Bilyara Hostel

RACS ID0214
1 Holman Place
COWRA NSW 2794

Approved provider:Cowra Retirement Village 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 one year until 16 May 2018.

We made our decision on 14 March 2017.

The audit was conducted on 07 February 2017 to 09 February 2017. The assessment team’s report is attached.

After considering the submission from the home including actions taken by the home, we decided that the home does now meet expected outcomes 2.13 Behavioural management, 3.6 Privacy and dignity and 4.4 Living environment.

The period of accreditation will provide the home with an opportunity to consolidate recent improvements, and be fully re-assessed within a 12-month period.

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: Bilyara Hostel
RACS ID: 02141Dates of audit: 07 February 2017 to 09 February 2017

Audit Report

Bilyara Hostel0214

Approved provider: Cowra Retirement Village Ltd

Introduction

This is the report of a Re-accreditation Audit from 07 February 2017 to 09 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:

  • 41 expected outcomes

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

  • 2.13 Behavioural management
  • 3.6 Privacy and dignity
  • 4.4 Living environment

Scope of this document

An assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 07 February 2017 to 09 February 2017.

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.

Details of home

Total number of allocated places: 82

Number of care recipients during audit: 79

Number of care recipients receiving high care during audit: 62

Special needs catered for: Nil

Audit trail

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

Interviews

Position title / Number
Chief executive officer / 1
Clinical supervisor / 1
Care manager / 1
Facility manager / 1
Quality systems manager / 1
Education coordinator / 1
Registered nurses / 2
Team leaders/care staff / 7
Administration assistant / 1
Consultants / 2
Laundry staff / 2
Cleaning staff / 3
Care recipients/representatives / 24
Maintenance staff / 1
Physiotherapy aide/assistant / 2

Sampled documents

Document type / Number
Care recipients’ files / 16
Adverse events and progress notes / 17
Medication charts / 15
Personnel files / 6

Other documents reviewed

The team also reviewed:

  • Admission package and checklist
  • Advance care plans
  • Adverse event data
  • Audits including: privacy and dignity
  • Care plan review schedule
  • Care recipient list
  • Care recipients’ information handbook
  • Care recipients’ information package and surveys
  • Comments and complaints documentation
  • Consolidated register of reportable incidents
  • Continence review and individual care recipient’s continence aid requirements
  • Contractors handbook
  • Cowra retirement village action plan 2016-17
  • Criminal history clearance process and documentation
  • Dietary sheets and needs profiles
  • Education documentation including: attendance sheets, competency assessments, questionnaires (elder abuse), compulsory education records, education calendar,
  • Electronic care documentation, handover day sheets, regular health monitoring records including weight, blood glucose levels
  • Human resource management documentation including: rosters, allocation sheets, job descriptions, new employee checklist, interview questions and reference checks,
  • Lifestyle activity program, lifestyle assessments and care plans, attendance at activities, social histories
  • Maintenance documentation including: log books,
  • Medication self-administration assessment
  • Meeting minutes including: Management, clinical team, staff, Cowra village retirement resident’s club, residents of Bilyara care, dietary and activities
  • Newsletters
  • Physiotherapy assessments, referrals and treatment lists
  • Policies and procedures including: adverse event response and management
  • Self-assessment
  • Smoking risk assessment and care plan
  • Specialist and health professional reports, letters
  • Staff handbook

Observations

The team observed the following:

  • Activities in progress, church service in chapel, programs on display, photographs of past events, My story page for two care recipients’ room, shop for supplies
  • Clinical whiteboard, specialised nursing care due dates
  • Comments and complaints notices, feedback box, advocacy information displayed in the home
  • Continence aid distribution system and information list
  • Equipment and supply storage areas: secure oxygen storage, supplies of linen, catering equipment, continence products, personal products, medical supplies, mobility and manual handling equipment
  • Fire safety statement and fire officer training record displayed at entry to the home
  • Fire safety system: sprinkler system, hose reels, fire blankets, extinguishers, correctly orientated emergency evacuation signage, clear fire egress, designated assembly areas
  • Infection control; personal protective equipment in use and in storage, hand sanitiser available, hand washing stations, staff practice, waste disposal systems, sharps containers, colour coded cleaning equipment in use, outbreak kits, instruction available to staff, spill kits
  • Handover between shift
  • Interactions between staff and care recipients
  • Living environment internal and external
  • Manual handling prompt cards in care recipients’ rooms
  • Meal service, staff discretely assisting care recipients to eat/drink and dietary recommendations being implemented
  • Medication trolleys, packing and storage of medications, random expiry dates, scheduled medication balance check, medication administration
  • Sign in/out registers, entry/exit and internal key pad and swipe card access
  • Staff work practices and work areas including nurses stations, treatment rooms, utility rooms, administrative, clinical, lifestyle, physiotherapy, catering, cleaning, laundry and maintenance
  • Sign in/out registers, entry/exit and internal key pad and swipe card access to the Ganya unit
  • Staff work practices and work areas including nurses stations, treatment rooms, utility rooms, administrative, clinical, lifestyle, catering, cleaning, laundry and maintenance
  • Vision and Mission statements and Charter of Care Recipients’ Rights and Responsibilities displayed
  • Wound care trolley and wound care products

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

The organisation has systems to pursue continuous improvement across the four Accreditation Standards. The quality program includes activities to monitor, assess, action, review and evaluate the home’s processes, practices and service delivery. Opportunities for improvement are identified through input from stakeholders and includes suggestion and complaints mechanisms, meetings, surveys, scheduled audits and monitoring of data.

Recent examples of continuous improvement in relation to Accreditation Standard One include:

  • The home’s rosters and staffing allocations have been reviewed in 2016. Clinical supervision has been improved since December 2016. The Clinical coordinator role has been developed and has oversight of clinical management and quality. Two additional registered nurses and an enrolled nurse have been recruited and now clinical expertise is provided seven days a week on morning and afternoon shifts. An additional night staff, float, position has been allocated. A “treatment” position has been developed with day and afternoon hours allocated to this role. The role includes pain management treatments, directed by the registered nurse, as well as the delivery of prescribed treatments such as inhalants and topical treatments.
  • The home’s organisational structure has been reviewed and reporting responsibilities clarified. Job descriptions have been reviewed to reflect reviewed roles and positions.
  • A contractor hand book has been developed to ensure orientation to the home and its policies are maintained.
  • Large white boards have been installed in several areas to improve information management. We observed staff using a new board in the clinic room and staff said this improvement is working well.
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 has a system to identify changes to legislation and regulations. These are provided through access to a peak body, various websites and information updates from industry bodies and government departments. The organisation also has access to a commercial legislation updating service which routinely sends information as legislative changes occur. Information on legislative changes is discussed at management meetings such as the quality meeting and work, health and safety. Staff advised any changes are discussed at staff meetings, education sessions or via memos. Recent legislative updates relating to Standard one, Management systems, staffing and organisational development includes:

  • Criminal history record checks are carried out for all staff, volunteers and contractors as required.
  • Contracts with external service providers confirm their responsibilities under relevant legislation, regulatory requirements and professional standards.
  • Notices were in place informing care recipients and representatives of the review audit.
  • There is a system for the secure storage, archiving and destruction of personal information in accordance with privacy legislation and regulations relating to care recipients’ records.
  • Comments and complaints and advocacy brochures are available in the home.
  • An anti-bullying policy has recently been released.
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

The home has a system that aims to assist management and staff members in gaining appropriate knowledge and skills to perform their roles effectively. There are minimum requirements for employment in the home. The organisation has a mandatory education program which covers key areas such as bullying and harassment (all staff completed the online training in 2016). Records of staff attendance at training sessions are maintained. Recent education sessions attended by various individual staff members include:

  • Accreditation: Your Responsibility, 91 staff attended
  • Adverse event management was provided in December 2016 and 61 staff attended
  • Seven of the management team attended a human resource training session which included workplace relations and right and responsibilities in the workplace.
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

There is a policy and procedures for complaints management. Care recipients and representatives are informed of internal and external complaints mechanisms on entry to the home. Complaints mechanisms are documented in the care recipient handbook and in the agreement. Feedback forms for suggestions, comments and complaints and suggestion box for feedback are accessible to stakeholders. Concerns reviewed have generally been addressed. Care recipients and representatives generally expressed satisfaction with complaints management and are able to raise concerns. Most care recipients and representatives said they would verbally provide feedback to management if there were any issues. We were told management are supportive of care recipients and there are minimal issues of concern.

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

The organisation is a community, not for profit, provider with a volunteer board of management. It has documented their vision, values and philosophy and commitment to quality. The vision, values and philosophy statements and commitment to continuous improvement are documented in the care recipient handbook, in the staff handbook, in corporate information and are on display in the home. The home’s vision, values, philosophy and the organisation’s commitment to continuous improvement are part of the staff orientation.

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

The home has appropriately qualified and sufficient staff to ensure services are delivered in accordance with the needs of the care recipients. Human resource policies and procedures direct the recruitment and performance management of staff. Criminal history and visa certification is obtained prior to employment and is monitored for renewal. Position descriptions, duty statements, staff handbooks, policies and procedures provide staff guidelines. Personnel files are maintained and stored securely. Part time staff provides replacement staff for annual or unscheduled leave. Staff said they are able to complete their duties in the allocated time. Care recipients and representatives said staff are caring.

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

The home demonstrates appropriate stocks of goods and equipment for quality service delivery are available. This includes health and personal care supplies and equipment, food, furniture and linen. There is a system for monitoring and management of inventory and equipment. Appropriate levels of stock and equipment are achieved through the implementation of procedures for budgeting, purchasing, inventory control, assets management and are maintained through a corrective and annual planned preventative maintenance program. The organisation has a “buy local” policy supporting the local community. Feedback from staff and care recipients confirms the availability and appropriateness of goods and equipment.