Uniting Mayflower Westmead

Uniting Mayflower Westmead

RACS ID 0184
2 Helen Street
WESTMEAD NSW 2145

Approved provider: The Uniting Church in Australia Property Trust (NSW)

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 02 February 2020.

We made our decision on 19 December 2016.

The audit was conducted on 15 November 2016 to 18 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: Uniting Mayflower Westmead
RACS ID: 0184 4 Dates of audit: 15 November 2016 to 18 November 2016

Audit Report

Uniting Mayflower Westmead 0184

Approved provider: The Uniting Church in Australia Property Trust (NSW)

Introduction

This is the report of a re-accreditation audit from 15 November 2016 to 18 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 15 November 2016 to 18 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: / Carol Lowe
Team member: / Maria Toman

Approved provider details

Approved provider: / The Uniting Church in Australia Property Trust (NSW)

Details of home

Name of home: / Uniting Mayflower Westmead
RACS ID: / 0184
Total number of allocated places: / 48
Number of care recipients during audit: / 37
Number of care recipients receiving high care during audit: / 35
Special needs catered for: / Nil
Street/PO Box: / 2 Helen Street
City/Town: / WESTMEAD
State: / NSW
Postcode: / 2145
Phone number: / 02 9891 3755
Facsimile: / 02 9633 5771
E-mail address: / Nil

Audit trail

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

Interviews

Category / Number /
Acting Service Manager / 1
Quality Specialist / 1
Clinical Care Manager / 1
Registered Nurse / 1
Cleaning company representatives (client service manager and relief area manager) / 2
Laundry staff / 3
Maintenance Manager / 1
Project Manager / 1
Kitchen Manager / 1
Kitchen staff / 3
Chaplain and Pastoral Care staff / 2
Care Recipients/Representatives / 8
Clinical Nurse Educators / 2
Administration Officer (Administration/Payroll and Purchasing) / 1
Care staff / 4
Cleaning staff / 1
Property Manager / 1
Maintenance Co-ordinator / 1
Leisure and Lifestyle staff / 3
Catering Operations Manager / 1
Physiotherapist / 1

Sampled documents

Category / Number /
Key performance indicator folders (audits for 2016) / 2
Residential agreements / 4
Care recipients’ files including care plans, medical notes and progress notes / 4
My performance and development plans / 5
Confidentiality agreements (staff files on computer system) / 4
Medication ID charts, primary medication charts, medication profiles / 4

Other documents reviewed

The team also reviewed:

·  Accident and incident reports, medication incidents, behaviour incidents, with data collation and reporting

·  Activity documentation: including leisure and lifestyle assessments, leisure and lifestyle care plan and care recipient social profile, activities calendars, individual visits records, activity participation records, evaluations and survey results

·  Allied health referral, assessment and care planning documentation

·  Australian Health Practitioner Regulatory Agency (APHRA) registration folder

·  Behaviour assessment tools, behaviour management and monitoring tools, referral to external specialists, assessment of triggers and plans implemented, restraint assessment and monitoring

·  Care recipients’ information package and handbook

·  Catering information including: NSW Food Authority licences for the organisation and catering company, menu (four weekly) and dietician review, temperature records for the delivery, storage, preparation and serving of food, cleaning and sanitising records, education records for catering staff, food suppliers hazard analysis and critical control point (HACCP) certificates and licences and internal audits

·  Cleaning company information including: education records for cleaning staff, duty statement, policies and procedures, safety data sheets for chemicals, cleaning signing book, laminated copies of the cleaning program including spring cleaning schedule for rooms

·  Clinical documentation including: care plans, monitoring and evaluation of care documents, assessment and treatment records, referral to external specialists, hospital discharge documents, vital signs charting, blood glucose level monitoring, advance care planning documents and specialised nursing care documents, clinical monitoring records and observation monitoring records

·  Comments and complaints register on computer

·  Communication books for staff, communication on electronic care system and communication tools for doctors

·  Continence management including: management plans, daily bowel monitoring records and continence aid allocation lists

·  Dietary preference assessments, catering documents and notices regarding preferred diets and food allergies

·  Documentation guides and care plan review schedules

·  Education including: Education folder – 2016, education and training reports folder, attendance records for education, evaluation forms, education calendar and on-line education system including mandatory components

·  End of life assessment and care management pathway tools

·  External contracts folder including: copies of relevant certificates, insurance documents, police checks and general registrations for allied health professionals

·  Fire information including: inspection tags on various items of fire-fighting equipment, evacuation diagrams, exits signs, annual fire safety certificate next to fire panel, fire system logbooks (sound and intercom system, sprinkler system, fire indicator panel and sprinkler, hydrant and hose reel pumps), emergency procedure manual, evacuation folder in the nurses’ station and letter from fire service company advising they are undertaking a review of the fire evacuation plan for the site

·  Handbooks – care recipients and staff

·  Health, safety and wellbeing (HSW) folder including HSW education promotion calendar, environmental audits and incident reporting system on computer

·  Maintenance information including: on-line maintenance system, thermostatic mixing valve service and temperature records (on-line), asset register, legionella testing reports, preventative maintenance schedule and audit on maintenance system

·  Mandatory reporting register on computer system

·  Medication management documents, diabetic medication delivery tools, assessments and monitoring records

·  Meeting minutes – staff, care recipients and medical advisory committee

·  Memo folder

·  Nutrition and hydration management including: individual dietician review, special diets, thickened fluids and nutritional supplements, menu choice forms, care recipient food and beverage preferences and allergies

·  Pain assessment tools for verbal and non-verbal assessment of pain, pain management monitoring charts and referral to external specialists

·  Physiotherapy assessments, mobility assessments, falls risk assessments, mobility care plans, manual handling guidelines and equipment ordering tools

·  Plan for continuous improvement

·  Police check register for staff on computer system

·  Policies and procedures

·  Regulatory compliance folder - 2016

·  Reportable incident records

·  Roster on computer and allocation folder

·  Self-assessment report for re-accreditation

·  Strategic plan 2014-2018 and organisational chart

·  Vaccination consent and administration records, hospital discharge records, specialist referral and attendance records

·  Volunteer service folder – including police check register for volunteers

Observations

The team observed the following:

·  Activities in progress and associated resources and notices

·  Australian Aged Care Quality Agency re-accreditation audit notice displayed

·  Charter of care recipients’ rights and responsibilities

·  Code of conduct and organisation’s mission statement

·  Equipment and supplies in use and in storage such as lifting equipment, manual handling aids, mobility equipment and pressure relieving aids in use and in storage including clinical stores and continence aids

·  Infection control equipment including: outbreak supplies, spill kits, sharps disposal containers, hand-washing facilities, waste disposal, hand sanitiser dispensers around the home, general and contaminated waste disposal systems, cytotoxic waste disposal system, colour coded cleaning equipment and personal protective equipment

·  Interactions between staff, care recipients and representatives including meal service and short group observation in living area of the home

·  Living environment internal and external

·  Medication administration across the home; secure storage of medication and emergency use medications

·  Posters and pamphlets in various locations on the organisational complaints and comments system and the Aged Care Complaints Commissioner (ACCC) and pamphlets in various community languages on the ACCC

·  Secure storage of confidential care recipient information

·  Staff work areas and practices

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

Uniting Mayflower Westmead (the home) and co-located nursing home participate in a commercial benchmarking audit program to review and monitor the quality of service delivery across both sites. An audit schedule guides the management team with the program of audits to be conducted across a range of clinical, environmental and administrative areas. Any issues arising through these audits are entered onto the home’s continuous improvement plan to enable management to effectively track any required improvements. Audit results are also able to be monitored by senior management at an organisational level. This enables management at the organisation’s head office to monitor any audit trends as well as ensuring audits are being completed. Improvements are also sourced via the “Have your say” comments and suggestion form. Feedback is also sought through the staff, care recipient and representative meetings. A sample of improvements relating to Standard One includes the following:

·  It was identified through an internal audit and by the acting service manager there were difficulties in completing staff appraisals in a timely manner. The acting service manager advised there were also issues in ensuring any matters raised through this process were followed up appropriately. A new user friendly appraisal format was introduced in June 2016 and information on the new system was provided to staff at the staff meeting. Staff members now make an appointment to speak with their manager to conduct the appraisal and a spreadsheet is being used to track that the appraisals are being completed. Initial feedback indicates there is improved compliance with the system.