Governor Phillip Manor

Governor Phillip Manor

RACS ID 1457
64 Glebe Place
PENRITH NSW 2750

Approved provider: RSL LifeCare Limited

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 26 April 2020.

We made our decision on 02 March 2017.

The audit was conducted on 07 February 2017 to 08 February 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: Governor Phillip Manor
RACS ID: 1457 4 Dates of audit: 07 February 2017 to 08 February 2017

Audit Report

Governor Phillip Manor 1457

Approved provider: RSL LifeCare Limited

Introduction

This is the report of a Re-accreditation Audit from 07 February 2017 to 08 February 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 07 February 2017 to 08 February 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: 82

Number of care recipients during audit: 75

Number of care recipients receiving high care during audit: 75

Special needs catered for: N/A

Audit trail

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

Interviews

Position title / Number /
Manager / 1
General manager – Central Sydney / 1
Regional manager / 1
Registered nurses / 4
Physiotherapist / 1
Care staff / 6
Activity and lifestyle staff / 2
Administration assistant / 1
Administration assistant to Special Projects / 1
Catering staff / 2
Care recipients/representatives / 10
Laundry staff / 2
Cleaning staff / 2
Maintenance supervisor / fire officer / 1

Sampled documents

Document type / Number /
Care recipients’ files / 12
Summary/quick reference care plans / 12
Medication charts / 11
Personnel files / 3
Signed residency agreements / 2

Other documents reviewed

The team also reviewed:

·  Accident and incident reports, medication incidents, behaviour incidents, with data collation and reporting

·  Activity documentation including: leisure and lifestyle assessments, leisure and lifestyle care plan and care recipient social profile, activities calendars, individual visits records, activity participation records, quality of life surveys

·  Advanced care directives

·  Allied health referral, assessment and care planning documentation

·  Audit schedule, audits, surveys

·  Behaviour assessment tools, behaviour management and monitoring tools, referral to external specialists, assessment of triggers and plans implemented; restraint assessment and monitoring

·  Care recipients' information package, handbook and agreements

·  Cleaning and maintenance schedules

·  Clinical documentation: including care plans, monitoring and evaluation of care documents, assessment and treatment records, referral to external specialists, hospital discharge documents, vital signs charting, blood glucose level monitoring, advance care planning documents and specialised nursing care documents; clinical monitoring records and observation monitoring records, resident of the day records

·  Communication books for staff, communication on electronic system and Doctors communication books

·  Continence management including management plans, daily bowel monitoring records and continence aid allocation lists

·  Dietary preference assessments, catering documents and notices regarding preferred diets and food allergies

·  Documentation guides

·  Education calendar, training records, attendance records, competency assessments, staff qualifications

·  Equipment registers and lists

·  External service providers’ contracts and service agreements, certificates of currency (insurances), contract list and service records

·  Feedback management system including comments, complaints and compliments

·  Fire and emergency documentation including annual fire safety statement, evacuation plans, fire equipment audits and testing records

·  Human resources documentation including policies and procedures, staff handbook, staff orientation program, job descriptions, duty statements, staff rosters, performance management documentation, privacy and confidentiality statements

·  Infection control documentation including training records, vaccinations records and consent forms, pest management service records

·  Medication management documents, diabetic medication delivery tools, assessments and monitoring records

·  Meeting minutes – staff, care recipients and medication advisory committee

·  Memo folder, newsletters, email communication

·  Menu, food preference lists, NSW Food Authority licence and annual audit report

·  Nutrition and hydration management including: individual dietician review, special diets, thickened fluids and nutritional supplements, menu choice forms, care recipient food and beverage preferences and allergies, and weight monitoring charts

·  Pain assessment tools for verbal and non-verbal assessment of pain, pain management monitoring charts, referral to external specialists

·  Physiotherapy assessments, mobility assessments, falls risk assessments, mobility care plans, manual handling guidelines and equipment ordering documents

·  Plan for continuous improvement

·  Police check register, nurse registrations, statutory declarations, visa documentation

·  Policies and procedures

·  Reportable incidents register

·  Self-assessment report for re-accreditation

·  Specialised nursing records including: diabetes management plans, in-dwelling and supra-pubic catheter care, wound and pain management

·  Vaccination consent and administration records, hospital discharge records, specialist referral and attendance records

·  Wound assessment and management records, referral to and review by wound specialists

Observations

The team observed the following:

·  Activities in progress and associated resources and notices

·  Complaints documentation, advocacy service brochures, information pamphlets on display

·  Dining environment during midday meal service including staff supervision and assistance

·  Electronic and hardcopy record keeping systems - clinical and administration

·  Equipment and supplies in use and in storage such as lifting equipment, manual handling aids, mobility equipment, motion sensor lights, bed sensor mats and pressure relieving aids in use and in storage; clinical stores and continence aids

·  Fire safety systems and equipment, evacuation kit, security systems, closed circuit television, in/out signing sheets

·  Infection control including: outbreak supplies, spill kits, sharps disposal containers, hand-washing facilities, waste disposal, hand sanitiser dispensers around the home, general and contaminated waste disposal systems, cytotoxic waste disposal system, colour coded cleaning equipment and personal protective equipment

·  Interactions between staff, care recipients and representatives including meal service and short group observation in secure area of the home

·  Living environment – internal and external

·  Medication administration across the home; secure storage of medication

·  Notices advising stakeholders of the dates for the re-accreditation audit on display

·  Safety data sheets

·  Secure storage of confidential care recipient information

·  Staff access to information systems including computers

·  Staff work practices and work areas including care services, catering, cleaning, laundry and maintenance

·  Video conferencing system in meeting room

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 has implemented a systematic approach for actively pursuing continuous improvement. The continuous improvement system is supported by an overall quality structure that has both local and organisational dimensions. At the RSL LifeCare organisational level there is a range of management services that provide overall direction, support and coordination of quality improvement activities. At the local level, various meetings provide a mechanism for input and feedback by the range of stakeholders. Examples of other local level quality activities include feedback forms, routine audits, surveys, external reviews, hazard reporting, accident and incident reporting, data collection and other monitoring systems.

Examples of specific improvements relating to Standard 1 Management systems, staffing and organisational development include:

·  The RSL LifeCare organisation has introduced its own intranet called ‘Cooee’ through which staff can access all corporate information and organisation policies and procedures. Cooee gives staff a single point of access to information relating to safe systems, policy updates, learning and development opportunities, organisation activities, internal contact directory, quality activities and reports, and a link to the electronic roster. Various staff interviewed in the home confirmed that the Cooee system is effective and has greatly assisted their access to information.

·  As part of an organisational initiative, the home has installed a new video conferencing system to allow staff full access to education materials from head office (Narrabeen) and to facilitate managers communicating remotely with one another.

·  The home has made several equipment purchases in order to improve staff and care recipients’ safety, comfort and amenity. For example, it has upgraded bed baths to enable easier use and manoeuvring in care recipients’ bathrooms. As part of falls prevention, it has also purchased and placed sensor mats under the beds of some care recipients (at risk of falling) to alert staff when there is movement at night. Similarly, extra lo-lo beds were purchased to assist with management of care recipients at risk of falling out of bed.

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’s management has systems in operation to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home is advised of any changes in regulatory requirements and professional standards by the RSL LifeCare organisational level, which monitors the regulatory environment through updates from government and industry bodies, industry conferences, internet access and various other mechanisms. Staff are advised of regulatory requirements and any relevant changes to them through various means including memos, updates to policies, meetings and education. Compliance with regulatory requirements and other standards is monitored through a comprehensive audit program as well as day-to-day supervisory arrangements. We sighted relevant legislation and/or legal documentation displayed in various locations in the home.