Gill Waminda Aged Care Plus Centre

Gill Waminda Aged Care Plus Centre

RACS ID 0076
2 Mary Street
GOULBURN NSW 2580

Approved provider: The Salvation Army (NSW) Property Trust

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 25 February 2020.

We made our decision on 29 December 2016.

The audit was conducted on 22 November 2016 to 24 November 2016. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits.

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome / Quality Agency decision /
1.1 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

Principles:

Care recipients’ physical and mental health will be promoted and achieved at the optimum level in partnership between each care recipient (or his or her representative) and the health care team.

Expected outcome / Quality Agency decision /
2.1 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.

Expected outcome / Quality Agency decision /
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

Principle:

Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors

Expected outcome / Quality Agency decision /
4.1 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: Gill Waminda Aged Care Plus Centre
RACS ID: 0076 4 Dates of audit: 22 November 2016 to 24 November 2016

Audit Report

Gill Waminda Aged Care Plus Centre 0076

Approved provider: The Salvation Army (NSW) Property Trust

Introduction

This is the report of a re-accreditation audit from 22 November 2016 to 24 November 2016 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

·  44 expected outcomes

Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 22 November 2016 to 24 November 2016.

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

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Assessment team

Team leader: / Shirley Beaumont Owles
Team member/s: / Nehad Saleh

Approved provider details

Approved provider: / The Salvation Army (NSW) Property Trust

Details of home

Name of home: / Gill Waminda Aged Care Plus Centre
RACS ID: / 0076
Total number of allocated places: / 103
Number of care recipients during audit: / 101
Number of care recipients receiving high care during audit: / 101
Special needs catered for: / 28 dementia specific unit
Street/PO Box: / 2 Mary Street
City/Town: / GOULBURN
State: / NSW
Postcode: / 2580
Phone number: / 02 4823 4300
Facsimile: / 02 4821 0005
E-mail address: /

Audit trail

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

Interviews

Category / Number /
Centre manager / 1
Care manager / 1
Area manager / 1
Quality and education coordinator / 1
Quality advisor / 1
Registered nurses / 3
Care staff / 10
Physiotherapist / 1
Occupational therapist / 1
Medical officer / 1
Pharmacist / 1
Office manager / 1
Care recipients / 10
Representatives / 6
Workplace health and safety representative / 1
Chaplains / 2
Recreational activity officers / 2
Maintenance staff / 1
Catering operation manager (contractor) / 1
Catering staff (contractor) / 2
Laundry quality consultant (corporate) / 1
Cleaning and laundry contract manager (contractor) / 1
Laundry staff (contract and support) / 4
Cleaning staff(contractor) / 2

Sampled documents

Category / Number /
Care recipients’ files / 11
Diabetic management plans / 10
Behaviour charts / 15
Wound charts / 16
Medication charts / 21
Personnel files / 8
Resident agreements / 5

Other documents reviewed

The team also reviewed:

·  Activity and spiritual program documentation - assessments, care plans, programs, attendance lists and evaluations

·  Care recipients’ handbook and information package

·  Catering services documentations including: menu, menu review documentation, menu changes form, care recipient dietary requirement and preferences, temperature control records, food safety plan, food safety licence, food safety audit, thickened fluid list, food ordering and delivery record, supplier list and calibration records

·  Cleaning and laundry services documentation including : colour coding chart, infection control manual, safety data sheets, toolbox training records, cleaning schedule, cleaning duty statement, safe work practices, laundry wash chart, cleaning manual, laundry operations manual, occupational health and safety manual, hazard report form and outbreak cleaning checklist

·  Clinical care documentation including assessments, care plans, nursing, medical officers and allied health progress notes, pathology reports, advanced care directives, behaviour, wound and pain management; nutrition and hydration preferences and plans, requirements and weight monitoring; specialised nursing care charts and records including diabetic management and blood glucose level parameters, risk assessments, restraint authorisations, referrals to health specialists, observation charts, bowel charts and family conference records

·  Compliments and complaints register, forms and documentation

·  Continence management documentation

·  Continuous improvement documentation including: quality assurance program 2016, continuous improvement plan/register and documentation, feedback form ‘Your matters matter’, self-assessment tool, clinical indicators, audit tools and reports, action plan, care recipients and representatives satisfaction survey results and World of Wellness (WOW) program

·  Education documentation including: education planner and tracker, attendance records, evaluation, orientation checklist, program and records, electronic learning resources, toolbox training documentation, competency/skill assessments, training announcements, letter regarding non-attendance of mandatory training and training needs analysis

·  Emergency and fire safety documentation including: annual fire safety statement, electrical testing and tagging records, care recipient emergency evacuation bag with care recipients details and identification tags, fire safety system maintenance and inspection records, business continuity and disaster plan manual, hazardous materials/chemical register, evacuation diagram, fire safety officer certificate, emergency procedure flip chart and risk assessments

·  Human resource documentation including: staff roster, daily allocation sheet, staff handbook, staff performance appraisals/review, position descriptions and duty lists, orientation checklist, human resources policies, procedures and forms, qualifications/certificates, grievance procedures and staff grievances form and offer of employment (including standards of conduct, confidentiality and privacy)

·  Infection control documentation including: infection statistics, outbreak management information kits and resources, care recipients’ and staff immunisation records, infection control policy and procedures manual, pest control service records, legionella testing records, waste management records, infection prevention and control quick reference, infection control equipment checklist and fridge temperature monitoring forms

·  Information system documentation including: policies, procedures and flowcharts, meeting minutes, memoranda, archived records system and documentation, organisation’s intranet, newsletter, communication book and handover records

·  Maintenance, stock management and external services documentation including: electronic stock management/ordering system, stock order form, electronic work request system, service providers agreements, preventative maintenance program and records, reactive maintenance records, external service providers insurances and other statutory requirements details (external service providers folder and documentation), maintenance and capital budgets, thermostatic mixing valves inspection and service records, contract approval process, contractors induction book, pre-purchase checklist and purchasing guidelines

·  Medication management documentation including; controlled drug (Schedule 8) registers; pharmaceutical review’s, anti-coagulant medication monitoring, medication incident reports, self-administered medication agreements, nurse initiated medication refrigerator temperature records and medication advisory committee meeting minutes

·  Physiotherapy assessments, care plans, heat therapy and massage lists and mobility chart updates

·  Regulatory compliance documentation including: compulsory reporting register and documentation, professional registrations, criminal history checks registers and documentation, statutory declarations, internal directive folder and regulatory updates from corporate office, consent to bed movement form and letter informing stakeholders of the reaccreditation audit

·  Self-assessment report for re-accreditation and associated documentation

·  Vision, mission and values statements

·  Work Health and Safety (WH&S) system records including: hazard/incident forms and report, safety data sheets, risk assessments, testing and tagging record, WH&S policy and procedures, injury management and return to work policy, infection control manual, safe work method statement and WH&S checklist audit.

Observations

The team observed the following:

·  Activities and exercise classes in progress

·  Care recipients’ and staff notice boards

·  Charter of Care Recipients’ Rights and Responsibilities (displayed)

·  Cleaning in progress

·  Closed circuit television monitoring system (CCTV)

·  Dining rooms during lunch service, morning and afternoon tea

·  Document archive room

·  Feedback forms (internal and external) and advocacy brochures readily available and suggestion box

·  Fire safety and fighting equipment including fire panel, fire extinguishers, blankets, hose reels, evacuation plans, sprinkler system, assembly point, evacuation bags with care recipient information, annual fire safety statement and emergency flip charts displayed appropriately

·  Infection control resources including: hand washing facilities and instructions, hand sanitiser dispensers, spills kits, sharps containers, personal protective equipment, outbreak kit, general and clinical waste and colour coding charts

·  Interactions between staff and care recipients, and other health and related services personnel

·  Living environment – internal and external

·  Medications (including storage, controlled drug cupboards, medication trolley’s, medication administration packs, medication refrigerators and medication rounds)

·  Mission and values statements

·  Mobility aids and care recipients being assisted with mobility

·  Notices informing care recipients and staff of the re-accreditation audit

·  NSW Food Authority certificate on display

·  Nurses stations and work areas

·  Palliative care box

·  Reportable incidents flowchart

·  Secure storage of care recipient and staff information

·  Short observation session in the chapel/activity room

·  Staff handover

·  Staff practices

·  Stocks of supplies and equipment and supply storage areas

·  Visitor/contractor sign in/out books

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 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

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

The home implements an organisation-wide quality system that assists in the identification of opportunities for improvement and the implementation of improvement initiatives. Opportunities for improvement are identified at both the organisation and the home level. A number of avenues are used to identify these opportunities including stakeholders’ feedback, management observation, results of audits, and monitoring of key clinical indicators. Initiatives are documented and their outcomes are evaluated to assess their effectiveness. Continuous improvement forms part of the staff orientation process and is discussed in relevant meetings. Feedback forms were observed at a number of locations within the home as well as a suggestion box. Care recipients, representatives and staff report that they are aware of and satisfied with access to feedback mechanisms.