Elouera Aged Care Centre

RACS ID3251
6-11 Kooringa Place
TORQUAY VIC 3228

Approved provider:Aged Care Services 28 (Elouera) Pty Ltd

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 11 April 2020.

We made our decision on 13 February 2017.

The audit was conducted on 10 January 2017 to 11 January 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
1.1Continuousimprovement / 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: Elouera Aged Care Centre
RACS ID: 32511Dates of audit: 10 January 2017 to 11 January 2017

Audit Report

Elouera Aged Care Centre 3251

Approved provider: Aged Care Services 28 (Elouera) Pty Ltd

Introduction

This is the report of a re-accreditation audit from 10 January 2017 to 11 January 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.

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 10 January 2017 to 11 January 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.

Assessment team

Team leader: / Mary Murray
Team member: / Bradley McKenzie

Approved provider details

Approved provider: / Aged Care Services 28 (Elouera) Pty Ltd

Details of home

Name of home: / Elouera Aged Care Centre
RACS ID: / 3251
Total number of allocated places: / 75
Number of care recipients during audit: / 75
Number of care recipients receiving high care during audit: / 75
Special needs catered for: / Care recipients living with dementia
Street/PO Box: / 6-11 Kooringa Place
City/Town: / TORQUAY
State: / VIC
Postcode: / 3228
Phone number: / 03 5261 9121
Facsimile: / -
E-mail address: /

Audit trail

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

Interviews

Category / Number
Facility manager / 1
Quality support staff / 2
Corporate support staff / 3
Clinical care coordinator / 1
Registered nurses / 2
Enrolled nurses / 1
Care staff / 7
Care recipients / 11
Representatives / 2
Administration assistant / 1
Lifestyle staff / 2
Physiotherapist / 1
Catering / environmental staff / 4
Maintenance staff / 1

Sampled documents

Category / Number
Care recipients’ files / 7
Wound charts / 6
Lifestyle care plans / 9
Medication charts / 7
Personnel files / 4

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

The organisation has an effective quality system driving continuous improvement. ‘Have your say’ forms and ‘resident’ meetings enable those living at the home and their representatives to provide written and verbal feedback to the management team. Management respond to feedback in a timely manner and develop priority action plans for more substantial or complex improvements the home undertakes. Staff record opportunities for improvement identified through surveys or the home’s audit system on ‘corrective action requests’ and monitor these requests for their completion. Care recipients, representatives and staff said they are encouraged to put forward their improvement suggestions and management has a continuous improvement focus.

Examples of continuous improvement relating to Standard 1 Management systems, staffing and organisational development include:

The organisation has implemented an electronic ‘time and attendance workforce management’ system to replace a number of paper based human resource administrative tasks. The system ensures governance and compliance requirements for items such as employment awards and rosters are effectively managed. Staff have individual access codes into the system to enable them to update their personal details, see leave balances and lodge queries for the human resource team. Staff said the system is easy to use and working well.
A project to build resilience within the staff team has been well received by its participants. The project led by an external consultancy group over several months covered a number of key topics such as managing stress, conflict resolution, recognising strengths and weakness in self and others and dealing with grief and bereavement. Management said the program has strengthened the teamwork ethos and those staff who undertook the course are actively using their new skills to support their colleagues.
To recognise the ongoing commitment of staff to the organisation, the home has introduced length of service awards. An annual presentation ceremony invites all employees to celebrate the work of their colleagues with badges awarded for five, ten and fifteen years of service. Staff were proudly wearing their badges during the visit.

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 organisation has a system for identifying relevant legislation and regulatory requirements and ensuring compliance with professional standards and guidelines. Information is received from a number of government and other sources and through the organisation’s membership of legislative update services. Corporate services distribute updates to facility managers for review and further dissemination. Regulatory compliance is a standing agenda item at staff meetings and any subsequent policy update is circulated to relevant staff. Care recipients and representatives are informed of changes to legislation through meetings, letters, notices or direct correspondence. Management monitor regulatory compliance using its audit system. Staff said they are informed about regulatory compliance.

Examples of regulatory compliance relating to Standard 1 Management systems, staffing and organisational development include:

The organisation has processes to monitor police clearance certificates for staff, volunteers and service providers.
The organisation has processes to monitor the current registration of nursing staff.
Personal information is collected, managed and destroyed in accordance with privacy legislation.

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

Management and staff have the knowledge and skills to undertake their roles effectively. The organisation develops a yearly education program based on compulsory training, skills development and competency requirements. Training platforms utilised include self-directed learning packages, in-service presentations, toolbox style sessions and attendance at external courses. There is an organisation wide program ensuring facility managers receive ongoing education either through leadership courses or attendance at ‘Better Practice’ seminars. The yearly education program is subject to change depending on staff and care recipient needs and short notice educational opportunities. Management monitor staff adherence to the self-directed learning modules and follow up non-attendance at compulsory training. Staff are satisfied with the educational opportunities available to them.

Examples of education relevant to Standard 1 Management systems, staffing and organisational development include:

aged care documentation
Better Practice seminar
incident management.

1.4Comments and complaints

This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".

Team’s findings

The home meets this expected outcome

Management has a system to encourage comments, complaints and feedback from care recipients, representatives and other interested parties. Information packs distributed to care recipients and representatives outline the comments and complaints process. The right to complain and take action to resolve disputes is emphasised on entry to the home. Staff are aware of their role in actioning comments and complaints. Management has an ‘open door’ approach to feedback and act on verbal and informal feedback. Staff log comments and complaints to ensure timely follow-up of issues and monitor items for resolution as required. Care recipients and representatives said they feel comfortable giving feedback and are aware of different avenues to raise comments and complaints.

1.5Planning and leadership

This expected outcome requires that "the organisation has documented the residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".

Team’s findings

The home meets this expected outcome

The organisation’s vision, mission and values statements are on display within their Elouera home and consistently recorded in documentation available to all stakeholders.

1.6Human resource management

This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the residential care service’s philosophy and objectives".

Team’s findings

The home meets this expected outcome

There are qualified staff available to meet care recipients’ care needs and lifestyle preferences. Local management follow established recruitment and selection processes which consider employee qualifications, reference checking and police clearance certification. New employees sign a contract and undertake an orientation program. Staff performance is monitored through observations, competency testing and an annual appraisal program. Staff have access to internal and external education opportunities and attend compulsory training. Local management monitor the staff roster and can adjust staff numbers in response to increased care recipient acuity. Care recipients are satisfied with the responsiveness of staff and the care they provide.

1.7Inventory and equipment

This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".

Team’s findings

The home meets this expected outcome

The home has a system to ensure equipment and consumables are available for quality service delivery. Key personnel monitor stock levels and the home uses ‘first in first out’ stock rotation. Staff monitor equipment for its safety and undertake regular maintenance and cleaning of items to ensure they remain fit for purpose. There is a maintenance program to support both planned and reactive maintenance processes. New equipment is trialled to ensure it meets care recipient and staff needs. Equipment, supplies, medications, chemicals and perishable goods are stored appropriately and securely. Staff and care recipients said there are sufficient supplies and equipment for their needs.

1.8Information systems

This expected outcome requires that "effective information management systems are in place".

Team’s findings

The home meets this expected outcome

There are effective information systems to guide management and staff in the delivery of care and services to care recipients. The organisation maintains a paper-based assessment, care planning and monitoring system, accessible to staff and visiting health professionals. Communication mechanisms include the use of diaries, electronic systems, memoranda and newsletters. New care recipients receive a service handbook upon entry and are offered a residential contract. Leisure and life staff circulate monthly activity planners and management convene regular care recipient and representative meetings. Management conduct surveys, complete audits and collect information regarding the quality of care and services provided in the home. Care recipients’ information is securely stored and there is a system for archiving and destruction of documents. Care recipients and representatives are satisfied management and staff keep them informed.

1.9External services

This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals".

Team’s findings

The home meets this expected outcome

Management has processes to ensure external providers deliver goods and services in a way that meets the home’s service goals. Procurement staff manage the appointment of all external services. Preferred suppliers are utilised to ensure consistency of service and contracts outline the standard of work expected. Contractors are orientated to the layout of the home and the values of the organisation. The performance of contractors is routinely evaluated, work inspections occur and stakeholder feedback on services is sought on an ongoing basis and prior to any contract renewal. Management, staff and care recipients are satisfied with the products and services currently supplied to the home from external providers.

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.