Bupa Clemton Park

RACS ID1024
1 Tedbury Street
CLEMTON PARK NSW 2206

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 18 February 2020.

We made our decision on 23 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
1.1Continuousimprovement / 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 Clemton Park
RACS ID: 10241Dates of audit: 22 November 2016 to 24 November 2016

Audit Report

Bupa Clemton Park 1024

Approved provider: Bupa Aged Care Australia Pty Ltd

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: / Joan Rafferty
Team member/s: / Jane Satterford

Approved provider details

Approved provider: / Bupa Aged Care Australia Pty Ltd

Details of home

Name of home: / Bupa Clemton Park
RACS ID: / 1024
Total number of allocated places: / 144
Number of care recipients during audit: / 141
Number of care recipients receiving high care during audit: / 141
Special needs catered for: / Dementia
Street/PO Box: / 1 Tedbury Street
City/Town: / CLEMTON PARK
State: / NSW
Postcode: / 2206
Phone number: / 02 9789 8400
Facsimile: / 02 9789 8433
E-mail address: / Nil

Audit trail

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

Interviews

Category / Number
General manager / 1
Regional support manager / 1
Regional property manager / 1
Business administration manager / 1
Business administrator / 1
Customer relations clerk / 1
Care managers / 4
Clinical manager / 1
Registered nurses / 4
Care staff / 11
Care recipients/representatives / 24
Chaplain / 1
Recreational activity staff / 3
Physiotherapy assistant / 1
Maintenance officer / 1
Chef/catering assistants / 3
General service officers / 2
Laundry staff / 3
Cleaning staff / 4

Sampled documents

Category / Number
Care recipients’ files / 16
Wound management files / 8
Medication charts / 11
Personnel files / 14

Other documents reviewed

The team also reviewed:

  • Allied health: physiotherapy pain management treatment and exercise, podiatry treatments, dietitian reviews, audiology and dental reviews and treatments
  • Care recipient information pack, handbook, resident and accommodation agreement
  • Care recipient room listing
  • Cleaning schedules, duties list
  • Clinical care: assessments and care plans, medical consults, care recipients advanced care directives and palliative care team reviews, case conference records, clinical monitoring charts including blood pressure, blood glucose levels, fluid intake, pain, weight, specialist consultations reviews, pathology
  • Continuous improvement documentation: improvement log status reports, continuous improvement plan, compliments folder, staff and care recipient surveys, internal audits schedule and results, incident and clinical indicator trends analysis and benchmarking reports
  • External contractors: contractor sign-in folder, contractor/supplier service agreements/contracts, preferred contractor/service supplier list, equipment service reports
  • Fire security and other emergencies: fire safety equipment and sprinkler system service records, fire safety audits, emergency evacuation and business continuity plan, care recipient fire evacuation list, annual fire safety statement
  • Food safety program: kitchen cleaning schedule, sanitising records, food and equipment temperatures, NSW food authority audit results
  • Human resource management: employee handbook, staff induction checklist, statutory declarations, visa status, privacy statement, position descriptions, duties statements, rosters, staff allocations, probationary performance appraisal records, ‘Bupa best’ peer nomination program
  • Infection control information: care recipient/staff vaccination program, audits, infection control clinical indicator reports, pest control service reports, refrigeration temperature monitoring
  • Information systems: electronic business management and information systems, policies and procedures, newsletters, memoranda, handover sheets, committee meeting minutes - care recipients/representatives, leadership, workplace health and safety, registered nurses, staff, leisure and lifestyle
  • Inventory and equipment: maintenance logs, preventative and reactive maintenance schedule, equipment service records; warm water testing reports, electrical test tagging records, Legionella testing reports
  • Laundry manual
  • Lifestyle: assessments, care plans, attendance records, activities calendar, residents’ meeting minutes, newsletters
  • Medication management: medication charts, schedule eight medication records, medication reviews, medication audits and incident reporting
  • Nutrition and hydration: diet analysis forms, diet allergy list, dietary needs matrix, menu, dietician review, drinks lists, thickened fluid requirements, Bupa dining experience standards
  • Pastoral care: assessments, care plans, activities records, spiritual/religious contacts
  • Regulatory compliance: confidential improvement log folder, consolidated incident reporting register, unexplained care recipient absences, staff criminal history checks, professional registrations - registered nurses and allied health
  • Self-assessment report for re-accreditation and associated documentation
  • Staff education: orientation/induction program and checklist, training needs analysis, monthly calendars, e-learning records, mandatory and non-mandatory education attendance records, evaluations, competencies - medication, hand washing, manual handling
  • Workplace health and safety (WH&S) information: hazard logs and risk assessments audits and workplace inspections, chemical register

Observations

The team observed the following:

  • Aged Care Complaints Commissioner and advocacy information on display
  • Archive room
  • Cleaning in progress, trolleys and supplies, wet floor signage in use
  • Coffee shop
  • Dining environment during midday meal services, morning and afternoon tea, staff serving/supervising
  • Displayed notices: Quality Agency re-accreditation audit notices, Charter of care recipients’ rights and responsibilities, vision and values statement
  • Equipment and supply storage areas including linen, continence and medical supplies
  • Firefighting equipment checked and tagged, fire indicator panel, sprinkler system, evacuation diagrams, evacuation pack, care recipient identification lanyards
  • Hairdresser in attendance
  • Infection control resources: hand washing facilities, hand sanitising gel, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies, locked clinical and cytotoxic medication bins, waste management
  • Information noticeboards
  • Interactions between staff and care recipients/visitors
  • Kitchen and serveries, information whiteboards, NSW food authority licence on display
  • Laundry, heat seal labelling machine
  • Living environment internal and external
  • Medication administration and storage
  • Medical officer consulting room, physiotherapy room
  • Menu on display
  • Nurse call bell system
  • Safe chemical and oxygen storage, safety data sheets (SDS) at point of use
  • Secure storage of care recipients’ clinical files and staff information
  • Sign in/out registers, keypad access, security cameras
  • Staff work practices and work areas
  • ‘We welcome your feedback’ forms on display, locked suggestion box

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.

1.1Continuous improvement

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

Team’s findings

The home meets this expected outcome

Management at Bupa Clemton Park actively pursues continuous improvement across the four Accreditation Standards. The home’s quality system identifies improvement opportunities from a range of sources that include audit results; surveys; incident and clinical indicator benchmarking reports; meetings and feedback mechanisms. The general manager develops an electronic continuous improvement plan to prioritise, action and evaluate identified opportunities for improvement. Care recipients/representatives and staff are encouraged to make improvement suggestions and stated they are informed regarding improvements undertaken in the home.

Examples of recent improvements implemented in relation to Accreditation Standard One include:

  • Bupa Clemton Park is a recently commencing home that opened on 7 March 2016. In addition to new care recipients entering the home, 88 care recipients and a number of staff transferred from a Bupa home in a nearby suburb that was closing. The home has been at full capacity since the end of April 2016. Through ongoing recruitment and induction of new staff and a proactive education program, a stable united work force has been established. Staff stated they enjoy working at the home and this is reflected in a staff satisfaction survey held in October 2016.
  • Management identified that personnel files of transferring staff were not well ordered. A one hundred per cent audit of personnel files was undertaken and an electronic staff file checklist developed. As a result new and existing staff personnel files are consistent and contain all relevant information.
  • The general manager, clinical manager and the four care managers were asked to select a Bupa value that they aligned with and to develop an education session to deliver to all staff. External presenters could also be invited to attend. For example: July 2016 pressure area care aligning with the Bupa value of caring; August 2016 oral and dental care aligning with the Bupa value of being open. The sessions have been successful and assist staff to appreciate how they can align the organisational values to their work in caring for care recipients.
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

Bupa Care Services has a legislative review committee to identify and ensure the home’s compliance with relevant legislation, regulatory requirements, professional standards and guidelines applicable to aged care. The general manager is informed by head office of updates to policies and procedures developed with reference to industry guidelines and legislation. Management notifies staff at the home of changes to policies, procedures and regulations through meetings; memoranda; at handover and by providing education. Updated policies, procedures and information manuals are readily available for staff electronically and in hard copy. The system for monitoring compliance with obligations under the Aged Care Act 1997 and other relevant legislation includes audits; incident and clinical indicator reporting; observation of staff practices and feedback.

Examples of regulatory compliance with Accreditation Standard One include:

  • Care recipients/representatives and staff were informed of the upcoming Quality Agency re-accreditation audit by notices, mail out and at meetings.
  • There is a system to monitor currency of staff and contractor criminal history check certificates.
  • There is a system to monitor professional registrations and authorities to practice for clinical and allied health staff.
  • Management ensures care recipients, staff and visitors to the home have access to internal and external comments and complaints mechanisms.
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 staff education and training program incorporates a range of topics across the four Accreditation Standards from both internal and external sources. The education calendar is developed by the general manager with reference to a staff training needs analysis; performance reviews; review of clinical indicators; feedback mechanisms; legislative requirements; survey and audit results. Staff are required to complete a suite of on-line education programs and role specific competency assessments annually. The training requirements and skills of staff are evaluated on an ongoing basis through observation; the changing needs of care recipients; and through feedback. Records are maintained to monitor staff attendance at mandatory and non-mandatory education. Staff stated the education program offered is varied and relevant to their role in the home.

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

  • Management forums; staff orientation/induction; electronic information systems; training with new equipment; aged care funding instrument (ACFI) documentation; bullying and discrimination; continuous improvement; complaints handling; customer service.
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

The home has a policy and procedures for feedback management. All stakeholders are encouraged to provide feedback on the services provided through meetings; newsletters; brochures and notices. Care recipients/representatives are informed of the internal and external complaints mechanisms on entry to the home. This is documented in the information pack provided and residential agreement. Management has an ‘open door’ policy for feedback from all stakeholders. ‘We welcome your feedback’ forms and a locked suggestion box are readily accessible for confidential issues. Information on the external Aged Care Complaints Commissioner and advocacy services is on display. Feedback received including concerns, suggestions and compliments are logged by management. Any complaints received are responded to and actioned in a timely manner. There is an escalation process to corporate management if required. Feedback is discussed at the home’s meetings on indication. Care recipients/representatives and staff stated management is readily available to discuss any concerns with them.

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