Boronia House

RACS ID1025
183 - 197 Boronia Road
ST MARYS NORTH NSW 2760

Approved provider:Thompson Health Care 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 19 April 2020.

We made our decision on 24 February 2017.

The audit was conducted on 17 January 2017 to 19 January 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: Boronia House
RACS ID: 10251Dates of audit: 17 January 2017 to 19 January 2017

Audit Report

Boronia House1025

Approved provider: Thompson Health Care Pty Ltd

Introduction

This is the report of a Re-accreditation Audit from 17 January 2017 to 19 January 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 17 January 2017 to 19 January 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: 124

Number of care recipients during audit: 123

Number of care recipients receiving high care during audit: 123

Special needs catered for: Dementia specific unit

Audit trail

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

Interviews

Position title / Number
Director of Nursing / 1
Deputy director of nursing / 1
Advisory director of nursing / 1
Clinical nurse educator / 1
Human resource manager / 1
Administration assistant / 1
Hospitality consultant / 1
Head chef / 1
Catering staff / 5
Care recipients/representatives / 19
Care recipient committee chairperson / 1
Property manager / 1
Registered nurses / 5
Care staff – Certificate 111 / 8
Certificate IV staff (Medication) / 4
Continence link nurse / 1
Maintenance supervisor / 1
Laundry staff / 2
Cleaning staff / 4
Recreation activities coordinator / 1
Recreation activities staff / 3
Aromatherapists / 2
Physiotherapist / 1
Physiotherapy aide / 1

Sampled documents

Document type / Number
Care recipients’ files including assessments, care plans, progress notes, care conferences, charts and forms, advanced care directives, allied health documentation, pathology, referrals, consultations and associated documentation / 12
Summary/quick reference care plans / 8
Leisure and lifestyle files / 6
Care recipient agreements / 2
Medication charts / 32
Personnel files / 4
External provider contracts / 2
Behaviour assessment/care plan / 1

Other documents reviewed

The team also reviewed:

  • Audit data, benchmarking reports
  • Care documentation including doctors lists, communication diary, 24 hour report - handover list
  • Care recipient handbook, residential agreement and pre-admission information pack
  • Catering records including: menu, food safety program and records, care recipient dietary information sheets, NSW Food Authority licence and audit report and kitchen communication diary, temperature and cleaning logs
  • Cleaning manual, spring cleaning schedule and records, cleaners’ training program and records, housekeeping duties schedule and cleaning audits
  • Comments and complaints and actions taken
  • Continence documentation including coordinator role, orders and education, individualised continence aid requirements
  • Continuous improvement system including: continuous improvement plan, quality management system framework, quality schedule and audits, benchmarking reports, management monthly reports and internal audit checklist
  • Education program including: orientation program, orientation checklist, training calendar, attendance records, evaluations, questionnaires, competency assessments, mandatory education matrix
  • Emergency manual including disaster management and recovery plan
  • Equipment inventory
  • Fire safety equipment inspection and testing schedule, records and annual fire safety statement
  • Handover sheets, staff work computer generated work logs
  • Heatwave check list and caring for older residents in heatwave conditions
  • Human resources management documentation including: position descriptions, duties lists, police certificate register, record of professional registrations, staff roster, allocation sheets, employee handbook, performance review, staff needs analysis and results, and employee satisfaction survey
  • Incidents – general and medication
  • Infection prevention and control manual, vaccination policy, pest control records,
  • Maintenance manual, responsive maintenance log, programmed maintenance log, weekly maintenance reports, contractor contact details and service records, maintenance duty list including equipment cleaning
  • Mandatory reporting register
  • Medication documentation including patch application history, nurse initiated medication, self administration assessment and authorisation, fridge temperature charts, fax/scan sheets for ordering/changing medication, medication crushing information sheet
  • Meeting calendar and meeting minutes
  • Physiotherapy folder, records and education, manual handling charts
  • Policies and procedures
  • Recreational activities documentation including residents list for activities and church services in Wattle, monthly activities program and monthly planner, one-on-one room visits, exercise list, monthly activities budgets, communication cards, hazard and risk assessments, activities evaluation, quarterly newsletter
  • Self-assessment for reaccreditation audit
  • Staff memorandum and messages
  • Work health and safety documentation including: environmental audits, monthly reports, meeting minutes, maintenance requests, hazard identification log, risk assessments

Observations

The team observed the following:

  • Activities in progress
  • Charter of Care Recipients’ Rights and Responsibilities displayed
  • Chemical storage and safety data sheets
  • Cleaning in progress
  • Complaints mechanisms, notices, brochures (multilingual), and forms available
  • Equipment and supply storage areas
  • Evacuation kit, emergency procedures charts and evacuation plans on display
  • Fire safety equipment and warning systems
  • Infection control equipment such as spill kits, outbreak box, contaminated waste disposal, hand-washing and disinfecting stations throughout the home,
  • Information technology equipment and backup systems
  • Interactions between staff and care recipients
  • Internal and external living environment
  • Medication administration: emergency box, emergency box register, nurse initiated, medication box,
  • Nurse call bell system and sensor alarm mats in use
  • Palliative care basket
  • Policies and procedures, instruction and guidelines available to staff
  • Secure storage of medications and medication trolleys
  • Security systems including: keypad entries, camera surveillance, exterior lighting, registered nurse night lock up procedures
  • Short group observation
  • Signs notifying stakeholders of reaccreditation dates

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 an effective system to actively 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 all stakeholders and include analysis of monitoring data. The quality improvement committee monitors the effectiveness of the system utilising data from audits, clinical indicators and feedback. Care recipients, representatives and staff have opportunities to make suggestions to improvement.

The home demonstrates it is actively pursuing continuous improvement in relation to Accreditation Standard One and recent examples include:

  • Staff needs analysis results identified the need for relevant clinical staff to receive intensive mentoring and training in the electronic care system and care recipient admission process. Staff have attended monthly workshops, and have access to telephone support as necessary. Extra administrative support has also been provided from another of the organisation’s facility. Staff report they have had guidance in how to ensure all relevant admission information is captured. Audit results show admission data is now being completed correctly, and clinical staff say they feel more confident in using the electronic program.
  • Incident and accident results in late 2016 showed a high proportion of care recipients with specific high care needs were being admitted. To ensure the facility is appropriately equipped to manage care recipient special care needs, management reviewed the entry criteria of prospective care recipients. A new, more comprehensive pre-admission pack has been developed to include details of care recipients’ clinical care needs and preferences. The clinical nurse specialist collects and enters this data, and is now more aware of individual special care needs and equipment needed before admission. This new process has resulted in improved clinical care and a reduction in clinical care complaints.
  • The organisation has introduced a new electronic human resource management system. Staff now log their availability for shifts, and annual leave requests online. Management can track rostering needs, and quickly identify staff available to fill sick and annual leave. The electronic system sends email alerts to relevant staff if a shift has not been filled. Management said these changes have reduced the need for agency staff and provides improved continuity of care.
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 identifies all relevant legislation, regulatory requirements, professional standards and guidelines through information received from government departments, peak industry bodies and other aged care and health industry organisations. All legislative updates are circulated to the management team and information is disseminated to staff at meetings and education sessions, via the intranet and memoranda. Updated policies, procedures and handbooks are readily available to staff. Care recipients and representatives receive relevant information through care recipients’ meetings, notices on display, and personal correspondence. The home’s system for monitoring compliance with obligations under The Aged Care Act 1997 and other relevant legislation includes audits, observation of staff practices, and feedback.

Examples of regulatory compliance with Accreditation Standard One include:

  • Criminal history record checks are carried out for all staff
  • Contracts with external service providers confirm their responsibilities under relevant legislation, regulatory requirements and professional standards and include criminal history record checks for contractors visiting the home.
  • 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.
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 a system to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. There is a comprehensive orientation program and an allocated buddy system to support new staff. The education program includes mandatory education and in-service training relevant to care recipients’ care needs and in response to audit results and analysis of clinical indicator data. Staff have access to in-service education by visiting trainers, one-to-one training and attendance at external education sessions. Records of attendance at training are maintained. The effectiveness of the training is monitored through questionnaires, competency assessments and observation of staff practices.

Examples of education and training attended by management and staff in relation to Accreditation Standard One include:

  • Accreditation standards
  • Monitoring and use of human resource electronic rostering program
  • The Deputy director of nursing attended a three day Understanding Accreditation course
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 a locked suggestion box for confidential feedback are readily accessible. Concerns reviewed have been addressed and evaluated. Care recipients and representatives expressed satisfaction with complaints management and are able to raise concerns and identify opportunities for improvement through care recipient meetings, satisfaction surveys and informally. Care recipients/representatives say they are aware of how to make comments or complaints, and feel confident concerns are addressed appropriately.

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 has documented their philosophy, vision, mission and commitment to quality. These 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 organisation’s philosophy, vision, mission and commitment to quality form part of 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 results of observations, documentation review and interviews demonstrate the home has appropriately skilled and qualified staff sufficient 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, and policies and procedures provide staff guidelines. Personnel files are maintained and stored securely. A casual pool and electronic availability list provides replacement staff for annual or unscheduled leave.