Published Decision (SA and RA)

Navorina Nursing Home

RACS ID: 2744

Approved provider: The Deniliquin Nursing Home Foundation Ltd

Home address: 5-9 Macauley St DENILIQUIN NSW 2710

Following an audit we decided that this home met 41 of the 44 expected outcomes of the Accreditation Standards. This home remains accredited until 03 November 2017.
We made our decision on 20 July 2017.
The audit was conducted on 20 June 2017 to 29 June 2017. The assessment team’s report is attached.
We will continue to monitor the performance of the home including through unannounced visits.

Important information:

On 3 July 2017, The Deniliquin Nursing Home Foundation Ltd 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 Met

1.7 Inventory and equipment Met

1.8 Information systems Not 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 Not met

2.8 Pain management Not 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: Navorina Nursing Home Date/s of audit: 20 June 2017 to 29 June 2017

RACS ID: 2744 2

Audit Report

Name of home: Navorina Nursing Home

RACS ID: 2744

Approved provider: The Deniliquin Nursing Home Foundation Ltd

Introduction

This is the report of a Review Audit from 20 June 2017 to 29 June 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:

·  41 expected outcomes

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

·  1.8 Information systems

·  2.7 Medication management

·  2.8 Pain management

Scope of this document

An assessment team appointed by the Quality Agency conducted the Review Audit from 20 June 2017 to 29 June 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: 50

Number of care recipients during audit: 46

Number of care recipients receiving high care during audit: 46

Special needs catered for: Dementia specific area

Audit trail

The assessment team spent 4 days on site and gathered information from the following:

Interviews

Position title / Number /
Chief executive officer / 1
Clinical care manager / 1
Finance officer/Maintenance supervisor/Fire warden / 1
Hospitality manager / 1
Human resource officer/Administration officer / 1
Registered nurses / 3
Endorsed Enrolled Nurses / 4
Assistants in nursing / 10
Diversional therapists / 2
Cooks / 2
Catering staff / 2
Care recipients and/or representatives / 30
Volunteers / 3
Laundry staff / 1
Cleaning staff / 2
Maintenance staff / 1
Work health and safety coordinator / 1
Board company secretary / 1
Mental health clinician / 1
Nurse consultant / 1

Sampled documents

Document type / Number /
Care recipients’ files including progress notes, assessments, care plans, care plan evaluations, pathology, referrals to medical practitioners and other health specialists / 15
Medication charts / 6
Personnel files / 8
Resident agreements / 4

Other documents reviewed

The team also reviewed:

·  Activity calendars, leisure and lifestyle assessments, activity attendance records and evaluations

·  Asset register

·  Audits and surveys

·  Care recipients’ risk assessments

·  Catering documentation including food safety folder, resident meal choices, dietary advice, allergies, food produce receiving register, cleaning schedules, maintenance folder, calibration records, temperature logs, menus, recipes

·  Cleaning documentation including infection control, duty lists

·  Clinical monitoring charts including bowels, pain, vital signs, weights, wounds, pain treatment directives and signature logs; resident assessed need snapshots; nutritional supplement signing sheet

·  Complaints register, complaints, comments and compliments forms, aged care complaints scheme and advocacy brochures, suggestion boxes, aged care complaints scheme posters

·  Consolidated records of allegations or suspicions of reportable assaults folder including compulsory reporting register

·  Continuous improvement documentation including continuous improvement plan, feedback forms, receipt letter samples, logs, projects

·  Contractor service agreements

·  Dietitian folder including dietitian referral sheet and food and fluid consumption charts

·  Education documentation including calendars, attendances, evaluations, toolbox talks, brochures, evaluations, competencies, mandatory education, orientation schedules, education reports

·  External auditor accreditation report

·  Healthcare emergency coordinator and portable firefighting equipment course folder

·  Human resource documentation including rosters, allocation lists, sick leave reports, registrations, orientation/induction, police checks, statutory declarations, performance appraisals, confidentiality agreements, position descriptions, social media policy

·  Incident reports, clinical indicator reports

·  Infection reports, unresolved infection reports, monthly infection rates analysis reports

·  Internal preventative and reactive maintenance documentation including testing and tagging records, thermostatic mixing valves, legionella reports

·  Inventory and supplies register

·  Laundry documentation including infection control, linen folder, cleaning duty lists

·  Medication management documentation including medication incident reports and medication incident analysis summaries, nurse initiated medications list, schedule 8 drug registers, refrigerator temperature checking sheet, weekly drug of dependence register management check, emergency medication list

·  Meeting minutes, meeting schedule

·  Policies and procedures

·  Refurbishment schedule and plans

·  Resident and staff handbooks

·  Resident of the day schedule, progress notes schedule, pain massage schedule, diaries at nurses stations, registered nurses’ handover information sheets, care staff handover day sheets, alerts on electronic clinical documentation system, doctors communication books, faxed communication with the pharmacy

·  Service records

·  Signed ‘refusal against advice’ waiver, risk assessments

·  Work health and safety documentation

Observations

The team observed the following:

·  Activities in progress

·  Annual food safety authority certificate

·  Archive room

·  Australian Aged Care Quality Agency visit notices on display

·  Care recipients going on a club outing

·  Care recipients’ call bell system, staff pager/phone system in use

·  Charter of care recipients’ rights and responsibilities on display

·  Church service in progress

·  Cleaning in progress with appropriate signage

·  Clinical supplies in storage and in use

·  Concert and happy hour in progress

·  Continuous improvement meeting

·  Contractors onsite completing refurbishment of home

·  Dining environments during lunch and beverage services with staff assistance including the serving and transport of meals and nutritional supplements, use of assistive devices for meals and care recipients being assisted with meals

·  Emergency equipment including extinguishers, blankets, sprinklers, evacuation bag, care recipient lists, emergency lighting, emergency flipcharts for staff

·  Equipment and supplies in use including manual handling equipment, mobility and pressure relieving equipment, hand rails, clinical and continence supplies

·  Equipment and supply storage rooms including clinical, linen stock in sufficient quantities and equipment available and in use for manual handling such as hand rails, lifters and mobile walkers, personal protective equipment

·  Guidelines and instruction available to staff

·  Hairdressing salon in operation

·  Infection control: signage, instruction for staff, visitors and care recipients, personal protective equipment available, hand washing and sanitising facilities available, outbreak box, colour coded cleaning equipment in use, specimen refrigerator

·  Interactions between staff, care recipients and visitors

·  Kitchen environments including, staff preparing, cooking and serving meals, selection of foods and food storage areas

·  Living environment internal and external

·  Medication management: storage including secure cupboards and trolleys, refrigerator, medication round in progress, emergency medication supplies, secure medication storage for care recipients who self-medicate, expiry/opened dates on non-packed medications

·  Mission, values and philosophy displayed

·  Noticeboards and posters, notices, brochures and forms displayed for care recipients, representatives and staff

·  Nurse call system in operation

·  Policies and procedures available to staff

·  Safety data sheets

·  Secure storage of confidential care recipient and staff information

·  Short group observation in Chamberlain wing

·  Staff work practices and work areas, including clinical, lifestyle, administration, catering, cleaning, laundry and maintenance

·  Visitors registers, sign in/out books and security measures

·  Work, health and safety representative conducting environmental audit

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 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 are provided with feedback about improvements. During this accreditation period the organisation has implemented initiatives to improve the quality of care and services it provides. Recent examples of improvements in Management systems, staffing and organisational development are:

·  Following a management review into the management structure and staffing levels, the following improvements were implemented:

o  Director of nursing role separated into two positions; Chief executive officer/director of nursing – responsible for managing Navorina Nursing Home. Deputy director of nursing – responsible for clinical governance for Navorina.

o  Administrator role redefined as a human resource/continuous improvement coordinator role.