Published Decision (SA and RA) s7

St John's Retirement Village Nursing Home

RACS ID: 4481

Approved provider: Trustees of the Anglican Diocese of Wangaratta

Home address: 138 Williams Road WANGARATTA VIC 3677

Following a review audit the Quality Agency decided that this home failed to meet 13 of the 44 expected outcomes of the Accreditation Standards. An accreditation decision, made on 19 October 2017, determined that this home is accredited until 21 August 2018.
The review audit was conducted on 19 September 2017 to 4 October 2017. The assessment team’s review audit report is attached.
This home is on a timetable for improvement that expires on 4 January 2018.
The Quality Agency 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 Not met

1.2 Regulatory compliance Not met

1.3 Education and staff development Met

1.4 Comments and complaints Not met

1.5 Planning and leadership Met

1.6 Human resource management Not 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 Not met

2.2 Regulatory compliance Not met

2.3 Education and staff development Met

2.4 Clinical care Not 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 Not 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 Not met

4.2 Regulatory compliance Not met

4.3 Education and staff development Not 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 Not met

4.8 Catering, cleaning and laundry services Not met

Home name: St John's Retirement Village Nursing Home Dates of audit: 19 September 2017 to 4 October 2017

RACS ID: 4481 4

Audit Report

Name of home: St John's Retirement Village Nursing Home

RACS ID: 4481

Approved provider: Trustees of the Anglican Diocese of Wangaratta

Introduction

This is the report of a Review Audit from 19 September 2017 to 4 October 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:

·  27 expected outcomes

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

·  1.1 Continuous improvement

·  1.2 Regulatory compliance

·  1.3 Education and staff development

·  1.4 Comments and complaints

·  1.6 Human resource management

·  1.8 Information systems

·  2.1 Continuous improvement

·  2.2 Regulatory compliance

·  2.4 Clinical care

·  2.8 Pain management

·  2.11 Skin care

·  3.2 Regulatory compliance

·  4.1 Continuous improvement

·  4.2 Regulatory compliance

·  4.3 Education and staff development

·  4.7 Infection control

·  4.8 Catering, cleaning and laundry

Scope of this document

An assessment team appointed by the Quality Agency conducted the Review Audit from 19 September 2017 to 4 October 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of four registered aged care quality surveyors.

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: 105

Number of care recipients during audit: 83

Number of care recipients receiving high care during audit: 78

Audit trail

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

Interviews

Position title / Number /
Chief executive officer / 1
Chairman of the board / 1
Board member/infection control support / 1
Care services manager / 1
External consultants / 2
Nursing staff / 10
Care staff / 7
Roster and administrative officer / 1
Human resource and payroll officer / 1
Care recipients / 23
Representatives / 12
Leisure and lifestyle staff / 2
Physiotherapist / 1
Catering staff / 2
Cleaning staff / 4
Laundry staff / 1
Maintenance staff / 1

Sampled documents

Document type / Number /
Care recipients’ files / 17
Medication charts / 10
Personnel files / 8

Other documents reviewed

The team also reviewed:

·  Activity calendar of events

·  Allied health and specialist reports and recommendations

·  Care recipient agreement sample

·  Care recipient bed list

·  Care recipient information booklet and information pack

·  Care recipient pharmacy medication reviews

·  Cleaning schedules and laundry documentation

·  Clinical assessments, charts, care plans and progress notes

·  Clinical care root cause analysis tool

·  Clinical risk assessments

·  Clinical risk indicator data

·  Compulsory reporting register

·  Continence communication book

·  Continuous improvement documentation

·  Contractor agreements

·  Controlled drug registers

·  Daily clinical reports

·  Education calendar, attendance records

·  Electrical safety certificates

·  Electrical test and tagging

·  Electronic mail and correspondence

·  Electronic risk management system

·  Emergency contact telephone numbers list

·  Environmental audits and schedule

·  Fire detection systems and firefighting equipment maintenance records

·  Fire evacuation list

·  Fire, safety, emergency, disaster and security plans

·  Food safety program, third party audit and associated documentation

·  Handover documentation

·  Human resource management documentation

·  Initial clinical assessment schedule

·  Maintenance purchase orders

·  Medical officer notes and specialist information

·  Medication chart review list

·  Medication temperature recording form

·  Meeting minutes

·  Mission statement/philosophy and objectives/vision and values

·  Occupational health and safety documentation

·  Outbreak action summary checklist, infection chart and outbreak report

·  Pest control records

·  Police certification and statutory declaration documentation

·  Policies, procedures and flowchart samples

·  Preventative and corrective maintenance documentation

·  Restraint documentation

·  Risk report register

·  Roster and staff allocation sheets

·  Safety data sheets

·  Satisfaction survey results for care recipients and staff

·  Specialised nursing care plans

·  Staff information handbook

·  Staff orientation and induction pack

·  Supplier list

·  Temperature and equipment monitoring records

·  Terminal care wishes forms

·  Verification of death and life extinct forms

·  Weight records

·  Workplace safety manual

·  Wound management documentation.

Observations

The team observed the following:

·  Activities in progress, activity resources

·  Chemical store

·  Cleaning in progress

·  Clinical equipment, supplies and storage

·  Equipment and supply storage areas

·  External complaints poster displayed

·  Fire-fighting equipment, evacuation pack

·  Infection control outbreak trolleys with personal protective equipment

·  Interactions between staff and care recipients

·  Living environment

·  Meal and refreshment services

·  Noticeboards and whiteboards

·  Notification of flu type illness in the home

·  Notification of Quality Agency visit displayed

·  Short observation ‘Anderson house’ memory support unit

·  Sling trolley

·  Storage of medications

·  The 'Charter of care recipients' rights and responsibilities - residential care' displayed

·  Waste management systems

·  Wound management trolley and supplies.

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 does not meet this expected outcome

The organisation does not have an effective system that demonstrates a proactive approach to continuous improvement across the Accreditation Standards. The home’s continuous improvement system lapsed in March 2017. Management and staff said roles and responsibilities for the continuous improvement system had not been clear. We were advised the care services manager had responsibility for the quality system until March 2017 when the manager of education and training was asked to coordinate continuous improvement. This manager was busy with the onsite registered training organisation, which provides accredited education and training to personal care staff. As late as July 2017 the manager of education and training was not clear they had responsibility for quality systems. Management and staff said from March 2017, quality activities were to be managed and reported in the new electronic risk management program. Staff were instructed to discard stakeholders’ improvement forms and enter them directly into the electronic system. Staff generally did not know how to use the system and did not enter improvement suggestions from stakeholders. Management did not identify the issues with documenting improvement suggestions and were not actively engaged with the continuous improvement system. Management could not show improved results in Standard 1, Management systems, staffing and organisational development.

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 does not meet this expected outcome

The organisation’s management does not have an effective system to identify and promote compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Regulatory compliance across the Accreditation Standards was not effectively monitored. Management and staff did not ensure the home was actively pursuing continuous improvement across the Accreditation Standards. Management were not aware staff were working outside their scope of practice in relation to verification of death, management of syringe drivers and controlled medication. Management did not ensure staff reported allegations of elder abuse in a timely manner. Management did not ensure the respiratory outbreak case list was complete and reflected all deaths and hospitalisations. Management did not ensure all deaths and hospitalisations related to the influenza and respiratory outbreak of August 2017 and September 2017 were consistently notified to the Department of Health and Human Services in a timely manner within 24 hours. Management did not have systems to ensure management and staff followed all relevant guidelines in identifying, actioning and monitoring the influenza and respiratory outbreak in a timely manner from the onset of symptoms.

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 does not meet this expected outcome

Management and staff cannot demonstrate they had the appropriate knowledge and skills to identify, contain and manage the influenza and respiratory outbreak of August 2017 and September 2017. These skill and knowledge deficits impacted negatively on care recipients. Management and staff were not consistently prepared or equipped with the appropriate knowledge and skills in relation to use of the home’s electronic risk management system. Management and staff knowledge and skills were inconsistent in relation to reporting or actioning incidents and infections and communicating about the health status of care recipients. While the home has an onsite registered training organisation that provides staff education, the program does not always identify and respond to staff training needs. Staff said management did not provide timely information and education to support the containment and management of the respiratory outbreak. Refer to expected outcomes 1.4 Comments and complaints, 1.6 Human resource management, 1.8 Information systems, 2.3 Education and staff development, and 4.7 Infection control for further information. Staff, care recipients and representatives were not satisfied that management and staff were aware of how to respond to or contain the outbreak.