Lemongrove Gardens Hostel

RACS ID: 0211

Approved provider: Anglican Community Services

Home address: 32 Gascoigne Street PENRITH NSW 2750

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 22 December 2020.
We made our decision on 16 November 2017.
The audit was conducted on 04 October 2017 to 05 October 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: Lemongrove Gardens Hostel Date/s of audit: 04 October 2017 to 05 October 2017

RACS ID: 0211 6

Audit Report

Name of home: Lemongrove Gardens Hostel

RACS ID: 0211

Approved provider: Anglican Community Services

Introduction

This is the report of a Re-accreditation Audit from 04 October 2017 to 05 October 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 04 October 2017 to 05 October 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: 59

Number of care recipients during audit: 56

Number of care recipients receiving high care during audit: 53

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 /
Care manager / 1
Care recipient representatives / 2
Care recipients / 12
Care staff / 6
Catering staff / 2
Chaplain / 1
Cleaning staff / 1
Clinical educator / 1
Clinical systems work place trainer / 1
Leisure and lifestyle coordinator / 1
Manager / 1
Pastoral carer / 1
Physiotherapist / 1
Physiotherapy aide / 1
Property officer (regional position) and maintenance staff / 2
Registered nurse / 2
Volunteer leader (regional position) and volunteer / 2

Sampled documents

Document type / Number /
Care recipients’ files / 7
Medication charts / 14
Wound care documentation and summary management plans / 6

Other documents reviewed

The team also reviewed:

·  Audits, clinical incident forms and indicator reports and survey results

·  Care recipient accommodation agreement template

·  Care recipient admission information pack, handbook, newsletters

·  Care recipient photograph consent forms

·  Care recipient room listing

·  Catering documentation including dietary records, equipment, care recipient meal choices and a current food authority certificate

·  Clinical care: various assessments including admission, complex health care needs, behaviour management, nutrition and hydration, dietary needs/preferences, abbey pain, communication, bowel, continence management, medication assessments and consents, falls risk, physiotherapist mobility and pain assessments, oral and dental health, toileting, skin integrity, sleep, sensory loss, social, cultural, spiritual and lifestyle

·  Clinical monitoring records: bowel charts, blood glucose level, infections, behaviour charts, wound management and treatment records, pain management and treatment records, vital sign records and weight monitoring, sensory checks records

·  Clinical notation records: general practitioner, registered nurse and care staff, podiatrist, physiotherapist, clinical pharmacist medication reviews, advance care plan, care conference records, diabetic plans, medication plans, health specialist reports

·  Compliments and complaints logs and related documentation

·  Continuous improvement documentation including logs, quality improvements register

·  Contractor agreements (electronic)

·  Education documentation including calendars, evaluations, attendance records, mandatory education, coaching and mentoring logs, staff training history records

·  Fire, security and other emergencies documentation: Emergency evacuation plans, emergency contingency plans and procedures, fire service records and current fire safety certificate, emergency management manual.

·  Human resource documentation including position descriptions, registrations, roster, competencies, performance appraisals, confidentiality agreements, qualifications, statutory declarations, police checks

·  Infection control information: microbiology reports, infection control forms and clinical indicator reports/ monthly summary and trend data, outbreak information folders/ audit results, medication refrigeration temperature monitoring

·  Information systems: organisation electronic management system, flowcharts, newsletters, memoranda, handover sheets, communication books, diaries, computer based information systems, various publications

·  Leisure and lifestyle: monthly calendars, leisure activities records, activity plans and evaluations, care recipients’ craft and photograph displays of leisure activities and event participation, care recipient participation feedback reports, social, cultural, spiritual and lifestyle assessments and care management plans, bus outings venue risk assessments, lifestyle meeting records

·  Maintenance documentation including electronic and paper schedules, environmental reports, schedule of planned capital improvements, and essential services maintenance and testing records for preventative and reactive maintenance

·  Mandatory reporting documentation

·  Medication management: schedule eight drug register, medication incident records, medication refrigerator temperature records, medication management protocols and guidelines, electronic medication administration signage system

·  Meeting minutes – various

·  Mobility and dexterity: group exercise program, individual exercise/mobility programs and evaluation records

·  Nutrition and hydration: diet analysis and preference forms, diet allergy list, food/fluid charts, drinks lists, thickened fluid requirements, nutritional supplements, weight monitoring records

·  Pastoral care folders and participation records

·  Policies and procedures

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

·  Volunteer folder and related documentation

·  Wellness program

·  Work health and safety (WHS) records including hazards, incidents an accident reports and action plans, hazard log and hazard identification reports, WHS meeting agenda and minutes, chemical register, safety data sheets

Observations

The team observed the following:

·  Activities in progress and monthly activity program on display

·  Activities calendar on display

·  Aged Care Complaints Commissioner and advocacy information on display, internal feedback forms and secure box for lodgement

·  Audio book corner

·  Brochures, pamphlets and Charter of Care Recipients’ Rights and Responsibilities displayed

·  Children’s outdoor play area

·  Cleaning in progress

·  Clinical care handover shift report

·  Closed circuit television system

·  Continuous improvement forms

·  Corporate intranet

·  Dining environments during midday meal services, morning and afternoon tea, staff serving/supervising

·  Equipment and supply storage areas

·  Fire safety systems including evacuation egresses, evacuation pack, evacuation signs and diagrams, fire indicator panel, firefight equipment and sprinkler system

·  Hairdresser salon

·  Infection control resources: hand washing facilities, hand sanitisers, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies and kit,

·  Information noticeboards – staff, care recipients, visitors

·  Interactions between staff, care recipients and visitors

·  Living environment internal and external

·  Medication administration rounds, medication trolleys, impress cupboard contents, scheduled medication register and registered nurses’ specimen signatures, staff resources for specialised care recipient care and medication management

·  Menu on display

·  Mission, philosophy, vision and values statements, and objectives

·  Mobility and lifting equipment including mechanical lifters; wheel chairs and walkers in use

·  Nurse call bell system

·  Online procurement system

·  Photographs of care recipients participating in leisure interests and events

·  Quality Agency re-accreditation audit notices on display

·  Reading, writing and sewing area for care recipients

·  Care recipient laundries

·  Secure key pad coded perimeter doors and staff work areas

·  Secure storage of care recipient information

·  Short group observation during midday dining

·  Sign in and out books

·  Single ensuite care recipient rooms

·  Staff work practices and work areas

·  Utility rooms

·  Waste management practices

·  Weigh station

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's system is aligned with the Approved Provider's organisational continuous improvement system. The continuous improvement program includes processes for identifying areas for improvement, implementing change, monitoring and evaluating the effectiveness of improvements. Feedback is sought from care recipients, representatives, staff and other stakeholders to direct improvement activities. Improvement activities are documented on the plan for continuous improvement. Management uses a range of monitoring processes such as audits and quality indicators to monitor the performance of the home's quality management systems. Outcomes are evaluated for effectiveness and ongoing monitoring of new processes occurs. Care recipients, representatives, staff and other personnel make suggestions for improvement and are provided with feedback about results. During this accreditation period the organisation has implemented initiatives to improve the quality of care and services it provides. Recent examples of improvements in Standard 1 Management systems, staffing and organisational development are:

·  As a result of the home’s bed numbers increasing from 46 to 59, staff numbers grew from 24 to 40. This rapid growth posed a challenge. To ensure a smooth integration of the new staff the home implemented a 60 day Culture Challenge. The longer term goal was to build an appreciative culture where the organisational values would be practiced by both care recipients and staff.

·  To support the 60 day Culture Challenge an external consultant was commissioned to assess how well the home’s staff culture aligned with the organisations’. Following the results of the culture assessment, the home conducted an internal workshop. Pre and post workshop evaluations were done for each staff member. The result was the development of individualised profiles linking the organisation’s values to each staff member. This process assisted all staff to better understand each other's professional motivations and values, how they could work better together and be more appreciative of each other’s strengths. Evidence of these cultural profiles is available in the staff room.

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”.