragrant garden has been created in a disused courtyard. Residents’ participated in

designing the garden and choosing the plants. The residents take part in caring for and maintaining the garden.

The home has provided a resident who loves to read with access to electronic books.

The resident said they love reading books and having access to the electronic books provides them with a lot of variety.

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 The home has systems in place to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s systems. Examples of regulatory compliance with Accreditation Standard Three include: The organisation has considered the implications of the Aged Care Amendment (Security

and Protection) Bill 2007 and has developed policies and processes to minimise instances of elder abuse. A consolidated mandatory reporting register is ready for use should any allegations of abuse be made. To ensure staff awareness of the legislation all staff receive education on elder abuse procedures during their orientation and annually.

To ensure confidentiality of residents’ personal information all records are securely

stored. The Charter of residents’ rights and responsibilities is displayed in the home.


25

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 to expected outcome 1.3 Education and staff development for a description of how the home provides education and monitors the results to ensure staff have appropriate skills and knowledge to effectively perform their roles. Examples of education and training related to Accreditation Standard Three include: Certificate lV Community services; leisure and lifestyle Leisure and lifestyle conference Sexuality in the older person Person centred care 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 a system in place to ensure residents receive support in adjusting to life in the home and on an ongoing basis. Residents and their representatives are interviewed prior to moving into the home and are provided with information about the home through a ‘welcome pack’. The resident’s emotional needs are assessed, documented and regularly reviewed. The education program enables the staff to better understand the needs of residents and observations of staff interactions with residents showed warmth, respect, empathy and understanding. The staff, and especially the recreational activity officer, provide one to one attention to the residents on a regular basis and at times of special need. Family and friends are encouraged to visit and community groups provide further emotional support for the residents. Residents and their representatives interviewed express satisfaction with the emotional support offered by management and staff. 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 Residents expressed satisfaction with the manner in which staff assist them to optimise their independence physically, socially, culturally and intellectually. Residents’ individual care needs including sensory needs and mobility are identified and assessed, and strategies are implemented to maintain maximum independence. Regular exercises and the strength and balance program assist residents to maintain optimal mobility and independence. Residents are encouraged to participate in the recreational activities of the home and are given the opportunity to go on regular outings including a weekly bus trip. The effectiveness of the assistance provided to residents in relation to their independence is monitored through regular review of care plans and resident satisfaction surveys, the comments and complaints


25

mechanism and residents/representatives meetings. Observations by the team, and residents and their representatives interviewed, confirm that residents are encouraged to maintain their independence and participate in the life of the community within and outside the home. 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 Staff are provided with training on privacy and residents’ rights during their orientation, and are required to sign privacy statements on appointment to their positions. The team observed interactions between staff and residents that demonstrates how staff respect the privacy and dignity of residents. All personal information is collected and stored securely with access by authorised staff only and there are procedures for archiving and disposing of documents in accordance with privacy legislation. Written consent is obtained from residents to place photographs on display and publish their names in newsletters. The system to maintain the privacy and dignity of residents is monitored by regular audits, the comments and complaints mechanism, and resident/representatives meetings. Staff interviewed provided examples of the ways they show respect for residents’ privacy and maintain their dignity and confidentiality. Residents and their representatives interviewed are satisfied that staff respect residents’ privacy and maintain their dignity and confidentiality. 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 Residents and their representatives expressed satisfaction with the range and amount of activities offered, including on weekends. The leisure officer prepares a monthly program to cater for the interests and capabilities of the residents, and includes a wide range of activities. One to one attention for the residents is an integral part of the program and caters for those residents who are less capable of active participation in the program or choose not to take part in group activities. Fortnightly bus trips provide an opportunity for residents who like to get out and about; and volunteers, community and church groups visit the home regularly to help the residents stay in touch with the wider community. The effectiveness of the activities program in meeting residents’ interests and needs is monitored through attendance records, activities evaluations, residents/representatives’ meetings, resident surveys and informal feedback given to the staff. The residents and their representatives interviewed indicate residents are encouraged and supported to participate in a wide range of interests and activities. 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 has a system for ensuring that residents’ individual interests, customs, beliefs and cultural and spiritual values are fostered. Residents/representatives are consulted in relation to their cultural and spiritual needs on entry into the home. The information is then


25

communicated to relevant staff members who discuss individual preferences with residents and their representatives. Clergy and representatives from Roman Catholic, Presbyterian and Free Presbyterian, Uniting and Anglican Churches conduct regular religious services at the home, and are available to provide pastoral care for residents and their representatives at times of special emotional and spiritual need. Provision is made for the celebration of special cultural and religious days, for example Christmas, Easter, Anzac Day and Australia Day. Many of the residents are from the local region and subscriptions to, and readings from, the local newspaper and bus trips to the local area help to maintain the cultural link with the local community. The residents and their representatives interviewed are satisfied residents have opportunities to engage in activities related to their ethnic and cultural backgrounds such as commemorative or holy days. 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 has processes in place to ensure residents participate in decisions about the services provided and are enabled to exercise choice and control in relation to their lifestyle. Residents and their representatives are provided with information to assist them in making informed choices. Residents indicate their likes and preferences when they move to the home and these are documented in resident notes and care plans. The team observed staff consulting with residents about their wishes and preferences, and the choices of residents are respected in all care activities, leisure interests, lifestyle and beliefs. The effectiveness of the system in place to ensure residents are able to exercise choice and control over their lives is monitored through resident surveys, meetings and the comments and complaints mechanism. Staff interviewed described a number of ways they encourage and support residents to make choices and decisions, and residents and their representatives interviewed confirm this to be the case. 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 The home provides a ‘welcome pack’ and corporate resident information hand book to residents and their representatives that includes a copy of residents’ rights and responsibilities and how to make a comment or complaint. In addition the Charter of residents’ rights and responsibilities is displayed on the wall of the home. Resident agreements include information on security of tenure, and interviews are held with residents and their families during which detailed explanations are provided regarding security of tenure. A record of resident’s power of attorney is maintained if available and residents are referred to the Guardianship Board where appropriate. Interpreters are provided for residents and their representatives who come from culturally and linguistically diverse backgrounds. Residents and their representatives are surveyed with information obtained used for the home’s continuous improvement process. Interviews with residents confirm they feel secure and happy living at the home.


25

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 to expected outcome 1.1 Continuous improvement for further information including a description of the overall system of continuous improvement. Management demonstrated results that show improvements in health and personal care and their responsiveness to the needs of residents, representatives and stakeholders. Some results achieved relating to Accreditation Standard Four includes: Management identified that it was difficult for families to stay with their resident who was

receiving palliative care whenever they wanted to visit. This was especially the case if the resident was sharing the room with another resident. A small sitting room was converted into a palliative care room through the addition of appropriate furniture including a sofa bed, table setting and repainting the room. The room is also used for other purposes when not required for palliation. A movie projector and screen and a large flat screen television has been purchased and installed into the room. Activities’ such as “Movie night” can be held or residents may use the room for special events such as Melbourne cup or during the football season.

The management team identified the need to create a more home like environment in the

nursing home. They have reconfigured the large dining area into different zones, an area for craft, dining and a lounge area has been created. Residents indicated they are happy with the change.

The home has developed an emergency box and a blackout box. The boxes contain

equipment and resources for use in an emergency such as the emergency manual, resident identification, torches and fire officer’s vests. Staff are aware of the location and contents of the kit and said it would be a useful resource in an emergency.

The home has installed hand sanitising gels, gloves and bags behind the door in each

resident room. The staff are easily able to access the equipment without leaving the room. The management team reported they have observed a decrease in resident eye infections since the equipment has been installed.

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 The home has systems in place to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Refer to expected outcome 1.2 Regulatory compliance for information regarding the home’s systems. Examples of regulatory compliance with Accreditation Standard Four include:


25

The home has a NSW Food Authority license to prepare and serve food to vulnerable populations. An audit by the NSW Food Authority in August 2011 resulted in the home receiving an “A” rating.

The home displays the current annual fire safety statement An occupational health and safety committee who meet on a regular basis Infection control reporting and practices consistent with government health regulations

and guidelines 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 to expected outcome 1.3 Education and staff development for a description of how the home provides education and monitors the results to ensure staff have appropriate skills and knowledge to effectively perform their roles. Examples of education and training related to Accreditation Standard Four include: manual handling chemical training Fire training Food safety Infection control Laundry operations 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 Residents in the home are accommodated in four, three and two bed rooms, with common facilities; there are also several one bed rooms. The home has a dining room and a recreation/lounge room. The home is air conditioned for cooling and warmth. The building has wide corridors with hand rails and all areas of the home are accessible to residents with walking aids or wheel chairs. The home is well maintained and was observed to be clean, free from odour and with low noise levels during the visit. The facility has a documented procedure on security routine and emergency duress to ensure resident and employee safety. The home employs a maintenance officer and a maintenance request log and hazards identification log are in place. Residents and their representatives interviewed by the team are satisfied with the living environment in the home.


25

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 The home’s occupational health and safety (OHS) systems include OHS policy, a designated OHS coordinator, an OHS committee and new staff orientation which includes OHS topics. The home has incidents/accidents documentation system, hazards logs and regular environmental audits in place. Manual handling instructions are in place for each resident. Materials safety data sheets are in place and appropriate personal protection equipment is readily available to staff. Staff interviewed by the team are satisfied with the safety of the working environment and provision of appropriate equipment in the home. 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 Fire safety systems in the home include two designated fire officers and annual fire safety training which is mandatory for all staff. New staff orientation includes fire safety aspects. Fire equipment is regularly maintained by external contractors and its locations are clearly marked and were observed to be free from obstructions. Evacuation plans are displayed throughout the home, emergency procedures flip-charts are provided at telephone locations and staff have access to an emergency manual. The home has an evacuation pack and blackout pack which contains individual resident details and other items for use in an emergency. External doors are alarmed to alert staff to unauthorised entry and exit. Residents interviewed feel safe in the home and staff interviewed were able to describe an appropriate response to a fire alarm. 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 The home has an effective infection control program to manage and minimise infections and infectious outbreaks. Staff receive training at orientation and on an ongoing basis. The home’s surveillance program includes monitoring of residents for infection and providing appropriate treatment and review. The team observed practices that embrace infection control requirements including the use of personal protective equipment, the use of colour coded equipment in all areas, adherence to food safety guidelines, a dirty to clean flow in the laundry, cleaning programs and safe disposal of contaminated and other waste. There are waste management and linen handling procedures and resident and staff vaccination programs. A food safety program is in place and includes regular monitoring of food and equipment temperatures. Staff interviewed by the team demonstrated an understanding of, and commitment to, infection control principles


25

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 systems and processes in place to ensure hospitality services are provided in a way that enhances residents’ quality of life and the working environment of staff. All meals are fresh cook according to appropriate food safety regulations (NSW Food Authority Licence current). Meals are prepared according to residents’ individual preferences and dietary requirements. Catering staff demonstrated knowledge of resident’s special diets and dislikes. The home has a four week rotational seasonal menu and the daily menu is displayed on a whiteboard in the dining room. Residents confirmed that they are given a variety of meals, are offered alternatives as needed and that they are satisfied with meals and quantity provided. The laundry service employs effective systems for the storage, laundering and delivery of linen. Residents’ personal clothing is laundered on site with linen being laundered by an external provider. The laundry was observed to have a dirty to clean flow with automatic chemical dispensers in place. There are processes in place to ensure frequency of service, return clothing to the correct resident, and control infection. The team observed the home to be clean and free of malodour. All cleaning is done according to cleaning schedules and protocols. The team observed that all cleaning equipment is appropriately stored and staff were observed to use cleaning equipment according to infection control principles. Residents interviewed were satisfied with food services, the overall cleanliness of the home, and with laundry services provided.

Wingham Court Nursing Home - Aged Care Quality€¦ · Wingham Court Nursing Home RACS ID 2632...

Documents

Transcript of Wingham Court Nursing Home - Aged Care Quality€¦ · Wingham Court Nursing Home RACS ID 2632...