HammondCare - Leighton Lodge

RACS ID0498
10 Murrua Road
NORTH TURRAMURRA NSW 2074

Approved provider:HammondCare

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for 3 years until 03 March 2020.

We made our decision on 03 January 2017.

The audit was conducted on 06 December 2016 to 09 December 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: HammondCare - Leighton Lodge
RACS ID: 04981Dates of audit: 06 December 2016 to 09 December 2016

Audit Report

HammondCare - Leighton Lodge 0498

Approved provider: HammondCare

Introduction

This is the report of a Re-accreditation Audit from 06 December 2016 to 09 December 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.

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 06 December 2016 to 09 December 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.

Details of home

Total number of allocated places: 60

Number of care recipients during audit: 57

Number of care recipients receiving high care during audit: 57

Special needs catered for: Dementia

Audit trail

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

Interviews

Category / Number
Facility manager / 1
Assistant manager / 1
Quality safety and risk manager/officer / 2
Residential care services manager / 1
Registered nurses / 2
Care staff / 5
Physiotherapist / 1
Dietician / 1
Client liaison manager / 1
Administration assistant / 1
Taking care is our business (TCB) coordinator and committee chair / 2
Workplace trainer / 1
Care recipients / 3
Representatives / 8
Consultant pharmacist / 1
Pastoral care coordinator / 1
Volunteer coordinator / 1
Life engagement staff / 1
Catering staff / 3
Laundry staff / 3
Contract cleaning managers / 2
Cleaning staff / 1
Property and maintenance managers – organisational level / 2
Maintenance staff / 1

Sampled documents

Category / Number
Care recipients’ files / 6
Wound charts with photographs / 8
Pain assessment and monitoring logs / 5
Medication charts (including signing sheets and nurse initiated medication / 11
Behaviour frequency charts / 6
Personnel files / 2

Other documents reviewed

The team also reviewed:

  • Audit schedule, audits, surveys
  • Care recipients’ consents
  • Care recipients’ welcome pack, handbook and agreements
  • Cleaning and maintenance schedules
  • Clinical care documentation including assessments, care plans, nursing, medical officers and allied health progress notes, pathology reports, advance care directives, behaviour, wound and pain management; nutrition and hydration preferences and plans, supplement charts and weight monitoring; referrals to health specialists, diabetic management including blood glucose level parameters; clinical observation charts and family conference records
  • Clinical indicators
  • Communication systems: - including communication books, diaries, handover sheets, meeting minutes, memoranda’, newsletters and other publications
  • Computer based information systems
  • Education calendar, training records, attendance records, competency assessments, staff qualifications
  • Equipment registers and lists
  • External service providers contracts and service agreements, certificates of currency (insurances), contract list and service records
  • Feedback management system including comments, complaints and compliments
  • Fire and emergency documentation including annual fire safety statement, evacuation plans, fire equipment audits and testing records
  • Infection control documentation including training records, vaccinations records and consent forms, pest management service records
  • Medication management documentation including; controlled drug (Schedule 8) registers; pharmaceutical review’s, anti-coagulant medication monitoring, Schedule 8 patch monitoring and medication records, medication refrigerator temperature records and medication advisory committee meeting minutes
  • Menu, food preference lists, NSW Food Authority licence and annual audit report
  • Notices advising care recipients, representatives and visitors of the re-accreditation audit
  • Organisational chart
  • Physiotherapy assessments and care plans and falls monitoring and analysis records
  • Police check register, nurse registrations, statutory declarations
  • Policies and procedures
  • Quality improvement project details (continuous improvement plan)
  • Recruitment policies and procedures, staff orientation program, manager checklist – new starter paperwork, job descriptions, duty statements, staff rosters and shift replacement form, performance management documentation, privacy and confidentiality statements
  • Reportable incidents register
  • Self-assessment report for re-accreditation and associated documentation
  • Volunteer information
  • Weekly activity calendars, lifestyle and social history and spiritual assessments

Observations

The team observed the following:

  • Activities and exercise class in progress
  • Care recipients’ and staff notice boards
  • Cleaning in progress
  • Complaints documentation, advocacy service brochures, information pamphlets on display
  • Dining environment during midday meal service including staff supervision and assistance
  • Electronic and hardcopy record keeping systems – clinical and administration
  • Equipment and supply storage areas
  • Fire safety systems and equipment, disaster management and evacuation kit, security systems, in/out signing sheets
  • Infection control resources including spill kits, outbreak resources, hand sanitisers, hand wash basins, personal protective equipment, and general and contaminated waste disposal
  • Information on noticeboards – staff, care recipients, visitors
  • Interactions between staff and care recipients, and other health and related services personnel
  • Living environment – internal and external
  • Medications: - including storage, controlled drug cupboards, medication trolley’s, medication blister packs, medication refrigerators and medication rounds
  • Mission, motivation and mission in action statements on display
  • Mobility aids and care recipients being assisted with mobility
  • Notices advising stakeholders of the dates for the re-accreditation audit on display
  • Nurses stations and work areas
  • Safety data sheets
  • Secure storage of care recipient information
  • Short observation session in the lounge room
  • Staff access to information systems including computers
  • Staff work practices and work areas including care services, catering, cleaning, laundry and maintenance
  • 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

HammondCare - Leighton Lodge actively pursues continuous improvement through the implementation of an integrated quality system which assesses, monitors and evaluates all areas of service provision and care recipient satisfaction. Various meetings provide a mechanism for input and feedback by the range of stakeholders. Examples of other quality activities include the comments, complaints and suggestions system, routine audits, surveys, external reviews, hazard and risk reporting, accident and incident reporting, data collection and other monitoring systems.

Examples of specific improvements relating to Standard 1 Management systems, staffing and organisational development include the following:

  • The home has participated in a new graduate program offering traineeships in aged care for registered nurses. This program has benefited the home by ensuring that there is a ready availability of registered nurses and thereby also assisting the home to avoid using agency staff to fill gaps in the roster.
  • The home has developed a clinical management plan which outlines the roles and responsibilities of all staff, including escalation protocols, in clinical care. The home’s management advises that, as a result, care plans and other documentation are now up to date.
  • The HammondCare organisation has developed a new procurement system, referred to as ‘P2P’. This system centralises a number of procurement processes, giving better visibility to stock ordering. This system is continuing to be reviewed, improved and streamlined.
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

As part of the HammondCare organisation, the home’s management has systems in operation to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. The home monitors the regulatory environment through updates from government and industry bodies, industry conferences, internet access and various other mechanisms. Staff are advised of regulatory requirements and any relevant changes to them through various means including memos, updates to policies, meetings and education. Compliance with regulatory requirements and other standards is monitored through a comprehensive audit program as well as day-to-day supervisory arrangements.

Examples of regulatory compliance related to Standard 1 Management systems, staffing and organisational development include:

  • care recipients and representatives were informed of the re-accreditation audit in keeping with legislative requirements;
  • ensuring care recipients and other stakeholders have access to complaints mechanisms;
  • ensuring police certificate checks are undertaken for staff, volunteers and relevant contractors;
  • ensuring relevant staff meet statutory declaration requirements;
  • monitoring external service providers for applicable registrations, licences, insurances and other necessary regulatory requirements.
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

It was evident from our observations, document review and interviews that management and staff have appropriate knowledge and skills to perform their roles effectively. The home has an education program which is based on educational needs identified through a wide range of mechanisms. These include feedback from various meetings, the staff appraisal process, and the quality improvement system. The education program is comprehensive and covers a range of functional areas encompassing all four Accreditation Standards, including Accreditation Standard 1 Management systems, staffing and organisational development. The program is reinforced by competency assessments in relevant areas. Staff also have access to relevant external educational opportunities and where appropriate are supported to obtain formal qualifications.

Recent education sessions related to Standard 1 include:

  • HammondCare mission, motivation and mission in action;
  • computer software program (various);
  • online electronic information systems (various aspects);
  • how to raise a complaint;
  • elder abuse and mandatory reporting processes;
  • team work and communication.

In addition, the home’s orientation program incorporates a range of topics relating to management systems, staffing and organisational development.

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 policies, procedures and processes to ensure each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms. Care recipients/representatives and staff are made aware of internal and external complaints mechanisms through the care recipients’ agreement, newsletters, complaints forms and care recipients/relatives’ meetings. There is a procedure to ensure any complaints raised are recorded for review; action, follow up and feedback as appropriate. Care recipients/representatives advised they feel comfortable approaching management about any concerns or suggestions they may have.

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

As part of the HammondCare organisation, Leighton Lodge has documented its vision, values, philosophy, objectives and commitment to quality. These elements are encapsulated in its mission, motivation and mission in action statements. These statements are communicated to all stakeholders in the home. They are published in key documentation. It is also on display in various locations in the home. In addition, staff are made aware of the home’s vision, mission, values and commitment to quality through its staff recruitment, orientation and education processes, staff meetings and other communication.

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 in operation a range of human resource policies and procedures. These ensure that there are appropriately skilled and qualified staff sufficient to ensure services are delivered in accordance with the Accreditation Standards and the home’s philosophy and objectives. This system consists of position descriptions, duty statements, recruitment and selection processes, staff rosters, induction and orientation, training and staff development, competency assessments, and performance management. We noted that care and other staff have obtained qualifications and/or attended specific education relevant to their job roles. There are systems and processes to monitor and ensure that staffing levels operate according to the care recipient mix and care recipients’ changing needs. Our observations, document review and interviews indicate the staffing roster is sufficient to ensure the desired quality of care in line with the demands and workflows of the daily routine of the home.

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