Klemzig Residential Care Services
RACS ID: 6957
Approved provider: Hahndorf Holdings Pty Ltd
Home address: 2 Leighton Avenue KLEMZIG SA 5087
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 08 October 2020.We made our decision on 10 August 2017.
The audit was conducted on 03 July 2017 to 05 July 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 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 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 care
Principle:
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.
2.1 Continuous improvement Met
2.2 Regulatory compliance Met
2.3 Education and staff development Met
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
Standard 3: Care recipient lifestyle
Principle:
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.
3.1 Continuous improvement Met
3.2 Regulatory compliance Met
3.3 Education and staff development Met
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 systems
Principle:
Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors
4.1 Continuous improvement Met
4.2 Regulatory compliance Met
4.3 Education and staff development Met
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: Klemzig Residential Care Services Dates of audit: 03 July 2017 to 05 July 2017
RACS ID: 6957 2
Audit Report
Name of home: Klemzig Residential Care Services
RACS ID: 6957
Approved provider: Hahndorf Holdings Pty Ltd
Introduction
This is the report of a Re-accreditation Audit from 03 July 2017 to 05 July 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 Standards
The information obtained through the audit of the home indicates the home meets:
· 44 expected outcomes.
Scope of this document
An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 03 July 2017 to 05 July 2017.
The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two assessors registered aged care quality assessors.
The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.
Details of home
Total number of allocated places: 87
Number of care recipients during audit: 76
Number of care recipients receiving high care during audit: 76
Special needs catered for: Care recipients living with Dementia or other related disorders and care recipients with culturally and linguistically diverse backgrounds.
Audit trail
The assessment team spent three days on site and gathered information from the following:
Interviews
Position title / Number /Acting care coordinator / 1
Acting care manager / 1
Acting site manager / 1
Ancillary staff / 7
Care recipients / 15
Clinical nursing staff / 4
Direct care workers / 5
Leisure and lifestyle coordinators / 2
National operations manager / 1
Regional clinical education and governance facilitator / 1
Regional learning and development officer / 1
Regional manager / 1
Regional project officer / 1
Representative’s / 4
Senior administration officer / 1
Volunteers / 1
Sampled documents
Document type / Number /Care recipients’ files / 8
Medication charts / 8
Personnel files / 7
Other documents reviewed
The team also reviewed:
· Care recipients’ information handbook
· Comments and complaints
· Continuous improvement plan
· Equipment purchase records
· External contractors documentation
· Food safety audit report
· Incidents data
· Maintenance records
· Menu
· Policies and procedures
· Self-assessment
· Staff files and documentation
· Staff roster
· Temperature monitoring records
· Triannual fire safety certificate
· Various audits
· Various meeting minutes
Observations
The team observed the following:
· Activities in progress
· Charter of care recipients’ rights and responsibilities
· Cleaning in progress
· Comments and complaints information
· Equipment and supply storage areas
· Evacuation maps and kits
· Hand hygiene stations
· Interactions between staff and care recipients
· Kitchen
· Laundry
· Living environment
· Meal service
· Noticeboards
· Short observation in the memory support unit
· Suggestion box
Assessment information
This 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 development
Principle:
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 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. The home has a commitment to continuous improvement as part of its quality management system and identifies continuous improvements through audits, monitoring, feedback, surveys, comments and complaints, meetings and observations. Identified continuous improvements and actions are recorded in the plan for continuous improvement activity log. Implemented improvements are evaluated and feedback is provided to care recipients, family members and staff. Results show that the home has a plan for continuous improvement in place and actively pursues continuous improvement. Care recipients, representatives and staff interviewed said they have the opportunity to make suggestions for improvement.
Improvement initiatives implemented by the home over the last 12 months in relation to Standard 1 Management systems, staffing and organisational development include:
· The home identified a range of gaps in the method, frequency and delivery of education across each staffing group and the methods of training did not provide a robust competency based learning environment. It was also identified that there were inconsistencies in the evaluation process of formal education provided. An online training program that contains a suite of training sessions pertinent to aged care was selected and introduced to the home in December 2016 and a corporate learning and development coordinator role was developed and introduced to coincide with the roll out of the online training. Training champions were identified and trained as champions of the system to provide on-site support to staff. Staff have been provided with a dedicated training room, computer and resource library. All staff are now actively using the online training as their primary source of learning and development and weekly compliance reports are generated within the system.
· Clinical and care documentation was previously maintained through a paper based documentation system. The system lacked consistency and hindered the ability for management to adequately monitor clinical compliance and care delivery. Management identified the need to create a more individualised care plan and the need for a more consistent approach to limit the risks of errors. A computerised software program was rolled out across the home from November 2016 to March 2017using a staged approach based on risk. All staff were trained with dedicated champions identified across senior clinical positions. A user manual and business rules guide were developed and made accessible for all nursing staff. Based on staff feedback, modifications to the system were implemented improving the functionality and quality of information recorded. The implementation of the computerised program was well received by all nursing staff and has allowed greater visibility for management to monitor and review documentation and check progress note entries. It has also improved reporting and trending abilities to identify actions that may be required.
· Staff raised the concern that they did not always feel consulted or informed on day to day issues and complained they were often unable to attend scheduled staff meetings out of their rostered hours. Buzz meeting templates were developed and made available for all department heads to use on a needs basis as matters arose or where identified. Nursing staff predominantly use this approach but it is available to all staffing groups and copies of the meeting minutes are made available to staff who were not present. Buzz meetings have contributed to a more effective and consultative approach to communication within the workplace across all staffing groups. All areas of the home are informed of day to day changes in a timely manner and issues can be discussed and addressed in a timely manner.
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 and processes in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The process is managed through the national and regional office through subscriptions to peak bodies and legislative update services. Policies, procedure changes and staff education are developed and communicated to the home. Staff are notified of relevant changes through memos, meetings, clinical safety alerts, noticeboards, policies/procedures, workshops and formal training. Compliance with legislation is monitored through supervision of work practices, audits and staff competencies. Results show there are corporate and site processes to ensure compliance with regulatory changes. Staff interviewed said they have access to information and their police checks are up-to-date. Care recipients and representatives interviewed said they are provided with relevant information.
Examples of systems in place to ensure compliance with Standard 1 Management systems, staffing and organisational development:
· Care recipients and representatives were notified of the re-accreditation audit and information displayed in the home.
· Criminal history checks for all staff and contractors: the home sends reminder letters two months prior to the due date and maintains a register.
· Confidentiality agreements are signed by all staff prior to commencement of duties.
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 systems and processes in place to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. The home has an orientation program for new employees on commencement of employment covering mandatory and core training topics including fire safety, reportable assault, missing residents, elder abuse, responding to difficult behaviours, dementia, infection control, food safety, work health and safety, and manual handling. All employees have access to online learning and development via the online training program and all staff are to complete their yearly mandatory training. Additional training is also provided either at staff request or as a learning plan for underperforming staff. The home monitors attendance at training and evaluates training through a feedback form. Results show the home provides relevant education across the four Standards. Staff interviewed said they are provided with opportunities to access online education and undertake mandatory yearly training. Care recipients and representatives interviewed said staff have the appropriate skills and knowledge to perform their roles effectively.
Examples of education in relation to Standard 1 Management systems, staffing and organisational development:
· Information technology training has been provided to clinical staff and management prior to the roll out of computerised software program.