Minchinbury Manor

RACS ID0601
Cnr of John Street & Rupertswood Road
ROOTY HILL NSW 2766

Approved provider:Australasian Accommodation Aged Care Pty 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 15 March 2020.

We made our decision on 17 January 2017.

The audit was conducted on 13 December 2016 to 15 December 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
1.1Continuousimprovement / Met
1.2Regulatorycompliance / Met
1.3Education and staffdevelopment / Met
1.4Comments andcomplaints / Met
1.5Planning andleadership / Met
1.6Human resourcemanagement / Met
1.7Inventory andequipment / Met
1.8Informationsystems / Met
1.9Externalservices / 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
2.1Continuousimprovement / Met
2.2Regulatorycompliance / Met
2.3Education and staffdevelopment / Met
2.4Clinicalcare / Met
2.5Specialised nursing careneeds / Met
2.6Other health and relatedservices / Met
2.7Medicationmanagement / Met
2.8Painmanagement / Met
2.9Palliativecare / Met
2.10Nutrition and hydration / Met
2.11Skin care / Met
2.12Continence management / Met
2.13Behavioural management / Met
2.14Mobility, dexterity and rehabilitation / Met
2.15Oral and dental care / Met
2.16Sensory loss / Met
2.17Sleep / 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
3.1Continuousimprovement / Met
3.2Regulatorycompliance / Met
3.3Education and staffdevelopment / Met
3.4Emotionalsupport / Met
3.5Independence / Met
3.6Privacy anddignity / Met
3.7Leisure interests andactivities / Met
3.8Cultural and spirituallife / Met
3.9Choice anddecision-making / Met
3.10Care 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
4.1Continuousimprovement / Met
4.2Regulatorycompliance / Met
4.3Education and staffdevelopment / Met
4.4Livingenvironment / Met
4.5Occupational health andsafety / Met
4.6Fire, security and otheremergencies / Met
4.7Infectioncontrol / Met
4.8Catering, cleaning and laundryservices / Met

Home name: Minchinbury Manor
RACS ID: 06011Dates of audit: 13 December 2016 to 15 December 2016

Audit Report

Minchinbury Manor 0601

Approved provider: Australasian Accommodation Aged Care Pty Limited

Introduction

This is the report of a Re-accreditation Audit from 13 December 2016 to 15 December 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.

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 13 December 2016 to 15 December 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.

Details of home

Total number of allocated places: 104

Number of care recipients during audit: 104

Number of care recipients receiving high care during audit: 75

Special needs catered for: Dementia – 17 bed secure unit

Audit trail

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

Interviews

Category / Number
Executive manager / 1
Director of care / 1
Assistant director of care / 1
Quality assurance coordinator / 1
Nurse educator / 1
Registered nurses / 5
Team leaders / 5
Care staff / 7
Administration officer / 1
Care recipients / 9
Representatives / 7
Recreational activities officers / 3
Physiotherapist / 1
Physiotherapy aide / 1
Catering staff / 1
Laundry staff / 2
Cleaning contractor staff / 3
Maintenance officer / 1

Sampled documents

Category / Number
Care recipients’ files including advance care directives, progress notes, medical officer notes and referrals, hospital discharge notes, pathology and radiology reports – permanent and respite (soft and hard copy) / 12
Care plans – permanent and respite / 12
Action plan – specialised nursing care needs / 1
Medication charts - primary and nurse initiated / 20
Staff files / 7
Service/supplier agreements / 10

Other documents reviewed

The team also reviewed:

  • Asset – equipment inventory
  • Case conference checklist - annual
  • Catering records including menu, food allergen register, food and drink register, NSW Food Authority licence and audit report, food safety program and records, catering supplier list
  • Cleaning manual, schedule, records and audits
  • Clinical assessments and evaluations including behaviours, continence,mobility, nutrition and hydration, medications, mobility, pain, oral and dental, sensory, skin,sleep, specialised nursing care including catheter care, complex wounds, oxygen therapy, palliative care, wounds including photographs – permanent and respite
  • Clinical indicator data - monthly and annual reports including aggressive behaviours, hospital transfers, falls, wounds new and ongoing
  • Clinical observations, monitoring and treatment charts including behaviours, blood pressure, blood glucose levels, pain, anticoagulant drug therapy and wounds including photographs
  • Complaints register
  • Daily and monthly care records including care recipient bowel monitoring, personal hygiene and weights, resident of the day
  • Diabetes therapy directives - doctors’ management directives – permanent and respite
  • Disaster management plan
  • Documented follow up on care recipients’ needs with medical and other related health personnel by registered nurses
  • Education/training records including needs analysis, calendar, attendance records, compulsory training matrix, orientation program, induction records, skills competency assessments, evaluations
  • Enquiry pack, care recipient handbook, care recipient agreement for residential care and new care recipient orientation checklist
  • Fire safety system inspection and maintenance records
  • Human resource management documentation including staff employment pack, staff information handbook, position descriptions, duty statements, buddy shift checklist, police certificate register, record of professional registrations, staff roster, casual staff contact list, staff appraisal schedule and employee performance reviews
  • Incident reports for individual care recipients including behaviours, falls, infections, skin tears
  • Infection control records including monthly infection surveillance and reports, individual care recipient infection reports, immunisation records for care recipients and staff
  • Laundry manual, cleaning schedule, maintenance schedule and linen inventory
  • Lifestyle assessments and evaluations including regular ‘global’ reviews, activity plans, resources including ‘how-to’ activity lists, activity attendance records and evaluations (individual and group) – soft and hard copy
  • Maintenance log, internal and external preventative maintenance schedules, contractor records/notes, monthly maintenance reports, contractors contact list, service reports
  • Medication records including controlled drugs registers, records of disposal of controlled dugs, records of reordering of packed and unpacked medications, medication error incident reports and follow up, medication advisory committee reports
  • Meetings schedule and minutes
  • Memos, communication books, handover sheets, doctor’s facsimile
  • Newsletters
  • Nursing care plan and assessment allocation schedules – 2016, 2017
  • Other health and related services - referrals, reports, assessments, plans of care: including behaviour management specialists, dietician, dermatologist, geriatrician, ophthalmology, physiotherapy, podiatry, psychogeriatrician, specialist physicians and surgeons, speech pathologist, wound care.
  • Plan for continuous improvement and improvement logs
  • Policies and procedures
  • Preferred supplier/service agreement register and clinical orders/delivery records
  • Quality program including audit calendars, audits, surveys, analysis and reports
  • Register for mandatory reporting of alleged and suspected assault and register of missing persons
  • Regulatory compliance information including correspondence and updates from government departments and industry bodies
  • Safety device authorisation forms, safety device release forms
  • Self-assessment report for re-accreditation
  • Work health and safety records including committee list, manual, meeting minutes, training resources, environmental audits, monthly incident analysis and reports

Observations

The team observed the following:

  • Activities, including exercises and concert, in progress
  • Annual fire safety statement on display
  • Archives
  • Charter of care recipients rights and responsibilities on display
  • Complaints mechanisms notices, brochures on display and improvement logs and comments/complaints box available at entrance of the home.
  • Daily handovers between registered nurses and care staff
  • Emergency evacuation kit
  • Equipment and supply storage areas including continence aids, clinical supplies, linen, mobility aids, manual handling equipment, personal hygiene and wound care requisites, palliative care kit, chemicals
  • Firefighting equipment and warning systems
  • Infection control facilities and equipment, waste management including clinical waste, outbreak management kits, spill kits, sharps containers, colour coding equipment in use, hand washing stations, antibacterial hand wash available and infection control posters displayed
  • Interactions between staff, care recipients and representatives including meal service, morning and afternoon tea, staff assisting and supervising care recipients with meals; small group observation in dementia care
  • Lifestyle resources and equipment
  • Living environment including renovations
  • Medication system and processes including administration and storage; controlled drugs, safety system for controlled drugs safes - keys, medication re-ordering program, delivery and disposal systems; medication supplies including eye drops and medicated creams
  • Mobility aids and care recipients being assisted with mobility
  • Noticeboards for care recipients, visitors and staff
  • Notification of re-accreditation audit on display
  • Nurse call system in operation including care recipient access
  • Secure storage of personal information
  • Security systems including electronic access and closed circuit television surveillance
  • Staff interacting with medical and other related health services personnel including medical officer, physiotherapist
  • Staff work practices and work areas including administrative, clinical, recreational, catering, cleaning, laundry and maintenance
  • Vision statement, philosophy and commitment to quality on display

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.

1.1Continuous improvement

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

Team’s findings

The home meets this expected outcome

A quality management system is in place and the home is actively pursuing continuous improvement. Areas for improvement are identified through input from all stakeholders using mechanisms that include: improvement logs, regular meetings, feedback mechanisms, a program of audits and surveys, and analysis of monitoring data. All opportunities for improvement that are identified are recorded on a plan for continuous improvement that enables the planning, implementation and evaluation of the improvements. This process is coordinated by the management team with the assistance of a quality assurance committee which meets monthly. Care recipients,representatives and staff are encouraged to actively contribute to this process and those interviewed report they are aware of the ways they can make suggestions for improvement. They say management is responsive to suggestions and they are consulted and kept informed about improvements at the home.

The home demonstrated it is actively pursuing continuous improvement in relation to Accreditation Standard One and recent examples of this are listed below.

  • Staff are required to complete one full day of mandatory training and twelve other training sessions each year as part of their ongoing education and professional development. Management identified some staff were having difficulty completing the required training, especially those who worked at night or on weekends. In response management introduced the option of on-line training to supplement the education program. New topics are introduced each month and the educator is available for support and follow-up. The feedback from staff has been very positive. They appreciate the flexibility and convenience of being able to access the training to suit their needs. It has also helped them achieve their education and professional development goals.
  • Due to the increasing needs of care recipients management reviewed the staffing levels at the home. As a result of the review the staffing levels were increased with the introduction of an extra team leader and two extra care staff each day. Extra casual staff have also been recruited to ensure they are able to cover any vacancies that arise in the roster. The increased staffing levels have helped to better meet the needs of care recipients.
1.2Regulatory 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 identifies all relevant legislation, regulatory requirements, professional standards and guidelines through information forwarded by government departments, peak industry bodies and other aged care and health industry organisations. This information is disseminated to staff through updated policies and procedures, regular meetings, memos and ongoing training. Relevant information is disseminated to care recipients and their representatives through meetings, newsletters, notices on display in the home and personal correspondence. Adherence to these requirements is monitored through the home’s continuous quality improvement system, which includes audits conducted internally and by external bodies. Staff practices are monitored regularly to ensure compliance with regulatory requirements.

The home is able to demonstrate its system for ensuring regulatory compliance is effective with the following examples relating to Accreditation Standard One.

  • Police certificates are obtained for all staff.
  • Contracts with external service providers confirm their responsibilities under relevant legislation, regulatory requirements and professional standards, and include police certificates for contractors visiting the home.
  • There is a system for the secure storage, archiving and destruction of personal information in accordance with privacy legislation and regulations relating to care recipients’ records.
  • Care recipients/representatives were informed of the re-accreditation site audit in accordance with the Quality Agency Principles 2013.
1.3Education 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 is a system to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. The recruitment process identifies the knowledge, skills and education required for each position. There is a comprehensive orientation program for all new staff and a buddy system is used to support the new staff during their first days of employment. There is an education program, including topics covering the four Accreditation Standards, which is developed with reference to training needs analysis, performance appraisals, regulatory requirements, staff input and management assessments. The program includes in-service training by senior staff, training by visiting trainers and suppliers, on the job training, on-line training and access to external training and courses. Records of attendance at training are maintained, the training is evaluated and the effectiveness of the training is monitored through performance appraisals and competency assessments. Management and staff interviewed report they are supported to attend relevant internal and external education and training. Care recipients and representatives interviewed say staff have the skills and knowledge to perform their roles effectively.