Milford House Nursing Home
RACS ID: 2035
Approved provider: Thompson Health Care Pty Ltd
Home address: 2-4 Milford Street RANDWICK NSW 2031
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 01 December 2020.We made our decision on 23 October 2017.
The audit was conducted on 12 September 2017 to 13 September 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: Milford House Nursing Home Date/s of audit: 12 September 2017 to 13 September 2017
RACS ID: 2035 4
Audit Report
Name of home: Milford House Nursing Home
RACS ID: 2035
Approved provider: Thompson Health Care Pty Ltd
Introduction
This is the report of a Re-accreditation Audit from 12 September 2017 to 13 September 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 12 September 2017 to 13 September 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: 51
Number of care recipients during audit: 44
Number of care recipients receiving high care during audit: 44
Special needs catered for: Extra services
Audit trail
The assessment team spent two days on site and gathered information from the following:
Interviews
Position title / Number /Care recipients and/or representatives / 19
Director of Nursing / 1
Approved provider / 1
Director / 1
Clinical nurse specialist / 1
Human resource manager / 1
Clinical nurse specialist / 1
Registered nurse / 2
Care staff / 7
Administration/reception staff / 1
Catering staff / 3
Hospitality consultant / 1
Laundry staff / 1
Cleaning staff / 1
Maintenance manager / 1
Maintenance staff / 1
Work health and safety representative / 1
Lifestyle manager / 1
Recreational activities officer / 1
Continence product supplier representative / 1
Sampled documents
Document type / Number /Care recipients’ files / 7
Medication incident reports / 5
Incident forms / 6
Medication charts / 15
Other documents reviewed
The team also reviewed:
· Catering, cleaning and laundry: menu, food safety records and program, audits, food service improvement management tool, meal quality targets, dietary needs records, speech pathology review, resident meal choices, cleaning and laundry records
· Clinical care: continence pad assessment forms, hearing aid checklist, admissions assessment guidelines
· Comments and complaints: complaints register, feedback and suggestion forms, emails, complaints and compliments, surveys
· Continence management: continence assessments, continence management plans, daily bowel monitoring records, continence aid allocation list, complex health care directives indwelling catheter care, catheter management report
· Continuous improvement: flowchart, committee membership, continuous improvement plan, audits, external benchmarking reports, analysis of results
· Education and staff development: attendance records, skill assessments, monthly education calendars, annual education plan, on line training modules, monthly learning and development report, orientation checklists and program, education annual matrix
· Fire, security and other emergencies: fire training attendance records, fire safety statement, fire equipment maintenance service records, contingency plans, emergency manual
· Human resource management: position descriptions, development reviews, sample staff pack, sample of staff orientation documentation
· Infection control: pest control records, Legionella test report, influenza outbreak report, updated outbreak management plan, influenza outbreak investigation – illness register (line listing)
· Information systems: meeting minutes, policies and procedures, communication diary, clinical handover documents, archive register
· Inventory and equipment and external services: external supplier and contractor list, allied services agreement
· Lifestyle: recreational activities survey, activities program, entertainment participants evaluation, listing of entertainers, one to one program for each care recipient, volunteer position descriptions and agreement, aromatherapy-hand reflexology chart, identification of changes in emotional status
· Living environment: preventative maintenance schedules, thermostatic mixing value temperature records, service history records
· Medication management: fridge temperature control record, self-administration approval forms, schedule 8 patch monitoring forms, nurse initiated medication approval form, emergency medication stock register, nurse initiated medication stock and emergency medication register, ward register of drugs of addiction
· Occupational health and safety: safety data sheets, hazard and risk assessments
· Planning and leadership: philosophy, vision and values
· Regulatory compliance: self-assessment report for reaccreditation, NSW Food Authority license, compulsory reporting register, staff, contractor and volunteer police check monitoring systems, professional registrations, visa monitoring, annual fire safety statement
· Security of tenure: resident agreements for residential care, resident handbook, inquiry pack
Observations
The team observed the following:
· Activities program resources in use and in storage
· Archives and paper destruction bins
· Aromatherapy resource baskets
· Australian Aged Care Quality Agency re-accreditation audit notice displayed
· Care recipients participating in recreational activities
· Charter of care recipients’ rights and responsibilities displayed
· Clinical equipment and supplies
· Dining environment during midday meal service, including staff serving meals, supervision and assisting care recipients, serving of morning and afternoon tea
· Electronic and hardcopy record keeping systems – clinical and administration
· Equipment and supplies including continence, clinical, linen, mobility, manual handling, personal hygiene, palliative care trolley, chemical storage
· Fire monitoring and firefighting equipment and signage, sprinkler system, emergency guidelines and procedures
· Infection control equipment and resources including handwashing facilities, outbreak kit and emergency supplies, sharps disposal bins, clinical cytotoxic waste bins, biohazard spill kits
· Information noticeboards
· Internal and external complaints information available and the suggestion box for secure lodgement
· Living environment
· Medication administration, storage of medications
· New gates and secure courtyard
· Palliative care team onsite for care recipient consultation
· Photographs of care recipients engaged in activities program
· Secure storage of care recipients’ clinical files and staff information, staff access to information systems including computers
· Supportive and professional interactions between staff and care recipients/visitors
· Visitors registers, sign in/out books and building security measures
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
Thompson Health Care has a quality system, which assists Milford House in the pursuit of continuous improvement across all four Accreditation Standards. The quality system supports the identification, implementation and evaluation of improvement opportunities and activities. The identification of areas for improvement occurs through scheduled audits, analysis of incidents and clinical indicators, legislative changes, community demands and regular meetings for care recipients, their representatives, management and staff. The comments and complaints system, surveys and direct feedback from care recipients, their representatives and staff also contribute to the home’s quality system. Strategies are developed, documented, monitored and evaluated to ensure satisfactory outcomes are achieved. Staff are aware of the systems for continuous improvement. Interviews with care recipients, representatives and staff confirm feedback has resulted in improvements occurring. Recent improvements relating to Accreditation Standard One include:
· A new suggestion box on a stand has been placed with the brochure display stand. The box is used for lodging complaint and feedback forms. The box is secure (locked) and is height adjustable improving access for those in wheelchairs.
· The organisation has recently launched an online training program for all staff. The program will retain staff learning histories and is easy for the management team to monitor staff progress. Staff state the training presentations are interesting and assist with learning. They also like the broad range of topics which are available to increase their knowledge.
· An education hub has been established with the installation of two purpose built computer stations with computers in a dedicated area. The area provides a quiet space for staff to complete online training modules. Staff state they like the learning environment and having easy access to the computers.
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”.
Team’s findings
The home meets this expected outcome
There are systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The Thompson Health Care management team monitors legislation, regulations and guidelines and updates policies and procedures in response to changes. The management team monitors the implementation of regulatory changes and adherence to regulatory requirements through audit processes, staff skill assessments and observation of staff practice. Communication to staff about changes in policy and procedure occurs through meetings, electronic messages and staff education programs. Examples of compliance with regulatory requirements specific to Accreditation Standard One Management systems, staffing and organisational development include:
· Systems and processes to ensure all staff, volunteers and contractors have current criminal history checks.
· Care recipients/representatives were notified of the re-accreditation site audit via notices in the home, at meetings and by letter and email.
· The provision of information to care recipients and stakeholders about internal and external complaint mechanisms.
1.3 Education 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 are processes to ensure management and staff have the appropriate knowledge and skills to perform their roles effectively. The review of documentation and interviews with management and staff demonstrate training needs are identified. Mandatory education which includes online modules, monthly programmed training opportunities and skill assessments ensure staff have the necessary knowledge and skills to meet the needs of the care recipients in their care. There are processes to monitor staff attendance at mandatory education. Guest speakers, qualified staff and external education opportunities are used to ensure a variety of training is provided. There is a recruitment procedure and orientation process for new staff. All staff interviewed reported they have access to education on a regular basis through the new online learning system. The review of education documentation and interviews confirm education has been provided in relation to Accreditation Standard One. Examples include new staff orientation, workplace bullying and harassment, use of equipment including new manual handling equipment and low to floor beds, comments and complaints, continuous improvement and the new learning management system. A staff member has completed the certificate four in training and assessment in 2017.