Mary Mackillop Care Flora Mcdonald

Mary MacKillop Care Flora McDonald

RACS ID 6816
206 Sir Donald Bradman Drive
COWANDILLA SA 5033

Approved provider: Mary MacKillop Care SA Ltd

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 09 April 2020.

We made our decision on 07 February 2017.

The audit was conducted on 09 January 2017 to 11 January 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.

Expected outcome / Quality 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

Principles:

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.

Expected outcome / Quality Agency decision /
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.

Expected outcome / Quality Agency decision /
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

Principle:

Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.

Expected outcome / Quality Agency decision /
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: Mary MacKillop Care Flora McDonald
RACS ID: 6816 28 Dates of audit: 09 January 2017 to 11 January 2017

Audit Report

Mary MacKillop Care Flora McDonald 6816

Approved provider: Mary MacKillop Care SA Ltd

Introduction

This is the report of a Re-accreditation Audit from 09 January 2017 to 11 January 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 09 January 2017 to 11 January 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 home

Total number of allocated places: 87

Number of care recipients during audit: 82

Number of care recipients receiving high care during audit: 82

Special needs catered for: Care recipients living with dementia and related disorders.

Audit trail

The assessment team spent three on site and gathered information from the following:

Interviews

Position title / Number /
Management / 1
Transition project manager / 1
Clinical Staff / 5
Care Staff / 8
Administration/Quality Staff / 2
Care recipients/representatives / 14
Volunteers / 2
Hospitality staff / 7
Maintenance staff / 1
Lifestyle/Pastoral care staff / 3

Sampled documents

Document type / Number /
Care recipients’ files / 10
Summary/quick reference care plans / 5
Medication charts / 10

Observations

The team observed the following:

· Activities in progress

· Chapel

· Charter of care recipients’ rights and responsibilities on display

· Equipment and supply storage areas

· Feedback forms and suggestion boxes

· Infection control stations

· Interactions between staff and care recipients

· Living environment

· Meal service and care recipient BBQ

· Medication round in progress

· Mission, vision and values on display

· Outbreak kits

· Secure document storage and archiving

· Service and maintenance areas

· Short group observation in the memory support unit

· Staff room

· Storage of medications

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

There is a continuous improvement system in place and the organisation actively pursues improvements across all Accreditation Standards. Improvements are identified through feedback, incident and hazard reporting, audits and evaluation of activities. Improvements are registered on improvement forms and collated in the continuous improvement log, which documents the source, idea, actions, due dates, outcomes and evaluation. Improvements are a standing agenda item at all meetings held at the home. Completion of improvements is reported on the monthly Quality report and monitored at Quality and Management meetings. Results show improvements are evaluated and further improvements have been identified through this process. Staff, volunteers, care recipients and representatives interviewed said they are able to make suggestions and management are responsive and open to their ideas.

In relation to Standard 1 Management systems and organisational development the home has implemented the following improvements in the last 12 months:

· Following audits completed regarding training delivered at the home it was identified staff would benefit from a more structured and planned approach to training. A survey was sent to staff to identify additional training staff would like to attend. Using data from the audit, staff survey, training session evaluations and the resulting training needs analysis a mandatory training day was implemented which collated all mandatory training into a one day session. In addition, recommended training topics were made available to staff on an electronic, online learning system and a training schedule was planned for the 2016/2017 period. Management also implemented a new induction program. Staff training attendance is now documented on an online record system. Evaluation of this improvement has shown improvement in staff knowledge, access to training and documentation of attendance.

· As a result of a suggestion from staff, a care recipient survey process was reinstated. The form which had previously been used was deemed not effective and a new survey template was developed. The survey was distributed to all care recipients and representatives and the results were collated. Evaluation of the survey showed a response rate of 60 per cent and comments received on the survey resulted in additional improvements being identified.

· Following a roster review, completed after the relocation to the new building, management identified an opportunity to build teamwork and leadership. Staff were involved in developing a set of agreed upon expectations and values. Rosters were changed to improve the opportunity for teamwork, with clinical staff involved in leadership tasks. Staff and management completed teamwork, leadership and customer service training. Evaluation occurred and results show staff feel more accountable for their roles, and teamwork and communication has improved. Interviews with staff confirm they feel there is effective teamwork across the site.

1.2 Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.

Team’s findings

The home meets this expected outcome

There are processes to identify and implement legislative changes identified across the Accreditation Standards. Relevant staff are advised of changes through communication from head office, peak body memberships and government announcements and newsletters. Relevant policies and processes are updated and communicated to staff through various methods such as memoranda, notices, messaging services, training, meetings and alerts. Changes affecting care recipients are communicated through meetings, notices, letters and discussions with care recipients and representatives. Monitoring processes include regular policy review, audits, feedback, staff registers and meetings. Results show relevant staff documents are checked regularly and policies are updated to reflect changes. Staff interviewed are able to identify changes to legislation affecting their 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

Management, staff and volunteers have appropriate skills and knowledge to perform their roles effectively. Recruitment processes ensure employees have the required qualifications and/or skills for their roles. Staff and volunteers complete induction processes and checklists to confirm they understand their role and responsibilities. There are processes to identify training needs of staff across the home and staff and volunteers are able to request additional training. A training calendar is developed and a mandatory training day is attended by all staff and volunteers. Additional training is offered through an electronic education system and staff can choose to complete additional training. Monitoring of staff skill requirements occurs through feedback, audits, training needs analysis, review of care recipient needs and the staff appraisal process. Evaluation of training activities occurs through the session feedback forms, which are reviewed prior to future education planning. Results show education sessions are targeted to ensure quality of care and services. Staff interviewed said they are given sufficient training to complete their roles. Care recipients and representatives interviewed said they are satisfied with the staff knowledge and skills.

Examples of education conducted over the last 12 months in relation to Standard 1 Management systems, staffing and organisation development include:

· Customer service

· Leadership training

· Team work

1.4 Comments and complaints

This expected outcome requires that "each care recipient (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

Care recipients, representatives and other interested parties have access to internal and external complaint mechanisms. Care recipients and representatives are advised of complaints processes during entry to the home. Information about complaints processes is displayed around the home, brochures are available, and staff and volunteers receive training on supporting care recipients and representatives to provide feedback. Feedback is captured through feedback forms, meetings and verbal discussions, which are documented in the homes’ complaints log. There are processes for lodging feedback anonymously and secure feedback boxes are placed around the home to ensure privacy and confidentiality when dealing with complaints. Monitoring occurs through trend analysis, audits, surveys and discussion of the complaints log entries during relevant meetings. Results show feedback is addressed promptly and is used to identify improvements. Staff and volunteers described processes for managing feedback. Care recipients and representatives confirmed feedback is listened to by management, and results in changes and improvements.

Mary Mackillop Care Flora Mcdonald