Opal Denhams Beach

RACS ID2801
269 Beach Road
DENHAMS BEACH NSW 2536

Approved provider:DPG Services 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 25 January 2020.

We made our decision on 13 December 2016.

The audit was conducted on 08 November 2016 to 10 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: Opal Denhams Beach
RACS ID: 28011Dates of audit: 08 November 2016 to 10 November 2016

Audit Report

Opal Denhams Beach 2801

Approved provider: DPG Services Pty Ltd

Introduction

This is the report of a re-accreditation audit from 08 November 2016 to 10 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 08 November 2016 to 10 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: / Barbara Knight
Team member: / Margaret Dawson

Approved provider details

Approved provider: / DPG Services Pty Ltd

Details of home

Name of home: / Opal Denhams Beach
RACS ID: / 2801
Total number of allocated places: / 130
Number of care recipients during audit: / 110
Number of care recipients receiving high care during audit: / 102
Special needs catered for: / Those living with dementia
Street/PO Box: / 269 Beach Road
City/Town: / DENHAMS BEACH
State: / NSW
Postcode: / 2536
Phone number: / 02 4472 8155
Facsimile: / 02 4472 8031
E-mail address: /

Audit trail

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

Interviews

Category / Number
Regional manager / 1
Relief facility manager / 1
Facility manager / 1
Care manager / 1
Quality advisor / 1
Registered nurses / 5
Care staff / 13
Workplace Health and safety manager / 1
Administration officer / 1
Recreational activities officers / 3
Care recipients/representatives / 18
Hospitality manager / 1
Chef / 2
Catering staff / 5
Laundry staff / 1
Cleaning staff / 2
Maintenance staff / 1
Fire officer/gardener / 1

Sampled documents

Category / Number
Care recipients’ files / 11
Summary/quick reference care plans / 11
Care recipient agreements / 5
Medication charts / 10
Personnel files / 6

Other documents reviewed

The team also reviewed:

  • Approved contractor register, external contracts and service agreements, contractor handbook, contractor insurance and police check records
  • Care recipient enquiry pack, welcome packs and admission pack including care recipient consent for photographs, videos and entry by staff to an unoccupied room, privacy amendment, care recipients’ handbook
  • Clinical assessment and observation tools: physiotherapy, speech pathology, behaviour, continence, skin, wound, mobility, pain verbal and non-verbal, sensory loss, nutrition and hydration, oral care, falls risk, specialised nursing care, bowel charts, weight charts, personal care charts, and others
  • Clinical care tools: specialist and allied health referral and review documents, accidents and incidents, assessment guidelines, various meeting agendas and minutes 2016, comprehensive medical assessments and evaluations clinical care system
  • Communication records between staff and care recipients doctors, appointment sheets, newsletters, notices, memoranda, handover sheets
  • Continuous improvement documentation including feedback/suggestion forms, compliments/complaints registers, plan for continuous improvement, audit and benchmarking schedule and results
  • Education documentation including education planner with a specific monthly focus, training records and evaluations, competency assessments
  • Human resource management including recruitment information, statutory declarations, visa status, letter of appointment, code of conduct and confidentiality processes, employee engagement checklist,employee handbook, position descriptions and duty statements, performance appraisal records, master roster, daily allocation sheets, education and training records, competency assessments
  • Infection control information including manual, trend data, outbreak management program, care recipients/staff vaccination records, infection incidence and antibiotic utilisation chart
  • Leisure and lifestyle: individual activity assessments, care recipient feedback and satisfaction surveys, recreational activities documentation, monthly activities program, activities evaluation and attendance records, minutes of meetings and associated documentation
  • Mandatory reporting register and associated reference documentation
  • Medication management reviews, medication incidents, medication/pathology refrigerator temperature readings, schedule 8 medication secure storage and registers, medication management system
  • NSW Food authority audit report, food safety manual, cleaning, temperature and sanitising records consistent with hazard analysis critical control point (HACCP) requirements
  • Policies and procedures
  • Preventative maintenance schedule and reports including pest control, thermostatic mixing valves, legionella testing
  • Professional staff registration records
  • Registered nurses resource folder including standards for practice, code of ethics, code of professional conduct, care documentation procedures, care plan review flowchart, behaviour management documentation pathway, post fall guidelines
  • Workplace inspection and environmental audits, hazard logs and risk assessments, work health and safety meeting minutes

Observations

The team observed the following:

  • Activity program on display, activities in progress and activity resources
  • Annual fire safety statement displayed, fire panel, mimic panels in each wing, emergency flip charts, fire evacuation plans, fire equipment, emergency manuals, emergency evacuation kit, disaster management plans, sign in/out registers
  • Care recipients utilising pressure relieving mattresses, bed rail protectors, hip and limb protection equipment
  • Charter of Care Recipients’ Rights and Responsibilities on display
  • Cleaning in progress, equipment in use and safe staff practices
  • Coloured table rotation chart in Ocean View dining room
  • Dining environments during lunch and beverage services with staff assistance, morning and afternoon tea, including resident seating, staff serving/supervising, use of assistive devices for meals and care recipients being assisted with meals in their rooms
  • Equipment and supply storage rooms including clinical, medication, toiletry, chemical, paper goods, continence and linen stock in sufficient quantities
  • Hairdressing salon
  • Infection control resources including infection control flip charts, hand washing facilities and hand sanitisers, personal protective and colour coded equipment, spills kits, sharps containers, contaminated waste disposal, outbreak management kits
  • Living environment internal and external, resident library/sitting room
  • Medical and allied health professionals in attendance
  • Medication round
  • Mobility equipment including walk belts, wheeled walkers, shower chairs, toilet seats, mechanical lifters, low beds, handrails and internal lift access between floors
  • Notice boards containing resident activity programs and notices, menus, memos, staff and resident information, comments and complaints information, advocacy brochures, notices informing care recipients/representatives of the re-accreditation site audit
  • Nurse call system and response by staff
  • Secure storage of medications, pathology storage fridge
  • Short group observation Waratah dining room.
  • Sign in books for visitors and tradesman/contractors
  • Staff work practices and work areas, including clinical, lifestyle, administration, catering, cleaning, laundry and maintenance, handover between staff at the change of shift.

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

Opal Denhams Beach has systems and processes that support continuous quality improvement. A continuous improvement plan is developed including improvements identified at organisation and local level. Information is obtained through comments and complaints, results of audits and surveys, incident reports, meetings, observation and informal feedback from staff, care recipients and representatives. Feedback to key stakeholders including management, staff, care recipients and family members is through meeting minutes, memoranda, noticeboards and newsletters.

Continuous improvement activities undertaken in relation to Accreditation Standard One – Management Systems, Staffing and Organisational Development include:

  • In response to issues identified with the recruitment and allocation of staffthe following have been implemented:
  • A focus on recruitment and increasing the staff pool with thirty staff recruited since June 2016. A New Employee checklist has improved the speed of recruitment. An additional registered nurse has been recruited for the morning and afternoon shift bringing the total to four registered nurses at these times.
  • An additional care staff member has been recruited for the morning and afternoon shifts.
  • Staff are now allocated to each wing to improve the consistency of care and emotional support for care recipients. The registered nurses allocate staff based on experience, knowledge and the ability to work together.Management and staff report this is working well with a more streamlined and manageable program.
  • Implementation of a clinic nurse consultant role to provide clinical oversight and coordination of the education program.
  • Following introduction of an orientation and education program at organisational level, the home has developed site programs to suit local conditions. Staff are able to access and complete training on-line. Feedback from staff has been very positive as they are able to complete training at work or from home if they prefer.
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

There are systems to identify and ensure compliance with relevant legislation, regulatory requirements and professional standards and guidelines. Information is disseminated throughout the organisation regarding legislative changes and any impact they may have at alocal level.Information is obtained through peak industry bodies, circulars and bulletins from government and non-government departments and professional organisations. Regulatory issues and updates are communicated to staff through memoranda, meetings and educations sessions. Staff state they are made aware of regulatory issues and that they have access to information regarding legislative and regulatory requirements.

Examples of the monitoring and compliance with regulatory requirements relevant to Accreditation Standard One are:

  • A system to ensure criminal history checks for all staff remain current and the maintenance of a criminal history check register.
  • A system to ensure compliance with legislation regarding the compulsory reporting of assaults.
  • Notification to care recipients/representatives of the accreditation site audit and their right to speak with the assessment team.
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

Opal Denhams Beach demonstrates that systems and processes ensure both management and staff have appropriate knowledge and skills to perform their roles effectively. Education is provided on line to meet organisational requirements and at a local level to support identified individual needs. Staff have access to external training programs as required.A flexible education calendar is developed which includes needs identified through staff appraisals, complaints, mandatory requirements, in response to care recipient needs and staff requests. Additionally there are tool box talks and competency assessments. A comprehensive orientation program provides new staff with training to perform their roles. Discussions with staff demonstrate that they have access to education to enable them to perform their roles effectively.

Education relevant to Accreditation Standard One includes:

  • Preparation for Accreditation
  • Elder abuse and mandatory reporting requirements
  • Roles and responsibilities
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 are systems to ensure that care recipients, their representatives and other interested parties have access to internal and external complaints mechanisms. Internal mechanisms include meetings, suggestions/complaints forms, and discussions with management. Care recipients and family members are encouraged to address any concerns directly with the home’s management. Information on external complaints mechanisms is available and detailed in the care recipient handbook and agreement. Review of the complaints register demonstrates that complaints are documented, actioned and closed off within appropriate timeframes. Interviews with care recipients/representatives confirm they are aware of internal and external complaints mechanisms and that any concerns are promptly addressed at local level.

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

Opal Denhams Beach Mission and Values Statements are documented and displayed in the home. The home’s continuous improvement plan demonstrates its ongoing commitment to quality care and service.Management and staff are aware of and understand the philosophy of the organisation and their commitment can be observed in the practices and attitudes and interactions between management, staff and care recipients/ representatives.

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

Opal Denhams Beach has systems and processes to ensure there are sufficient staff with the appropriate knowledge and skills to provide care and services to the care recipients. There are recruitment and selection processes, an orientation program including buddy shifts, ongoing education and a performance management system. Position descriptions and duty statements guide staff in their duties. Staff interviewed advised they have the opportunity to provide feedback on staffing levels as care recipients’ care needs increase.Care recipients/ representatives interviewed are satisfied that there are appropriately skilled and qualified staff available to meet their needs.