Uniting Amala Gordon ACT

Uniting Amala Gordon ACT

RACS ID 2949
200 Woodcock Drive
GORDON ACT 2906

Approved provider: The Uniting Church in Australia Property Trust (NSW)

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 15 February 2020.

We made our decision on 23 December 2016.

The audit was conducted on 22 November 2016 to 23 November 2016. 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: Uniting Amala Gordon ACT
RACS ID: 2949 6 Dates of audit: 22 November 2016 to 23 November 2016

Audit Report

Uniting Amala Gordon ACT 2949

Approved provider: The Uniting Church in Australia Property Trust (NSW)

Introduction

This is the report of a re-accreditation audit from 22 November 2016 to 23 November 2016 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.

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 audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 22 November 2016 to 23 November 2016.

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.

Assessment team

Team leader: / Janice Stewart
Team member: / Judith Charlesworth

Approved provider details

Approved provider: / The Uniting Church in Australia Property Trust (NSW)

Details of home

Name of home: / Uniting Amala Gordon ACT
RACS ID: / 2949
Total number of allocated places: / 42
Number of care recipients during audit: / 30
Number of care recipients receiving high care during audit: / 1
Special needs catered for: / N/A
Street/PO Box: / 200 Woodcock Drive
City/Town: / GORDON
State: / ACT
Postcode: / 2906
Phone number: / 02 6249 4100
Facsimile: / N/A
E-mail address: / Nil

Audit trail

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

Interviews

Category / Number /
Service managers / 2
Registered nurses / 2
Organisational quality improvement coordinator / 1
Head of residential / 1
Homemakers / 2
Physiotherapist / 1
Regional maintenance manager / 1
Care recipients/representatives / 11
Chaplain / 1
Organisational business operations manager / 1
Residential business head / 1
Care staff / 2
Care, laundry and catering staff / 5
Clinical learning and development delivery manager / 1

Sampled documents

Category / Number /
Care recipients’ files / 6
Observation charts: bowels, weights, vital signs, blood glucose levels, wound, fluid balance, pain and behaviours / 24
Care recipient agreements / 2
Medication charts / 4
Personnel files including confidentiality agreements / 4

Other documents reviewed

The team also reviewed:

·  Asset register

·  Care recipient admission package including: privacy consent, care recipient handbook, information brochures, care recipient admission pack guidelines

·  Cleaning schedules, environmental cleaning for outbreak information

·  Comments, complaints and suggestions register

·  Equipment orders and stock control documentation

·  Food safety program, audit results and ACT Food licence, seasonal menus, dietician menu review, food temperature monitoring, equipment temperature checklists, kitchen equipment and servery cleaning schedules, care recipient meal preference notes

·  Human resource management including staff handbook, new employee orientation package, job descriptions, duty statements, master roster and working rosters, staff availability and casual list, statutory declarations and staff working visa lists

·  Incident and accident reports, hazard log, risk assessments

·  Infection control: resource material, outbreak management records, infection surveillance data, vaccination programs, audit reports, water analysis and pest control reports

·  Information management including: minutes of meetings, handover reports, information notice boards, memoranda, communication diaries, care recipient handbook, newsletters

·  Lifestyle program, social and spiritual assessments, care plans and hobbies and interests folders

·  Maintenance systems include equipment and high cleaning schedules, preventative and routine maintenance, maintenance requests, warm water testing records

·  Medication: reviews, schedule 8 drug registers, self-administration assessments, patch application, warfarin, nurse initiated medications, PRN, and fridge temperature monitoring books

·  Policy and procedures, including accident and incident reporting and medication incidents

·  Quality system including: Continuous improvement logs, audit schedule and reports, feedback brochures

·  Regulatory compliance including: police record check matrix, elder abuse reporting, consolidated records, professional registrations, government legislative alert documentation

·  Self-assessment report for re-accreditation and associated documentation

·  Staff and Care recipients’ information handbooks

·  Staff signed memoranda

·  Work, health and safety manual, safe workplace audits, networking meeting minutes

Observations

The team observed the following:

·  Activities in progress and resources

·  Equipment and supply storage areas and equipment in use

·  Infection control: food safety, outbreak management kit, sharps waste disposal, spill kits, personal protective equipment, colour coded equipment, hand washing and hand hygiene equipment and waste management

·  Information on display: Aged Care Quality Agency re-accreditation site audit, vision, philosophy and values, comments and complaints, advocacy services and charter of care recipients’ rights and responsibilities, menus

·  Interactions between staff and care recipients/representatives

·  Living environment

·  Meals service

·  Medication: administration, fridges and secure storage

·  Memorial book acknowledging the passing away of care recipients

·  Secure storage of care recipients and staff information

·  Security cameras, locked keypads, night patrol documentation, automatic night lock up systems, fire fighting equipment, evacuation kits

·  Short group observation

·  Staff practices and work areas

·  White board with care recipients’ complex care needs in staff area

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 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

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

Uniting Amala has an overarching organisational system that enables it to actively pursue continuous improvement and monitor its performance against the Accreditation Standards. The identification of areas for improvement occurs through meetings, audits, comments and complaints, reporting of incidents and accidents, clinical indicators and verbal feedback. Strategies are developed and monitored to ensure satisfactory outcomes are achieved. Staff and care recipients/representatives are aware of the systems for continuous improvement and confirmed they are involved in continuous improvement activities. Interviews with care recipients/representatives and staff confirmed feedback has resulted in improvements for care recipients.

The home has made planned improvements in relation to Accreditation Standard One - Management systems, staffing and organisational development, including:

·  As care recipient occupancy in the facility increased, management identified the need to review registered nurse staffing levels. As a result of the review, extra staff have been employed to ensure a registered nurse is on duty twenty four hours per day. Management said this has resulted in increased monitoring of staff, and improved care for care recipients.

·  Recently it was identified there were no formalised break times for staff, and this was causing confusion at times. In consultation with staff, guidelines for morning, lunch and tea breaks have been developed. Staff take into consideration care recipients’ needs and preferences before taking breaks. Generally, staff feedback has been positive, and management are still monitoring the effectiveness of this initiative.

1.2 Regulatory compliance

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

Team’s findings

The home meets this expected outcome

There are systems to ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. The organisation receives regulatory compliance information from government departments and agencies as well as professional conferences and networks. Management at the home monitors compliance through observation of staff practices, performance appraisals, the audit program and feedback. Relevant changes in legislation and guidelines are communicated to staff through meetings, memoranda, noticeboards, toolbox talks and education sessions. Staff state they are satisfied with the information provided to them about legislation, regulatory requirements, professional standards and guidelines relevant to their work. Examples of compliance with regulatory requirements specific to Accreditation Standard One - Management systems, staffing and organisational development include:

·  A system and processes ensure all staff, allied health professionals and volunteers have current criminal history checks.

·  The provision of information to care recipients and stakeholders about internal and external complaint mechanisms.

·  Notification of the re-accreditation audit to care recipients/representatives occurred via notices in the home and verbal notification.

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

There are processes to ensure management and staff have the appropriate knowledge and skills to perform their roles effectively. The review of documentation and interviews with management and staff demonstrated training needs are identified. Compulsory and planned education opportunities and competency testing ensure staff have the necessary knowledge and skills to meet the needs of care recipients in their care. Guest speakers, qualified staff, online and external education opportunities are used to ensure a variety of training is provided. There is a recruitment procedure and orientation process for new staff. All staff interviewed reported they have access to education on a regular basis.

Review of the education documentation and interviews confirmed education has been provided in relation to Accreditation Standard One - Management systems, staffing and organisational development. Examples include:

·  Four staff have been trained as super users in the electronic incident management program, and the electronic care management program, as well as mentoring.