Garrawarra Centre

RACS ID: 1456

Approved provider: NSW State Government (NSW Ministry of Health)

Home address: 1810 Old Princes Highway WATERFALL NSW 2233

Following an audit we decided that this home met 37 of the 44 expected outcomes of the Accreditation Standards. We decided to vary this home’s accreditation period. This home is now accredited until 14 December 2017.
We made our decision on 14 June 2017.
The audit was conducted on 15 May 2017 to 23 May 2017. The assessment team’s report is attached.
The short period of accreditation will provide the home with the opportunity to develop and implement effective monitoring systems while addressing the areas identified as not met.
We will continue to monitor the performance of the home including through unannounced visits.

Important information:

On 26 May 2017, NSW State Government (NSW Ministry of Health) was notified of a decision of the delegate of the CEO of the Australian Aged Care Quality Agency that a failure to meet one or more expected outcomes in the Accreditation Standards has placed, or may place, the safety, health or wellbeing of a care recipient at serious risk.

The Department of Health has been notified of the risk. The Secretary of the Department of health may impose sanctions on an approved provider that has not complied, or is not complying, with its responsibilities under the Aged Care Act 1997. If applicable, sanctions are published at the My Aged Care compliance information webpage[1].

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 Not 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 Not 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 Not 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 Not met

3.3 Education and staff development Met

3.4 Emotional Support Met

3.5 Independence Met

3.6 Privacy and dignity Not 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 Not met

4.5 Occupational health and safety Not met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met

Home name: Garrawarra Centre Date/s of audit: 15 May 2017 to 23 May 2017

RACS ID: 1456 2

Audit Report

Name of home: Garrawarra Centre

RACS ID: 1456

Approved provider: NSW State Government (NSW Ministry of Health)

Introduction

This is the report of a Review Audit from 15 May 2017 to 23 May 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:

·  37 expected outcomes

The information obtained through the audit of the home indicates the home does not meet the following expected outcomes:

·  1.6 Human resource management

·  2.3 Education and staff development

·  2.13 Behavioural management

·  3.2 Regulatory compliance

·  3.6 Privacy and dignity

·  4.4 Living environment

·  4.5 Occupational health and safety

Scope of this document

An assessment team appointed by the Quality Agency conducted the Review Audit from 15 May 2017 to 23 May 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of three 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: 120

Number of care recipients during audit: 117

Number of care recipients receiving high care during audit: 117

Special needs catered for: Care recipients with dementia and behavioural and psychological symptoms of dementia

Audit trail

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

Interviews

Position title / Number /
General manager/nurse manager / 1
Nurse unit managers / 4
Nurse manager residential / 1
Registered nurses/endorsed enrolled nurses / 11
Administration assistant / 1
Business quality manager / 1
Registered nurse/clinical nurse consultant / 1
Nurse educators / 4
Security staff / 1
Diversional therapists / 2
Assistants in nursing / 21
Geriatrician / 1
Care recipients / 4
Care recipient representatives / 24
University students on placement / 2
Clinical nurse consultant/infection control coordinator / 1
Diversional therapy coordinator / 1
Work health and safety officer (SESLHD) / 1
Rehabilitation case manager (SESLHD) / 1
Administration staff / 3
Maintenance staff / 1
Cleaning staff / 5
Laundry staff / 2
Hospitality staff / 5

Sampled documents

Document type / Number /
Care recipients’ files / 17
Summary/quick reference care plans / 17
Medication charts / 12
Care recipients’ files – leisure and lifestyle, spiritual, quality of life / 10
Personnel files / 9

Other documents reviewed

The team also reviewed:

·  Catering, cleaning and laundry: care recipients' dietary and food preference information, four weekly seasonal menu, cleaning attendance records for individual rooms, catering, cleaning and laundry cleaning schedules and duty lists

·  Clinical assessment and observation tools including: physiotherapy, speech pathology, behaviour, continence, skin, wound, mobility, pain verbal and non-verbal, sensory loss, nutrition and hydration, oral care, falls risk, specialised nursing care, observation, bowel charts, weight charts and personal care charts

·  Clinical care tools including: specialist and allied health referral and review documents, accidents and incidents, assessment guidelines, comprehensive medical assessments

·  Communication records between staff and care recipients doctors, appointment books, newsletters, notices, memoranda and handover sheets

·  Education documentation: education monthly calendars, education training attendance records, educational resource information, staff mandatory training requirements

·  Fire safety and emergencies documentation: including annual fire safety statement, emergency evacuation diagrams, emergency management manual, evacuation details of care recipients, emergency response guide flipcharts

·  Food safety: NSW Food Authority licence

·  Human resource management documentation: employment documentation, staff rosters, position descriptions, employment information pack, employee orientation documentation, staff performance appraisals, code of conduct agreements

·  Information management: including communication newsletters, meeting schedule and minutes, resident and relative information handbook and information pack, handover sheets

·  Infection control information including: infection control manual, trend data, outbreak management program, care recipients and staff vaccination records, infection incidence and antibiotic utilisation charts

·  Leisure and lifestyle information including: individual activity assessments, care recipient feedback and satisfaction surveys, recreational activities documentation, monthly activities program, activities evaluation and attendance records, risk assessments, pet care plans, minutes of meetings and associated documentation

·  Maintenance documentation: preventative maintenance schedules, maintenance request logs

·  Meeting minutes: quality, nurse unit manager, cottage staff meetings, carers’ meetings

·  Medication management reviews, medication incidents, medication/pathology refrigerator temperature readings, schedule 8 medication secure storage and registers and medication management system

·  Quality management system: mission, values, organisational charts, policies and procedures, audits and incident documentation, continuous improvement documentation, compliments and complaints folder, audit schedule

·  Regulatory compliance documentation: compulsory reporting log register, staff police check records, NSW Food Authority Licence, professional registration records

·  Resident agreements (for respite and permanent care recipients)

·  Work health and safety system documentation: incident and hazard reports, work health and safety documentation, safety data sheets, consolidated incident reports, staff/visitor/contractor incident summary, daily disposition books, safe work procedures, workplace inspections, work health and safety development folder.

Observations

The team observed the following:

·  Activities in progress

·  Australian Aged Care Quality Agency notices of audit displayed

·  Care recipients utilising pressure relieving mattresses, bed rail protectors, hip and limb protection equipment

·  Charter of care recipients rights and responsibilities displayed.

·  Chemical storage and safety data sheets

·  Different vision, values, philosophy, statements displayed in each cottage

·  Emergency exits marked and free from obstruction

·  Equipment and supplies in use an in storage rooms including clinical, medication, toiletries, chemical, paper goods, continence and linen stock

·  Fire panel, fire-fighting equipment, emergency exits, emergency evacuation diagrams, emergency response guide flipcharts, annual fire safety statement

·  Hand hygiene facilities

·  Interactions between staff and care recipients including meal service, morning and afternoon teas

·  Living environment – internal and external (chicken coop and guinea pig hutch)

·  Medication management: administration and storage areas, emergency stocks of medication

·  Mobility equipment including walk belts, wheeled walkers, shower chairs, toilet seats, mechanical lifters, low beds, handrails and internal lift access between floors

·  Notice boards containing activity programs and notices, menus, memos, staff and care recipient information, comments and complaints information, advocacy brochures and notices informing care recipients

·  Nurse call system in operation, duress alarms in use

·  Secure storage of medications, pathology storage fridge and medication round, emergency stocks of medication

·  Short group observations in Acacia cottage and Grevillea cottage

·  Sign in books for visitors and tradesman/contractors, secure coded entry/exits

·  Safety huddle agenda items

·  Staff work areas and staff work practices

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

Garrawarra Centre has a continuous improvement system to identify and implement improvements across the four Accreditation Standards. Care recipients/representatives/ stakeholders and staff use formal and informal mechanisms to provide feedback on aspects of care and service delivery. Mechanisms include audits, legislative changes and input from advisory bodies, comments and complaints and meetings. Continuous improvement matters are captured in a continuous improvement plan and actions logged on the plan are followed up in a timely manner. Continuous improvement matters are discussed and reported at various meetings. Meetings are held to progress initiatives. Staff are familiar with continuous improvement mechanisms and are aware of recent improvements. Care recipients/ representatives/stakeholders and staff are encouraged to make suggestions and to put forward ideas for improvement using the various feedback mechanisms.

·  The South East Sydney Local Health District (SESLHD) has decided to adopt an improved maintenance request system to replace the current system. The new data base will contain alerts for the preventative maintenance of all equipment and linked to the Building Code of Australia (BCA) and other regulations. A further advantage of the new program is that it will be linked to the Finance department’s asset information. The system will be trialled and monitored to evaluate its effectiveness.

·  The current pay system is being phased out and replaced with a new health roster program. The new program is linked to the award conditions for employees including Stafflink and will contain ability for staff to self-roster.