Decision to accredit Yaralla Place - Aged Care Quality...Decision to accredit Yaralla Place The Aged...

Decision to accredit

Yaralla Place

The Aged Care Standards and Accreditation Agency Ltd has decided to accredit Yaralla Place in accordance with the Accreditation Grant Principles 1999. The Agency has decided that the period of accreditation of Yaralla Place is two years until 12 July 2012. The Agency has found the home complies with 44 of the 44 expected outcomes of the Accreditation Standards. This is shown in the ‘Agency findings’ column appended to the following executive summary of the assessment team’s site audit report. The accreditation period will provide the home with the opportunity to demonstrate that it is capable of monitoring systems, evaluating the effectiveness of actions taken and maintaining compliance with the Accreditation Standards over a longer period of time. The Agency is satisfied the home will undertake continuous improvement measured against the Accreditation Standards. The Agency will undertake support contacts to monitor progress with improvements and compliance with the Accreditation Standards. Information considered in making an accreditation decision The Agency has taken into account the following: • the desk audit report and site audit report received from the assessment team; and • information (if any) received from the Secretary of the Department of Health and Ageing;

and • other information (if any) received from the approved provider including actions taken

since the audit; and • whether the decision-maker is satisfied that the residential care home will undertake

continuous improvement measured against the Accreditation Standards, if it is accredited.

Home name: Yaralla Place Date/s of audit: 13 April 2010 to 15 April 2010 RACS ID: 5438 AS_RP_00851 v2.5

2

Home and approved provider details

Details of the home Home’s name: Yaralla Place

RACS ID: 5438

Number of beds: 99 Number of high care residents: 74

Special needs group catered for: • Dementia and related disorders

Street/PO Box: Cnr Winston Noble Drive and Yaralla Street

City: MARYBOROUGH

State: QLD Postcode: 4650

Phone: 07 4122 8364 Facsimile: 07 4122 8119

Email address: [email protected]

Approved provider Approved provider: QLD Health - Fraser Coast Health Service District

Assessment team Team leader: Stewart Brumm

Team member/s: Jordan Toomey

Date/s of audit: 13 April 2010 to 15 April 2010


3

Executive summary of assessment team’s report Accreditation decision

Standard 1: Management systems, staffing and organisational development

Expected outcome Assessment team recommendations

Agency findings

1.1 Continuous improvement Does comply Does comply 1.2 Regulatory compliance Does comply Does comply 1.3 Education and staff development Does comply Does comply 1.4 Comments and complaints Does comply Does comply 1.5 Planning and leadership Does comply Does comply 1.6 Human resource management Does comply Does comply 1.7 Inventory and equipment Does comply Does comply 1.8 Information systems Does comply Does comply 1.9 External services Does comply Does comply

Standard 2: Health and personal care


Agency findings

2.1 Continuous improvement Does comply Does comply 2.2 Regulatory compliance Does comply Does comply 2.3 Education and staff development Does comply Does comply 2.4 Clinical care Does comply Does comply 2.5 Specialised nursing care needs Does comply Does comply 2.6 Other health and related services Does comply Does comply 2.7 Medication management Does comply Does comply 2.8 Pain management Does comply Does comply 2.9 Palliative care Does comply Does comply 2.10 Nutrition and hydration Does comply Does comply 2.11 Skin care Does comply Does comply 2.12 Continence management Does comply Does comply 2.13 Behavioural management Does comply Does comply 2.14 Mobility, dexterity and rehabilitation Does comply Does comply 2.15 Oral and dental care Does comply Does comply 2.16 Sensory loss Does comply Does comply 2.17 Sleep Does comply Does comply


4

Executive summary of assessment team’s report Accreditation decision

Standard 3: Resident lifestyle


Agency findings

3.1 Continuous improvement Does comply Does comply

3.2 Regulatory compliance Does comply Does comply

3.3 Education and staff development Does comply Does comply

3.4 Emotional support Does comply Does comply

3.5 Independence Does comply Does comply

3.6 Privacy and dignity Does comply Does comply

3.7 Leisure interests and activities Does comply Does comply

3.8 Cultural and spiritual life Does comply Does comply

3.9 Choice and decision-making Does comply Does comply

3.10 Resident security of tenure and responsibilities

Does comply Does comply

Standard 4: Physical environment and safe systems


Agency findings

4.1 Continuous improvement Does comply Does comply

4.2 Regulatory compliance Does comply Does comply

4.3 Education and staff development Does comply Does comply

4.4 Living environment Does comply Does comply

4.5 Occupational health and safety Does comply Does comply

4.6 Fire, security and other emergencies Does comply Does comply

4.7 Infection control Does comply Does comply

4.8 Catering, cleaning and laundry services

Does comply Does comply


5

Assessment team’s reasons for recommendations to the Agency The assessment team’s recommendations about the home’s compliance with the Accreditation Standards are set out below. Please note the Agency may have findings different from these recommendations.

SITE AUDIT REPORT

Name of home Yaralla Place

RACS ID 5438 Executive summary This is the report of a site audit of Yaralla Place 5438 Cnr Winston Noble Drive and Yaralla Street MARYBOROUGH QLD from 13 April 2010 to 15 April 2010 submitted to the Aged Care Standards and Accreditation Agency Ltd. Assessment team’s recommendation regarding compliance The assessment team considers the information obtained through audit of the home indicates that the home complies with: • 44 expected outcomes Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Yaralla Place. The assessment team recommends the period of accreditation be three years. Assessment team’s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation.


6


7

Site audit report Scope of audit An assessment team appointed by the Aged Care Standards and Accreditation Agency Ltd conducted the audit from 13 April 2010 to 15 April 2010. The audit was conducted in accordance with the Accreditation Grant Principles 1999 and the Accountability Principles 1998. The assessment team consisted of two registered aged care quality assessors. The audit was against the 44 expected outcomes of the Accreditation Standards as set out in the Quality of Care Principles 1997. Assessment team Team leader: Stewart Brumm

Team member/s: Jordan Toomey Approved provider details Approved provider: Queensland Health

Details of home Name of home: Yaralla Place

RACS ID: 5438

Total number of allocated places: 99

Number of residents during site audit: 86

Number of high care residents during site audit:

74

Special needs catered for: Dementia and related disorders

Street/PO Box: Cnr Winston Noble Drive and Yaralla Street State: QLD

City/Town: MARYBOROUGH Postcode: 4650

Phone number: 07 4122 8110 Facsimile: 07 4122 8119

E-mail address: [email protected]


8

Assessment team’s recommendation regarding accreditation The assessment team recommends the Aged Care Standards and Accreditation Agency Ltd accredit Yaralla Place. The assessment team recommends the period of accreditation be three years. Assessment team’s recommendations regarding support contacts The assessment team recommends there be at least one unannounced support contact each year during the period of accreditation. Assessment team’s reasons for recommendations The team has assessed the quality of care provided by the home against the Accreditation Standards and the reasons for its recommendations are outlined below. Audit trail The assessment team spent three days on-site and gathered information from the following: Interviews

Number Number Director of nursing 1 Residents/ relatives 15

Nurse unit manager 3 Regional management staff 6

Operations service manager 1 Catering supervisor 1

Finance officer 1 Operational services staff 4

Endorsed enrolled nurse 1 Nurse educator 1

Assistant in nursing 8 Nurse director 1

Human resource manager 1 Clinical nurses 4

Registered nurses 2

Sampled documents

Number Number

Residents’ files 10 Medication charts 10

Personnel files 9 Other documents reviewed The team also reviewed: • Accident and incident data • Action plans • Activities attendance report • Activities planner • Activity evaluation • After hours contact lists • Aged Care certification assessment instrument • Audit schedule 2010 • Audits/surveys • Bowel management pathway


9

• Care for residents with safety devices • Care plan review checklist • Certificate of maintenance • Cleaning schedules • Comments/complaints mechanism/records • Communication diaries and books • Complaint issue summary • Compulsory reporting flowchart • Confidentiality guidelines for staff • Continuous improvement forms and log • Controlled drug register • Corporate grievance report • Criminal history data • Daily record care • Daily wound evaluation • Days 1-28 post admission checklist • Diabetic record sheet • Dietary profiles • Duty statements • Education attendance records and matrix • Education plan • Emergency disaster plan • Enteral feeding guide • Equipment temperature records • Evidence of current registrations • Family/carer conference form • Fire equipment maintenance records • Fire evacuation plans • Fire safety audit • Food temperature records • Handover sheets • Hazardous substance register • Hourly rounding log • Hypoglycaemic flow chart • Improvements list (activities) • Incident records and analysis • Infection control references/guidelines and surveillance report • Letters and cards of appreciation • Maintenance compliance records • Maintenance requests log • Manual handling guidelines • Material safety data sheets • Meeting agenda • Meeting minutes • Meetings calendar • Memoranda • Menu choices • Mission statement and philosophy • Monthly reports • News letters • Notices • Nutrition flow chart • Pain observation form


10

• Pathology results • Performance assessments • Pest control register • Planned preventative maintenance schedule • Policies and procedures • Reported clinical incident summary • Resident choice of diets form • Residents mobility list • Residents’ information handbook • Restraint authorisations • Risk review report • Service agreements • Service improvement register • Shower list • Skin tear prevention and management • Smoking policy • Staff competencies • Staff handbook • Ward Diaries/communication diaries • Waste management guidelines • Weight graphs • Wound assessment and management plan • Wound management procedures • Yaralla place hand hygiene compliance 2009-2010 Observations The team observed the following: • Activities in progress • Advocacy brochures and posters • Chemical storage • Cleaner’s trolley • Egress and exit routes • Equipment and supply storage areas • Fire exit lights • Fire warden notification notices • Instruction charts for waste on display • Interactions between staff and residents • Internal and external living environment • Kitchen • Linen supplies • Meal service • Medication storage and administration • Notice boards for residents and staff • Residents wearing clothes protectors at meals • Safety signage • Sharps' containers • Spill kits • Staff accessing and wearing personal protective equipment • Staff lockers • Suggestion box


11

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 residents, 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 recommendation Does comply Yaralla Place Residential Aged Care Facility (the home) identifies opportunities for continuous improvement, in particular in management systems, staffing and organisational development using improvement forms, surveys, audits, resident and staff meetings, incident /hazard reports, staff appraisals, comments/complaints mechanisms and one on one with management/key personnel. Monitoring of improvements is achieved through action plans, continuous improvement reports, accident and hazard reports and analysis of incidents. Staff and resident meetings or individual consultations are used to provide progress reports and feedback. Staff and residents verify they are able to make suggestions for improvement, management is responsive and feedback is provided regarding progress and outcomes in a timely manner.

Examples of recent improvements relating to Standard One include:

• New shelving has been placed in a dedicated archive area. Management reports archived materials have been labelled and entered onto a register. All achievable records have been relocated to the new area. Staff state they have access if needed and archiving is stored in accordance to regulations.

• As a result of deficiencies identified in work processes and audit information a review of staff work instructions and audit tools has been conducted. Management report a stream-lined process has been developed and initiated to ensure audits are completed in a timely manner and staff have continuity for work loads and instructions. Staff report satisfaction with this initiative and state they can complete their duties with in the allocated times.

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 recommendation Does comply The home has systems and processes to identify current legislation, professional standards, regulatory requirements and guidelines applicable to Standard One, through the organisation’s intranet, membership with advisory groups and industry bodies. Staff are kept informed of these changes with policy updates and reviews, memoranda and meetings; requirements are implemented via new or revised work schedules, protocols and guidelines. Residents/representatives are kept informed of legislative changes via meetings and notices. Processes are in place to monitor staff’s awareness and compliance with relevant legislation and these include: performance appraisals, competency audits, training questionnaires and education. Key personnel and head office People and Culture management monitor relevant staff and volunteers’ police checks and registrations. There is a system in place to ensure


12

residents and their representatives are informed of accreditation audits. Staff feedback demonstrated knowledge of their legislative responsibilities. 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 recommendation Does comply The home provides an education program for staff based on identified clinical care and lifestyle issues, legislative and advisory requirements, organisational needs, and performance appraisals. Rostering strategies are used to improve access to education and training opportunities and staff have obligations to attend education. The home ensures that mandatory topics, including fire and manual handling, can be attended in work time or staff are renumerated for attendance outside working hours. Key personnel maintain records and use a matrix to monitor staff attendance at these sessions; measures are taken to follow up and action non-attendance. Management monitor the skills and knowledge of staff using audits, competency assessments and observation of practice. Staff indicated they have access to ongoing learning opportunities, are kept informed of their training obligations and the program assists them in the performance of their work roles. 1.4 Comments and complaints This expected outcome requires that "each resident (or his or her representative) and other interested parties have access to internal and external complaints mechanisms". Team’s recommendation Does comply Residents/representatives, staff and other stakeholders have access to internal and external complaint mechanisms. Forms are available, the nurse unit managers and Nursing Director have an open door policy and staff are trained to complete forms on behalf of residents where necessary. Issues and complaints raised through a range of forums including the comments and complaints system, meetings and verbal discussions are responded to in a timely manner and may, if appropriate, be discussed at resident and staff meetings and issues raised, where appropriate, contribute to the home’s continuous improvement plan. Residents and staff indicate they are familiar with the home’s compliments and complaints system and they are satisfied that management deal with issues in a timely manner. 1.5 Planning 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 recommendation Does comply The home has documented its commitment to quality throughout the service and the organisation’s vision, values, philosophy and objectives; these are outlined in organisational documents including the resident handbook and displayed throughout the home. Residents and representatives are aware of the home’s vision, values, philosophy and objectives.


13

1.6 Human 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 recommendation Does comply There are processes for the recruitment and selection of appropriately qualified and skilled staff. Staff roles are outlined in position descriptions which are reflected in work schedules; orientation processes ensure a shared understanding of the home’s philosophy and vision, residents’ rights and responsibilities and other relevant policies and procedures. Staffing levels and skills mix are monitored using, but not restricted to, an organisational matrix, information from residents, staff and key personnel feedback and the monitoring of residents’ care needs. A base roster is maintained with flexibility to increase hours as required. Planned and unplanned leave is covered by internal staff. Staff performance is monitored and there are annual performance appraisals. Performance management and mandatory training requirements ensure consistency in the quality of service provision and these are undertaken as per the home’s procedures. Residents/representatives are satisfied with the ability of staff to provide appropriate care and services in a timely manner. 1.7 Inventory and equipment This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available". Team’s recommendation Does comply The home has processes to identify, maintain and purchase appropriate goods and equipment for the delivery of services. Service agreements include provision for feedback and replacement when goods or services are unsuitable. Management, maintenance and workplace health and safety personnel ensure that equipment is suitable for its intended use. Minimum stock levels are maintained across all areas of the home in consideration of variations in staff and residents’ requirements. A preventive maintenance program ensures equipment is serviced and maintained according to manufacturer’s recommendations. Staff and key personnel have procedures/authority to repair equipment and goods as necessary and have access to emergency contacts for urgent and after hours repairs. Residents and staff have access to a consistent supply of stock and suitable equipment to meet their needs. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s recommendation Does comply The home has processes to manage information effectively and ensure its security and confidentiality. Paper based information facilitates resident care provision, whilst computer based information aids reporting requirements and supports service provision. Access to residents’ and staff files is restricted and they are stored in a secure area; archived material can be retrieved readily and back-up systems are in place for computer records. Handover processes communicate residents’ care information to nursing staff and all staff groups are kept informed with one-to-one directions, communication books, meetings, memos, meeting minutes, education and training reminders/schedules, policy updates, electronic mail and


14

notice boards. Residents have meetings, noticeboards and other correspondence to keep them informed. Resident and staff feedback indicates communication of information is timely and effective. 1.9 External 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 recommendation Does comply The home has a list of selected external providers with service agreements to ensure their compliance with the home’s quality, workplace health and safety and legislated requirements. Arrangements are in place to ensure alternative and after hour’s availability as needed. Key personnel monitor the activities of external providers; a register of scheduled servicing is used to track and ensure requirements are being met as planned. Service agreements are reviewed as required with input from relevant stakeholders. A list of external providers is accessible to staff who can obtain authority to contact these providers when issues occur. Resident and staff feedback identified external services are maintained to ensure a standard that meets their needs.


15

Standard 2 – Health and personal care Principle: Residents’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each resident (or his or her representative) and the health care team. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home identifies opportunities for continuous improvement in health and personal care using improvement forms, surveys, audits, resident and staff meetings, incident /hazard reports, staff appraisals, comments/complaints mechanisms and one on one with management/key personnel. Monitoring of improvements is achieved through action plans, continuous improvement reports, accident and hazard reports and analysis of incidents. Staff and resident meetings or individual consultations are used to provide progress reports and feedback. Staff and residents verify they are able to make suggestions for improvement, management is responsive and feedback is provided regarding progress and outcomes.

Examples of recent improvements relating to Standard Two include:

• To improve follow up processes for the staff review of care plans in the event of changes to resident status a red alert sticker has been developed and is now placed on the residents files. Management reports staff are alerted to changes for resident care and staff follow up in a scheduled time frame. Staff state it has made an impact on prompt follow up for resident care.

• A magnetic resident identification system has been developed to alert staff of the needs of residents at a quick glance. These “unit scrum boards” has each residents photograph on display and for example a magnetic picture of an ambulance may be beside their picture to indicate the resident has transferred to hospital. Staff report the system is working well.

2.2 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 about health and personal care”. Team’s recommendation Does comply The home has systems and processes to identify current legislation, professional standards, regulatory requirements and guidelines applicable to Standard Two, through the organisation’s intranet, membership with advisory groups and industry bodies. Staff are kept informed of these changes with policy updates and reviews, memoranda and meetings; requirements are implemented via new or revised work schedules, protocols and guidelines. Residents/representatives are kept informed of legislative changes via meetings and notices. Processes are in place to monitor staff’s awareness and compliance with relevant legislation and these include: performance appraisals, competency audits, training questionnaires and education. There is a system in place regarding reporting requirements for absconding and staff is aware of reporting time lines. Staff feedback demonstrated knowledge of their legislative responsibilities.


16

2.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home provides an education program for staff based on identified clinical care and lifestyle issues, legislative and advisory requirements, organisational needs, and performance appraisals. Rostering strategies are used, to improve access to education and training opportunities and staff have obligations to attend education. The home ensures that mandatory topics, including health and personal care, can be attended in work time or staff are renumerated for attendance outside working hours. Key personnel maintain records and use a matrix to monitor staff attendance at these sessions and measures are taken to follow up and action non-attendance. Management monitor the skills and knowledge of staff using audits, competency assessments and observation of practice. Staff indicated they have access to ongoing learning opportunities, are kept informed of their training obligations and the program assists them in the performance of their work roles. 2.4 Clinical care This expected outcome requires that “residents receive appropriate clinical care”. Team’s recommendation Does comply Residents’ care needs are assessed on admission and an interim care plan developed, a comprehensive assessment is then undertaken over 28 days by a registered nurse, from this information a care plan is established, care plans are reviewed three monthly. Acute episodes are managed through the progress notes with seven and 14 day follow up to acute episodes occurring. Case conferences are held annually with the care team and the resident/representative. Care delivery is monitored by the clinical nurses, with support from the registered nurses. Residents are referred to their medical officer or specialist service as required. Staff are aware of the care requirements of residents. Residents/representatives are satisfied with the care being provided. 2.5 Specialised nursing care needs This expected outcome requires that “residents’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”. Team’s recommendation Does comply Residents requiring specialised nursing care are identified on admission through the initial assessment process, specialised nursing care directives are recorded on the care plan. The clinical nurse conducts the assessment and management of specialised nursing procedures. Staff have access to resources and specialist information. Equipment requirements are identified and are available to ensure residents’ care requirements are met. Implementation of specialised care is monitored by the clinical nurses and the effectiveness of care is reviewed and processes are in place for ongoing evaluation. Residents /representatives advised that they are satisfied with the care provided.


17

2.6 Other health and related services This expected outcome requires that “residents are referred to appropriate health specialists in accordance with the resident’s needs and preferences”. Team’s recommendation Does comply The home has a system and processes in place to assess resident need for referral to health specialists such as social worker, dietician, speech pathologist, physiotherapist, audiologist, dentist, optometrist, and podiatrist. Nursing staff, in liaison with the resident’s medical officer, co-ordinate health specialist appointments for residents in a timely manner. Staff and/or resident representatives support and assist residents to attend external appointments with health professionals of their preference. Care plans are amended as required following referrals. Residents/representatives are satisfied they receive referrals to appropriate health specialists of their choice when required. 2.7 Medication management This expected outcome requires that “residents’ medication is managed safely and correctly”. Team’s recommendation Does comply The home has processes in place to ensure that residents’ medication is managed safely and correctly by appropriately qualified and trained staff. Medical officers prescribe medication orders and these are dispensed by the external pharmacy service. The home utilises a multi dose sachet system and alternatives if the resident utilizes a pharmacy of their choice. Resident medication is stored safely and securely. Medication incidents are recorded and reviewed by the Nurse Unit Manager, with a monthly report produced. Effectiveness of the medication management system is monitored through the completion of audits and medical and pharmaceutical review. Staff administering resident medications demonstrated awareness of their responsibilities in relation to medication administration and of the guidelines in place to ensure residents medications are administered safely and correctly. Endorsed enrolled nurses are aware of their requirement to contact a registered nurse for direction and instruction on administering “PRN” as required medications. Residents/representatives are satisfied with the management of their medications, as well as with the assistance and support provided. 2.8 Pain management This expected outcome requires that “all residents are as free as possible from pain”. Team’s recommendation Does comply Residents’ pain is identified during initial assessment, and reassessment is undertaken as required. Care plans are developed from the assessed information and care plans are reviewed three monthly by a registered nurse to ensure interventions remain effective. The medical officer and allied health professionals are involved in the management of residents’ pain; strategies to manage pain include non-pharmacological and pharmacological intervention. The effectiveness of interventions is monitored by the clinical and registered nurses, including the use of ‘as required’ (PRN) analgesia which is documented with re-assessment as indicated. Non-verbal pain assessment tools are available for residents unable to articulate their pain. Residents/representatives are satisfied with current pain management strategies and the provision of additional assistance if and when pain persists.


18

2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill residents is maintained”. Team’s recommendation Does comply Residents’ end of life care options are discussed on entry to the home or at a later stage if this is the preference of the resident/representative. Once directives are known these are documented and accessible to staff involved in the provision of care. A palliative care plan is developed to manage care during the palliative phase. As a resident’s needs change and their condition deteriorates, the staff of the home liaise with the resident and their family members or significant others to ensure that the resident’s physical, spiritual, cultural and emotional needs are respected and provided for. Palliative care is monitored by the clinical nurses. Consultation with the resident’s medical officer ensures pain relief is optimised. Staff are aware of interventions to ensure the comfort and dignity of residents. Residents/representatives are satisfied with the care provided. 2.10 Nutrition and hydration This expected outcome requires that “residents receive adequate nourishment and hydration”. Team’s recommendation Does comply Residents’ dietary requirements, preferences, allergies and special needs are identified and recorded on entry to the home and this information is forwarded to the catering staff. Residents are weighed on admission and then monthly, a weight management policy guides staff practice and any variations are assessed, monitored and actioned with strategies implemented to manage unplanned weight loss or gain if required. Strategies include more frequent weight monitoring, dietician and/or speech pathologist assessment, and introduction of food supplements and/or special diets as required. The clinical nurses monitor the weight management at the home. Residents identified with swallowing problems, are assessed by the speech pathologist. Residents are assisted with meals and fluids, and special eating utensils supplied as necessary. The catering staff monitor food wastage and resident satisfaction with meals. Residents/representatives are satisfied that their nutrition and hydration requirements are met 2.11 Skin care This expected outcome requires that “residents’ skin integrity is consistent with their general health”. Team’s recommendation Does comply On entry to the home residents are assessed for their skin care needs through comprehensive assessment and in consultation with residents to determine their needs and preferences. Care plans reflect strategies to improve and/or maintain residents’ skin consistent with their general health. Care strategies include the daily application of moisturisers, correct manual handling procedures, pressure area care, and pressure relieving aids. Podiatry services are provided. The registered nurses oversee wound management with endorsed enrolled nurses responsible for wound treatments, completion of


19

treatment records, and documenting interventions. Residents/representatives are satisfied with the assistance provided to maintain skin integrity. 2.12 Continence management This expected outcome requires that “residents’ continence is managed effectively”. Team’s recommendation Does comply Processes are in place for ensuring that residents’ continence is managed effectively. Residents’ urinary and faecal continence needs are assessed during the comprehensive assessment and supported with the use of focal assessments, reassessments occur as required for changes in resident condition. Continence management plans are in place and communicated to staff. Guidelines and resources are available to guide staff practices in relation to continence management and programs are implemented and monitored by the clinical nurses. Care staff outlined continence management strategies for individual residents and understand reporting requirements should there be a change to residents normal patterns. Residents/representatives are satisfied with the care provided by staff in relation to continence management. 2.13 Behavioural management This expected outcome requires that “the needs of residents with challenging behaviours are managed effectively”. Team’s recommendation Does comply On entry to the home residents with challenging behaviours are assessed, including the time, resident action, the trigger, the nurses’ response and the outcome of the intervention, then a behaviour care plan developed. Residents are reassessed as care needs change or current interventions are ineffective. Behaviour management is monitored by the clinical nurses. Recreational activities are used to enhance effective behavioural management intervention. The team observed staff interacting calmly with residents when attending to cares or when re-directing residents. Residents/representatives are satisfied with the management of challenging behaviours at the home. 2.14 Mobility, dexterity and rehabilitation This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all residents”. Team’s recommendation Does comply The home has processes in place to ensure that residents achieve optimum levels of mobility and dexterity. Residents are assessed through the comprehensive assessment on admission, including assessment by the physiotherapist and on an ongoing basis as resident needs indicate. Assessed needs and strategies for care are communicated to staff through the care plan, and care plans are reviewed three monthly to ensure interventions remain effective. Falls are reported and are monitored by the Nurse Unit Manager for analysis and trending. Aids to maintain and improve mobility and dexterity such as walking aids and specific dietary utensils are available. Exercise programs are available to residents to help maintain strength and balance. Residents/representatives are satisfied with the assistance they receive in achieving optimum levels of mobility and dexterity.


20

2.15 Oral and dental care This expected outcome requires that “residents’ oral and dental health is maintained”. Team’s recommendation Does comply Residents’ needs and preferences relating to teeth and denture management and other oral/dental care requirements are identified through the comprehensive assessment. Care strategies are documented on the care plan. Care staff assist residents with their oral care and the clinical nurse arranges dental referrals as necessary. Residents have a choice of dentist and are assisted to attend external appointments as arranged. Equipment to meet residents’ oral hygiene needs is available. Residents/representatives are satisfied with the assistance given by staff to maintain their dentures and overall oral hygiene. 2.16 Sensory loss This expected outcome requires that “residents’ sensory losses are identified and managed effectively”. Team’s recommendation Does comply Residents care needs in relation to sensory loss which include vision, hearing, smell, touch and taste, is collected through the comprehensive assessment. Care plans identify needs and individual preferences and are reviewed three monthly. Residents are referred to specialists such as audiologists, optometrists and speech pathologists according to assessed need or resident request and are assisted to attend appointments as required. Staff receive instruction in the correct use and care of sensory aids and are aware of the interventions required to meet individual residents’ needs. The clinical nurses monitor ongoing needs. Residents are satisfied with the assistance provided by staff to optimise sensory function. 2.17 Sleep This expected outcome requires that “residents are able to achieve natural sleep patterns”. Team’s recommendation Does comply Residents usual sleep patterns, settling routines and personal preferences are identified during the initial comprehensive assessment and on an ongoing basis. Care plans are developed and reviewed to ensure interventions remain effective. Residents experiencing difficulty sleeping are offered warm drinks and snacks and assisted with hygiene requirements should this be required. The registered nurses monitor ongoing needs. Residents/representatives are satisfied with the care and comfort measures implemented by staff in relation to promoting sleep.


21

Standard 3 – Resident lifestyle Principle: Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the residential care service and in the community. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home identifies opportunities for continuous improvement in resident lifestyle using improvement forms, surveys, audits, resident and staff meetings, incident /hazard reports, staff appraisals, comments/complaints mechanisms and one on one with management/key personnel. Monitoring of improvements is achieved through action plans, continuous improvement reports, accident and hazard reports and analysis of incidents. Staff and resident meetings or individual consultations are used to provide progress reports and feedback. Staff and residents verify they are able to make suggestions for improvement, management is responsive and feedback is provided regarding progress and outcomes.

Examples of recent improvements relating to Standard Three include:

• In an effort to empower residents in the home “brainstorming sessions” are held monthly with residents to set activities and get ideas for outings and activities. Staff report as a result of these sessions’ new games and a train set has been purchased for residents use. Residents report they are satisfied with the activities on offer to them at the home.

• As a result of a service improvement form from a staff member who suggested the practice of packing deceased residents cloths into rubbish bin bags for pick up by family members was not always received well. The home has purchased a “nice” bag to replace the bin bags and management report these are now used to pack deceased resident clothing into.

• Management report they have purchased a computer based game and had one donated to them by the local community. These games have been set up in the home. Management report that they are encouraging families stay longer as the grandchildren can use them.

3.2 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, about resident lifestyle”. Team’s recommendation Does comply The home has systems and processes to identify current legislation, professional standards, regulatory requirements and guidelines applicable to Standard Three, through the organisation’s intranet, membership with advisory groups and industry bodies. Staff are kept informed of these changes with policy updates and reviews, memoranda and meetings; requirements are implemented via new or revised work schedules, protocols and guidelines. Residents/representatives are kept informed of legislative changes via meetings and notices. Processes are in place to monitor staff’s awareness and compliance with relevant legislation and these include: performance appraisals, competency audits, training questionnaires and


22

education. There is a system in place to manage the reporting of assaults to the police and Department of Health and Ageing in accordance with regulatory requirements. Staff feedback demonstrated knowledge of their legislative responsibilities and compulsory reporting requirements. 3.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home provides an education program for staff based on identified lifestyle issues, legislative and advisory requirements, organisational needs, and performance appraisals. Rostering strategies are used, to improve access to education and training opportunities and staff have obligations to attend education. The home ensures that mandatory topics, including fire and manual handling, can be attended in work time or staff are renumerated for attendance outside working hours. Key personnel maintain records and use a matrix to monitor staff attendance at these sessions and measures are taken to follow up and action non-attendance. Management monitor the skills and knowledge of staff using audits, competency assessments and observation of practice. Staff indicated they have access to ongoing learning opportunities, are kept informed of their training obligations and the program assists them in the performance of their work roles. 3.4 Emotional support This expected outcome requires that "each resident receives support in adjusting to life in the new environment and on an ongoing basis". Team’s recommendation Does comply Residents/representatives are provided with information prior to entry and a resident information book on admission which provides an overview of life within the home. Residents are assessed for their emotional support needs during the initial assessment phase. Residents are monitored for ongoing support needs via the care staff, and activities officer. Care staff are advised of any ongoing emotional support needs through the handover process. Staff provide residents with one to one support and will refer residents to the social worker or chaplain for additional support as required. Residents/representatives are happy with the level of emotional support provided, and residents are encouraged to furnish their rooms to their liking. 3.5 Independence This expected outcome requires that "residents are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service". Team’s recommendation Does comply The home assists residents to maintain independence through initial and ongoing review of their needs utilising clinical and social assessments. Strategies to promote and maximize independence are reviewed three monthly during the care plan reviews. Residents are supported to access the local community with regular outings. Residents are encouraged to


23

maintain friendships and external social networks, residents are supported by the activities officer to achieve this. Care staff are aware of their responsibility to promote resident independence and follow care plans to assist residents to achieve a maximum level of independence. Residents are satisfied with the level of independence and autonomy they can exercise at the home, residents reported they are supported to maintain friendships and access the local community. 3.6 Privacy and dignity This expected outcome requires that "each resident’s right to privacy, dignity and confidentiality is recognised and respected". Team’s recommendation Does comply The home has policies and procedures to govern staff practice in maintaining residents’ privacy and dignity. Staff are provided training on privacy and dignity issues during orientation and staff also adhere to a code of conduct that governs practices in relation to resident privacy and dignity. Resident information is stored in a secure location. Staff practices are monitored by the clinical nurses and registered nurses. Staff are aware of strategies to maintain residents’ privacy and dignity when providing resident cares. Residents/representatives are satisfied with the level of privacy and respect for their dignity being provided by staff at the home. 3.7 Leisure interests and activities This expected outcome requires that "residents are encouraged and supported to participate in a wide range of interests and activities of interest to them". Team’s recommendation Does comply Residents leisure interests and activities are assessed on admission utilising a profile completed by the resident/representative and a lifestyle assessment; an individual care plan is developed from the assessment information and these care plans are reviewed three monthly by the activities officer. A monthly planner is developed from the assessed resident information, historical activities and resident requests; this planner is displayed throughout the facility. Residents can complete an annual satisfaction survey and resident participation is also assessed based on the level of involvement in the activity, and this information is used in the evaluation of individual activities. Residents have input into the ongoing activities planner through the resident meetings, brainstorming sessions and via one to one feedback with the activities officer. Resident/representatives are satisfied with the choice and variety of activities available to them. 3.8 Cultural and spiritual life This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered". Team’s recommendation Does comply Resident’s cultural and spiritual needs are assessed on admission using the resident/representative completed profile; a care plan is developed as required from the assessment information. Residents have access to religious services held at the home and are assisted to attend church services in the local community. Residents are assisted to


24

attend cultural activities conducted in the home and the community, and days of significance are celebrated at the home. Residents’ ongoing cultural and spiritual needs are monitored by the activities officer. Residents are satisfied with the spiritual and cultural support provided. 3.9 Choice and decision-making This expected outcome requires that "each resident (or his or her representative) participates in decisions about the services the resident receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people". Team’s recommendation Does comply Residents are encouraged and supported to make decisions about their care, lifestyle and routines; information is provided to residents/representatives prior to and on admission outlining their rights and responsibilities. Staff provide opportunities for choice and utilise strategies to incorporate choice into residents’ daily care routines and leisure interests and residents are provided a choice with meal selection where appropriate. Staff practice regarding choice and decision making is monitored by clinical nurses. Residents/representatives are satisfied that they are able to exercise choice in relation to their care and lifestyle. 3.10 Resident security of tenure and responsibilities This expected outcome requires that "residents have secure tenure within the residential care service, and understand their rights and responsibilities". Team’s recommendation Does comply Processes are in place to ensure that each resident/representative is provided with a resident agreement and information book prior to or on admission; the contents of these documents are explained to the resident/representative. Information provided to residents/representatives includes the home’s consultative process, residents’ rights and responsibilities, fees and charges, security of tenure, circumstances in which a resident may need to be re-located within the home, internal and external complaint mechanisms, and the care, services and routines provided at the home. Residents and their representatives are notified about any changes relating to security of tenure, rights and responsibilities or fees payable via personal letters and one-to-one meetings when required. Residents indicated they felt their stay in the home was secure and are aware of their rights and responsibilities.


25

Standard 4 – Physical environment and safe systems Principle: Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s recommendation Does comply The home identifies opportunities for continuous improvement in relation to the physical environment and safe systems using improvement forms, surveys, audits, resident and staff meetings, incident /hazard reports, staff appraisals, comments/complaints mechanisms and one on one with management/key personnel. Monitoring of improvements is achieved through action plans, continuous improvement reports, accident and hazard reports and analysis of incidents. Staff and resident meetings or individual consultations are used to provide progress reports and feedback. Staff and residents verify they are able to make suggestions for improvement, management is responsive and feedback is provided regarding progress and outcomes. Examples of recent improvements relating to Standard Four include:

• Due to an increase of children visiting the home during the summer holidays a concern was raised as to the safety of the oxygen storage facilities. A risk assessment was completed and a cage was built around it. The work instruction was reviewed and revised and management report the storage area is safe and secure.

• Residents suggested they would like to have more shaded areas outside in the gardens. As a result shade sails were erected to enable residents to participate in more out door activities. Residents report they were able to choose the colours and are satisfied with the additional shaded areas they can utilise.

4.2 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, about physical environment and safe systems”. Team’s recommendation Does comply The home has systems and processes to identify current legislation, professional standards, regulatory requirements and guidelines applicable to Standard Four, through the organisation’s intranet, membership with advisory groups and industry bodies. Staff are kept informed of these changes with policy updates and reviews, memoranda and meetings; requirements are implemented via new or revised work schedules, protocols and guidelines. Residents/representatives are kept informed of legislative changes via meetings and notices. Processes are in place to monitor staff’s awareness and compliance with relevant legislation and these include: performance appraisals, competency audits, training questionnaires and education. There is a system to ensure certification and other environmental requirements are met including a food safety plan that is in place. Staff feedback demonstrated knowledge of their legislative responsibilities


26

4.3 Education and staff development This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”. Team’s recommendation Does comply The home provides an education program for staff based on identified physical environment and safe systems, clinical care and lifestyle issues, legislative and advisory requirements, organisational needs, and performance appraisals. Rostering strategies are used, to improve access to education and training opportunities and staff have obligations to attend education. The home ensures that mandatory topics, including fire and manual handling, can be attended in work time or staff are renumerated for attendance outside working hours. Key personnel maintain records and use a matrix to monitor staff attendance at these sessions and measures are taken to follow up and action non-attendance. Management monitor the skills and knowledge of staff using audits, competency assessments and observation of practice. Staff indicated they have access to ongoing learning opportunities, are kept informed of their training obligations and the program assists them in the performance of their work roles. 4.4 Living environment This expected outcome requires that "management of the residential care service is actively working to provide a safe and comfortable environment consistent with residents’ care needs". Team’s recommendation Does comply Residents have single rooms with shared bathrooms, residents are able to personalise their space with small items. The home provides a variety of meeting areas available to residents and their families, with seating and amenities that are maintained via preventive/reactive maintenance and cleaning routines. Environmental audits, hazard and risk assessment processes are in place to identify potential risks and support decisions concerning the living environment. Staff store mobility aids and furnishings safely when not in use. Security procedures including a key card access system, staff lock up procedures, an electronic alarm system, individual night staff personal duress alarms and nightly security patrols promote resident and staff safety. Residents and staff are satisfied with the level of comfort and safety at the home. 4.5 Occupational health and safety This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements". Team’s recommendation Does comply The home has systems in place to orientate and train staff in workplace health and safety at induction and re-assess this on an ongoing basis. There are processes to assess the workplace using environmental and process audits. Hazard reporting and risk assessment processes guide appropriate actions, including management and evaluation of residents’ and staff incidents/risks. Signage and information posters alert residents, visitors and staff to safety issues and appointed safety representatives monitor work practices and provide support as required; staff are updated through staff meetings and mandatory training. Staff


27

demonstrate effective knowledge and understanding of workplace health and safety obligations and use of incident reporting processes as required. 4.6 Fire, security and other emergencies This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks". Team’s recommendation Does comply The home has processes in place to ensure management and staff are actively working to provide an environment and safe systems that minimise fire, security and other emergency risks. There are fire fighting and evacuation procedures in place; records of maintenance of fire equipment, fire safety inspections, certification inspection reports and education and fire drills are available and current. There is a system to monitor staff attendance at training for fire and other emergencies, and equipment and procedures in place to respond to emergencies such as power failure, personal threat, chemical spills, floods, cyclones and other natural disasters. Staff are aware of security and other emergencies procedures as they relate to their position and have practiced the specific fire fighting procedures required to be implemented until support from emergency services arrives. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s recommendation Does comply The home has a process in place to provide an infection control program that is overseen by the clinical nurse. Outbreak plans and infection control manuals are available and cleaning, kitchen and laundry staff reported they had received training in infection control and that they are familiar with their roles in minimising infections. Cleaning schedules are used to guide general cleaning and cleaners use colour coded equipment and are familiar with the use of personal protective equipment and spills kits. Facilities and equipment such as single use clinical products, gloves, aprons, sharps containers, hand washing facilities, waste receptacles and storage areas are provided to enable infection control practices to be implemented. Staff demonstrated awareness of infection control guidelines and practices applicable to their area of duty including the use of personal protective equipment, hand washing, barrier nursing and outbreak procedures. 4.8 Catering, cleaning and laundry services This expected outcome requires that "hospitality services are provided in a way that enhances residents’ quality of life and the staff’s working environment". Team’s recommendation Does comply Catering services are provided to meet residents’ dietary needs and preferences. The two weekly cycle menu varies seasonally, and reflects changes made in response to resident feedback; a dietician ensures that the menu meets residents’ nutritional requirements. Meal alternatives are available at residents’ request or if changes to their health status require it; staff follow safe food handling practices throughout preparation and meal service. Routines and schedules are in place to guide cleaning of residents’ rooms, common areas, high surfaces, windows and external areas. All flat linen and residents personal clothing is


28

contracted for cleaning off site and is returned in a timely manner. Operational services staff demonstrate an understanding of the infection control principles related to cleaning processes. Management monitor the effectiveness of services, and skills and knowledge of staff, using audits, competency assessments and observation of practice and provide support as required. Residents are satisfied with the operational services at the home.

Date post:	19-Jun-2020
Category:	Documents
Upload:	others
View:	1 times
Download:	0 times

Decision to accredit Yaralla Place - Aged Care Quality...Decision to accredit Yaralla Place The Aged...

Documents