Blue Care Emerald Avalon Aged Care Facility

RACS ID5986
126 Borilla Street
EMERALD QLD 4720

Approved provider:The Uniting Church in Australia Property Trust (Q.)

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 10 April 2020.

We made our decision on 20 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: Blue Care Emerald Avalon Aged Care Facility
RACS ID: 59861Dates of audit: 17 January 2017 to 19 January 2017

Audit Report

Blue Care Emerald Avalon Aged Care Facility 5986

Approved provider: The Uniting Church in Australia Property Trust (Q.)

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 2 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: 20

Number of care recipients during audit: 18

Number of care recipients receiving high care during audit: 15

Special needs catered for: Not applicable

Audit trail

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

Interviews

Position title / Number
Activity officer / 1
Administration assistant / 1
Care recipient/representative / 7
Care support worker / 3
Clinical manager / 1
Diversional therapist / 1
Facilities maintenance manager / 1
General manager / 1
Hospitality officer / 4
Hospitality outcomes officer (phone) / 1
Hospitality supervisor / 1
Human resource officer – cluster (phone) / 1
Integrated service manager / 1
Learning and development officer / 1
Maintenance officer / 1
Registered staff / 2
Support officer care / 1

Sampled documents

Document type / Number
Care recipients’ files / 5
Medication charts / 11

Observations

The team observed the following:

Accreditation information on display
Activities in progress
Administration and storage of medications
Advocacy and complaints agencies’ brochures on display
Chemical storage
Comments form lodgement box
Emergency exits, lighting and egress routes
Equipment, goods and supply storage areas
Falls prevention, mobility and dexterity aids in use
Fire panel
Fire/smoke detection and firefighting equipment and inspection tags
Interactions between care recipients, staff and visitors
Internal and external living and working environments
Maintenance workshop
Midday meal, setting, service and practices
Morning and afternoon tea service
Outbreak kits and equipment
Personal protective equipment in use
Safety signage
Sharp waste disposal containers
Short group observation
Sign in/out registers
Staff work practices
Values and philosophy statements on display
Waste disposal

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

Blue Care Emerald Avalon Aged Care Facility (the home) has a continuous improvement system that is comprised of processes for the identification of improvement opportunities and the implementation, monitoring and evaluation of improvement solutions. A system of forms, audits, staff and care recipient meetings, maintenance requests and complaints and compliments inform the improvement process. Communication of quality activities occurs through various means such as meetings and minutes of meetings, bulletins, newsletters and notice boards. Care recipients/representatives and staff are satisfied improvements continue to be implemented at the home and that their suggestions are considered.

An example of an improvement initiative related to Standard 1, Management systems, staffing and organisational development, implemented by the home:

In response to requests for more fresh food options to be added to the care recipients’ meal menus, the home introduced a monthly barbeque. They are held the first Friday of each month; are themed; there are live music performances; home care clients are invited; care recipients consulted in regard to provisions required, and the home provides salads accompanied by meat and vegetables that are cooked fresh on the barbeque. Care recipients reported satisfaction with this initiative, and due to its popularity, management stated they are to be scheduled fortnightly. The barbeque increases socialisation; improves care recipient satisfaction with the consultation process and access to cook-fresh meals.

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 home has an established system to identify and manage compliance with the range of legislation, professional standards and industry guidelines; has access to the organisation’s resources and government bodies and industry sources which provide regular updates of legislative and regulatory requirements. This system is monitored by head office and the home’s management and updates are discussed with key personnel, and actioned at management meetings. Changes are communicated to staff via policy and procedure reviews, education sessions (toolbox, orientation and compulsory annual training), posted on notice boards and electronic and paper-based memoranda. Changes are also communicated to care recipients and representatives where appropriate. Compliance with legislation is monitored through the audit process, performance appraisals and observation of staff work practices. There are systems to notify care recipients and their representatives of the re-accreditation audit; to present self-assessment information and to ensure all relevant personnel, volunteers and contractors have a current police certificate.

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 ensures management and staff have appropriate knowledge and skills to perform their roles through provision of ongoing education, training and other staff development processes. Staff education needs are identified through legislative requirements/changes, staff and care recipient feedback, care recipient needs, complaints and improvement mechanisms such as audits, incident investigation, performance appraisals and observation of staff practices. A range of training delivery modes is used to ensure all staff have access to a learning style suited to their needs. Staff are also encouraged to participate in external education opportunities to enhance their knowledge and skills. The organisation has programs to support staff to upgrade their qualifications or enter the nursing field. All staff complete orientation and annual compulsory training sessions; education/attendance records are maintained. Staff are satisfied with the support they receive to identify and develop their skills to enable them to perform their roles effectively. Care recipients/representatives are satisfied with the skills and knowledge of management and staff.

Examples of training and education topics relevant to Standard 1 include Understanding accreditation, Audits: making them work for you, Team work: managing conflict, Incident investigation and reporting, basic computer training, online care and clinical management system, values-based leadership, professional boundaries, grievance and complaints, and Frontline leadership development program.

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

Information regarding internal and external complaints processes is provided in the care recipient handbook, the care recipient agreements and on display in the home. Care recipients/representatives are invited to make verbal complaints one-on-one with management and/or staff, or through meetings. Forms can be completed and placed in a comments box in the home. There is the opportunity for complaints to be made in-confidence. Complaints are logged and actioned with outcomes monitored. Care recipients/representatives and staff are satisfied with the internal and external comments/complaints processes.

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 its values and philosophy and they are on display within the home. They are reflected in policies and procedures of human resource management, care and lifestyle support, and underpin information provided at interview, orientation, meetings and in care recipient and staff information books.

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 processes for ensuring there is appropriately skilled and qualified staff sufficient to ensure care and services are delivered in accordance with the Aged Care Act 1997, Accreditation Standards and the home’s values. The recruitment and selection of staff is undertaken based on the relevant skills, qualifications and experience held. Staff are orientated and provided with ongoing educational opportunities to support skill development. Internal processes ensure staff skills are monitored and evaluated through competency assessments, performance reviews and feedback mechanisms. A process is used to ensure the currency of police certificates and medical/nursing registrations. Rosters are adjusted to ensure a mix of staff skills and qualifications to provide relevant services and strategies implemented for the replacement of staff. The sufficiency of staff is monitored through feedback mechanisms, quality data analysis, observations and review of care recipient needs; action is taken as required. Care recipients/representatives are satisfied with staff skill levels and responsiveness of staff to care recipients’ needs.

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 identifies equipment needs through discussion with staff, quality improvement systems, and monitoring of maintenance. Staff receive training in the use of new equipment and, where appropriate, instructions are available to guide staff in equipment usage. There is a planned preventative maintenance program – the maintenance team and work health and safety team together with external contractors, manage the safe working order of equipment.Equipment and supplies are monitored through auditing programs, observations, staff feedback and maintenance requests. Supplies to support clinical care and hospitality and environmental services are maintained at the home. Stock is stored and rotated appropriately. Care recipients/representatives and staff are satisfied with the quality and sufficiency of supplies and equipment.

1.8Information systems

This expected outcome requires that "effective information management systems are in place".

Team’s findings

The home meets this expected outcome

The organisation and home have established processes to manage information. Information is disseminated to staff, care recipients/representatives, external service providers and other stakeholders through policies and procedures, electronic and written documentation and communication, and staff education and training. Information is also transmitted through noticeboards, meetings, staff handover processes, handbooks and correspondence. Staff have access to information relevant to their position and changes to care recipients’ needs are communicated to them in a timely manner. Electronic information is secured by passwords, with restricted access depending on the role in the organisation, and regularly backed up to prevent loss of information. There is a system to archive information appropriately. Care recipients/representatives are satisfied with internal communication processes and have access to information about care and service delivery.

Blue Care Emerald Avalon Aged Care Facility