Bupa Greensborough

RACS ID3677
264 Diamond Creek Road
GREENSBOROUGH VIC 3088

Approved provider:Bupa Aged Care Australia Pty Ltd

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 30 April 2020.

We made our decision on 02 March 2017.

The audit was conducted on 31 January 2017 to 01 February 2017. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome / Quality Agency decision
1.1Continuousimprovement / Met
1.2Regulatorycompliance / Met
1.3Education and staffdevelopment / Met
1.4Comments andcomplaints / Met
1.5Planning andleadership / Met
1.6Human resourcemanagement / Met
1.7Inventory andequipment / Met
1.8Informationsystems / Met
1.9Externalservices / 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
2.1Continuousimprovement / Met
2.2Regulatorycompliance / Met
2.3Education and staffdevelopment / Met
2.4Clinicalcare / Met
2.5Specialised nursing careneeds / Met
2.6Other health and relatedservices / Met
2.7Medicationmanagement / Met
2.8Painmanagement / Met
2.9Palliativecare / Met
2.10Nutrition and hydration / Met
2.11Skin care / Met
2.12Continence management / Met
2.13Behavioural management / Met
2.14Mobility, dexterity and rehabilitation / Met
2.15Oral and dental care / Met
2.16Sensory loss / Met
2.17Sleep / 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
3.1Continuousimprovement / Met
3.2Regulatorycompliance / Met
3.3Education and staffdevelopment / Met
3.4Emotionalsupport / Met
3.5Independence / Met
3.6Privacy anddignity / Met
3.7Leisure interests andactivities / Met
3.8Cultural and spirituallife / Met
3.9Choice anddecision-making / Met
3.10Care 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
4.1Continuousimprovement / Met
4.2Regulatorycompliance / Met
4.3Education and staffdevelopment / Met
4.4Livingenvironment / Met
4.5Occupational health andsafety / Met
4.6Fire, security and otheremergencies / Met
4.7Infectioncontrol / Met
4.8Catering, cleaning and laundryservices / Met

Home name: Bupa Greensborough
RACS ID: 36771Dates of audit: 31 January 2017 to 01 February 2017

Audit Report

Bupa Greensborough3677

Approved provider: Bupa Aged Care Australia Pty Ltd

Introduction

This is the report of a Re-accreditation Audit from 31 January 2017 to 01 February 2017 submitted to the Quality Agency.

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

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

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

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

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation Standards

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

  • 44 expected outcomes

Scope of this document

An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 31 January 2017 to 01 February 2017.

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

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

Details of home

Total number of allocated places: 90

Number of care recipients during audit: 87

Number of care recipients receiving high care during audit: 87

Special needs catered for: Safe unit for care recipients living with dementia.

Audit trail

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

Interviews

Position title / Number
General Manager / 1
Registered and enrolled nurses / 5
Care staff / 8
Administration staff / 2
Care recipients/representatives / 19
Lifestyle staff / 3
Volunteers / 1
Catering, cleaning and laundry staff / 5
General practitioner and physiotherapist / 2
Maintenance staff / 1

Sampled documents

Document type / Number
Care recipients’ files / 12
Medication charts / 10
Personnel files / 10

Other documents reviewed

The team also reviewed:

  • Activity calendars, attendance and evaluation records
  • Approved supplier and contractor lists and associated contracts
  • Audits, schedules and results
  • Care recipient agreements
  • Care recipients’ information package and surveys
  • Cleaning and laundry documentation
  • Clinical documents including allied health information
  • Clinical indicators and benchmarking data
  • Comments and complaints’ documentation
  • Confidential log
  • Continuous improvement documentation
  • Education records
  • Essential service records and emergency manual
  • Food safety plan and associated documentation
  • Infection control and management data
  • Lifestyle documentation
  • Maintenance records
  • Mandatory reporting register
  • Meeting minutes
  • Mission, vision and values statements
  • Occupational health and safety information
  • Police certificates and statutory declarations and registers
  • Policies and procedures
  • Position descriptions
  • Professional registrations
  • Regulatory compliance folder
  • Roster
  • Safety data sheets
  • Staff handbook.

Observations

The team observed the following:

  • Activities in progress including visiting entertainers
  • Archive room
  • Care recipient and staff noticeboards
  • Charter of care recipients' rights and responsibilities - residential care on display
  • Emergency evacuation maps, evacuation kit and accessible firefighting equipment
  • Equipment, chemical storage and supply areas
  • Interactions between staff and care recipients
  • Living environment including care recipient smoking area
  • Pest control bait stations
  • Short group observation in Emerald dining room
  • Staff room
  • Storage and administration of medications
  • Suggestion box, feedback forms and complaints brochure displays.

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.

1.1Continuous improvement

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

Team’s findings

The home meets this expected outcome

Bupa Greensborough actively pursues continuous improvement. Corporate and local management and staff assess the home’s level of performance across the Accreditation Standards assisted by a suite of surveys, audits and clinical indicator data. The information gathered is benchmarked against other homes within the group to give management a comparison of how the home is performing. A variety of established processes, which include management observations, informal and formal stakeholder feedback, the monitoring of key performance indicators and scheduled meetings provide further insight into improvement opportunities. Continuous quality improvement documentation identifies actions and supports the monitoring of progress towards satisfactory outcomes. Established informal and formal processes guide evaluation and management keep stakeholders informed through a range of communication strategies. Care recipients, representatives and staff are satisfied with the information provided about improvements occurring at the home.

Examples of recent improvements undertaken in relation to Standard 1 Management systems, staffing and organisational development include the following:

  • An organisational initiative resulted in a clinical manager forum being developed across sites. The forums are held regularly at rotating sites giving the clinical managers networking, growth and problem solving opportunities on a broader scale. Feedback has been very positive.
  • A site based leadership team meeting schedule has been established on a weekly basis. Management report this results in a more holistic and people centred approach to managing care issues and gives the developing leadership team additional support. Management report it is working well.
  • To assist the recruitment process, key staff, including administration staff, received training on recruitment processes. The trained staff now assist in recruitment on various levels such as shortlisting candidates and sitting on the interview panel where appropriate. Management report the training was a great success and trained staff now share the recruitment load enabling management to better determine if a candidate will be a good organisational fit at floor level.
1.2Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.

Team’s findings

The home meets this expected outcome

The organisation’s management has systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Notification of updates occurs at the organisational level through membership of a professional advisory service, information provided by an industry body and through government publications. Established communication and documentation processes keep staff informed of changes relevant to their roles. Monitoring of regulatory compliance occurs through management observation of staff practice, scheduled internal and external audits and the regular analysis of key performance indicators. Staff are satisfied management ensures they understand their responsibilities in relation to their roles and they are provided with timely updates of regulatory changes. Care recipients and representatives are satisfied management provide them with timely information updates.

Examples of responsiveness to regulatory compliance relating to Standard 1 Management systems, staffing and organisational development include the following:

  • Monitoring the currency of health professionals’ registrations.
  • Established organisational processes to ensure all current staff and relevant contractors provide a statuary declaration and comply with the requirement to have a current police certificate.
  • The secure storage of confidential documents.
  • Information about internal and external complaints mechanisms and advocacy services are available.
  • Notification to all stakeholders of the re-accreditation audit within the required time frame.
1.3Education and staff development

This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.

Team’s findings

The home meets this expected outcome

There is an education program available to management and staff enabling them to maintain the relevant knowledge and skills to perform their roles effectively. Management develop an education program based on training needs analysis, specialised nursing care needs, competency requirements and better practice initiatives. A range of delivery methods are used including in-services, attendance at external conferences and an online education portal. There is a mandatory education program and management monitor attendance at sessions. Attendance at mandatory education is maximised through networking with other Bupa homes in the metropolitan area. Staff are satisfied with the education available to them and care recipients and representatives are satisfied with the knowledge and skills of staff.

Recent education opportunities relevant to management systems, staffing and organisational development include:

  • accreditation preparation
  • aged care funding instrument
  • code of ethics
  • instructor training.
1.4Comments and complaints

This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".

Team’s findings

The home meets this expected outcome

Each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms. Information about the internal and external feedback mechanism is included in staff and care recipient information and orientation programs. Pamphlets outlining external complaints and advocacy services are readily available in English and languages other than English relevant to the home’s population. Management utilise a range of communication processes to encourage all stakeholders to provide feedback which can be done confidentially if desired. Staff and family members support care recipients who are less able to express their feedback independently. Monitoring of actions to address identified issues occurs through the continuous quality improvement system and a confidential log is kept of any complaints. Care recipients, representatives and staff are aware of available feedback mechanisms and said they feel satisfied with the timely response to feedback.

1.5Planning 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 findings

The home meets this expected outcome

Bupa’s vision, values and mission statements and commitment to continuous improvement underpins the work practices of all stakeholders. These statements and the home’s commitment to quality throughout the service are documented in a wide range of stakeholder information, are displayed within the home and reinforced through a range of established communication processes.

1.6Human 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 findings

The home meets this expected outcome

There are appropriately skilled and qualified staff sufficient to ensure services are delivered in accordance with these standards and Bupa’s philosophy and objectives. The recruitment, selection and induction of new staff is guided by an established organisational system. Probationary staff are supported by management when they start at the home and receive supernumerary ‘buddy’ shifts while they gain familiarity with the home. An annual review of performance is conducted with staff encouraged to have input into the direction they wish to take their job. Management monitors staff rosters and regularly seeks feedback from stakeholders to ensure the maintenance of appropriate staff numbers and skill mix. Registered nurses are rostered on duty across each shift and are supported by on-call management. To meet the objective of continuity of care, internal staffing resources from a casual bank and other home’s within the group are used to fill shift vacancies. Staff are satisfied with the current staffing levels, management’s support and the commitment of their colleagues to ensure the provision of person first care. Care recipients and representatives expressed satisfaction with the quality of staff skills, their caring manner and their timely assistance.

1.7Inventory and equipment

This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".

Team’s findings

The home meets this expected outcome

There are sufficient supplies of appropriate goods and equipment to provide quality service delivery. The home has established stock ordering processes. Management order clinical and non-clinical supplies and use effective stock management practices. Goods are stored safely and there are cleaning and maintenance programs to ensure equipment remains in good repair. There are processes to trial new products and equipment which ensure staff are educated in their safe and effective use. Staff, care recipients and representatives are satisfied with the quantity and quality of supplies and equipment available.

1.8Information systems

This expected outcome requires that "effective information management systems are in place".

Team’s findings

The home meets this expected outcome

The home has effective information management systems in place. Confidential information, including care recipients’ and personnel files are stored securely. Staff utilise a paper based care documentation system to record care recipients’ needs and preferences. The timely communication of care needs occurs through the handover process and assists in maintaining current awareness of practice requirements. Access to computer based software is password protected and limited in line with delegated authority. There are processes to ensure regular back up of electronic information and the archiving and destruction of confidential documents as required. Management communicate with care recipients, representatives and staff through a variety of established formal and informal communication strategies. Care recipients, representatives and staff are satisfied with the variety of communication methods available to ensure they have access to information appropriate to their needs.

1.9External 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".