Sir William Hudson Memorial Centre

Sir William Hudson Memorial Centre

RACS ID 2691
8 Fachin Avenue
COOMA NSW 2630

Approved provider: Sir William Hudson Memorial Centre 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 06 May 2020.

We made our decision on 20 March 2017.

The audit was conducted on 07 February 2017 to 08 February 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 /
1.1 Continuous improvement / Met
1.2 Regulatory compliance / Met
1.3 Education and staff development / Met
1.4 Comments and complaints / Met
1.5 Planning and leadership / Met
1.6 Human resource management / Met
1.7 Inventory and equipment / Met
1.8 Information systems / Met
1.9 External services / 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 /
2.1 Continuous improvement / Met
2.2 Regulatory compliance / Met
2.3 Education and staff development / Met
2.4 Clinical care / Met
2.5 Specialised nursing care needs / Met
2.6 Other health and related services / Met
2.7 Medication management / Met
2.8 Pain management / Met
2.9 Palliative care / Met
2.10 Nutrition and hydration / Met
2.11 Skin care / Met
2.12 Continence management / Met
2.13 Behavioural management / Met
2.14 Mobility, dexterity and rehabilitation / Met
2.15 Oral and dental care / Met
2.16 Sensory loss / Met
2.17 Sleep / 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 /
3.1 Continuous improvement / Met
3.2 Regulatory compliance / Met
3.3 Education and staff development / Met
3.4 Emotional support / Met
3.5 Independence / Met
3.6 Privacy and dignity / Met
3.7 Leisure interests and activities / Met
3.8 Cultural and spiritual life / Met
3.9 Choice and decision-making / Met
3.10 Care 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 /
4.1 Continuous improvement / Met
4.2 Regulatory compliance / Met
4.3 Education and staff development / Met
4.4 Living environment / Met
4.5 Occupational health and safety / Met
4.6 Fire, security and other emergencies / Met
4.7 Infection control / Met
4.8 Catering, cleaning and laundry services / Met

Home name: Sir William Hudson Memorial Centre
RACS ID: 2691 4 Dates of audit: 07 February 2017 to 08 February 2017

Audit Report

Sir William Hudson Memorial Centre 2691

Approved provider: Sir William Hudson Memorial Centre Ltd

Introduction

This is the report of a Re-accreditation Audit from 07 February 2017 to 08 February 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 07 February 2017 to 08 February 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: 72

Number of care recipients during audit: 67

Number of care recipients receiving high care during audit: 62

Special needs catered for: Nil

Audit trail

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

Interviews

Position title / Number /
Director of nursing / 1
Assistant manager / 1
Registered nurse / 3
Enrolled nurse / 2
Team leader / 1
Care staff / 7
Office administrator / 1
Administration intake officer / 1
Catering staff / 2
Care recipients/representatives / 13
Volunteer / 1
Laundry staff / 1
Cleaning staff / 1
Maintenance staff / 1
Gardening staff / 1
Infection control officer / 1
Physiotherapist / 1
Recreational officer / 1

Sampled documents

Document type / Number /
Care recipients’ files / 10
Wound charts / 7
Medication charts / 16
Personnel files / 5

Other documents reviewed

The team also reviewed:

·  Catering, cleaning and laundry: NSW Food Authority audit, menus, dietary information and lists, weekly cleaning schedule, laundry procedures and duty list

·  Clinical care: bowel charts, blood glucose level monitoring, continence management, meals and drinks, weight monitoring, skin charts, wound management/dressings, mobility and pain charts, medical officers directives of care, food supplement and special diet list and case conferences, electronic care documentation, physiotherapist documentation including assessments, care plans, guides, treatment sheets, registered nurse check list

·  Comments and complaints: compliments, suggestion and complaints forms

·  Continuous improvement: continuous improvement plan, audits, surveys, improvement log register, summary of improvements and achievements

·  Education and staff development: education calendar, attendance records, competencies, orientation checklist

·  Fire, security and other emergencies: care recipient evacuation lists and lanyard cards, fire equipment service records, disaster plan

·  Human resource management: position descriptions, duties lists, professional registration records, staffing rosters, staff statutory declarations, police check documentation, staff orientation pack

·  Infection control documentation including: care recipient vaccination records, care recipient consent for vaccination, infection data collection sheet and summary report and statistics, infection prevention and control chart, outbreak procedure and post outbreak evaluation

·  Information systems: meeting minutes and meeting schedules, memoranda, communication books, policies and procedures, notices, residents, relatives and friends handbook, staff handbook, draft policies and procedures, phone lists, communication diaries, shift handover report forms

·  Inventory and equipment and external services: service agreements with licences, police checks and insurances, contractor orientation handbook, minimum stock lists

·  Living environment: preventative maintenance schedule, thermostatic mixing valve reports and temperature monitoring records, maintenance logs, microbiological water test records, audits

·  Medication management: drugs of addiction register, medication care plans, medication incidents, medication refrigerator temperature records and incident reports

·  Occupational health and safety: safety data sheets, hazard flowchart, register and forms, environmental audits, manual handling competency records, chemical register

·  Planning and leadership: organisational chart, vision, mission, philosophy and quality statement and objectives

·  Regulatory compliance: reaccreditation self-assessment report and associated documentation in each Accreditation Standard, NSW Food Authority licence, compulsory reporting register, staff, contractor, board and volunteer police check records, clinical and allied health staff professional registrations, annual fire safety statement

·  Security of tenure: resident information pack, resident and accommodation agreement, respite agreement, resident interview checklist

Observations

The team observed the following:

·  Archive storage and shredder

·  Australian Aged Care Quality Agency re-accreditation audit notices displayed

·  Care recipients participating in activities, entertainment, activity program on display

·  Care recipients using mobility aids

·  Charter of Care Recipients' Rights and Responsibilities displayed

·  Dining environments during midday meal service, morning and afternoon tea, including care recipient seating, staff serving/supervising, use of assistive devices for meals and care recipients being assisted with meals, daily menu displayed

·  Equipment and supply storage rooms including clinical, medication and linen stock in sufficient quantities and equipment available

·  Fire monitoring and firefighting equipment and signage, evacuation information, sprinkler system, emergency evacuation bags

·  Infection control items including: spills kits, personal protective equipment, hand washing facilities, sanitising gel, colour coded equipment; sharps' containers, personal protective equipment, hand washing sinks, hand hygiene dispensers around the home

·  Information brochures on display for care recipients, visitors and staff

·  Information on noticeboards for care recipients, staff and visitors

·  Interactions between staff and care recipients/relatives/visitors during: meal service, lifestyle activities and staff answering call bells in a timely manner

·  Internal and external complaints and advocacy information available, secure suggestion box accessible to care recipients/stakeholders for secure lodgement

·  Living environment - internal and external

·  Medication administration and storage

·  Medication and clinical stock in sufficient quantities and equipment available and in use for manual handling such as hand rails, ramps, walk belts, mobile walkers and walking sticks, pressure relieving mattresses, bed rail protectors, crash mats

·  Mission, values and philosophy displayed

·  Nurse call system and response by staff

·  Secure storage of care recipient care files, staff information and other documents

·  Small group observation in dining room

·  Staff handover

·  Staff practices and interactions with care recipients, visitors and other staff, including knocking on doors, drawing curtains and addressing residents using their preferred name

·  Staff work areas (including clinic/treatment/staff room, reception and offices)

·  Visitors registers, sign in/out books and security measures

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.

1.1 Continuous improvement

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

Team’s findings

The home meets this expected outcome

Sir William Hudson Memorial Centre has a quality system, which assists in the active pursuit of continuous improvement across all four Accreditation Standards. The quality system supports the identification, implementation and evaluation of improvement opportunities and activities. The identification of areas for improvement occurs through scheduled audits, analysis of incidents and clinical indicators and regular meetings for care recipients, their representatives, management and staff. The comments and complaints system, surveys and direct feedback from care recipients, their representatives and staff also contribute to the home’s quality system. Strategies are developed, documented, monitored and evaluated to ensure satisfactory outcomes are achieved. Information about improvements is communicated through meetings and associated minutes and notices. Staff are aware of the systems for continuous improvement and confirm they are involved in continuous improvement activities. Interviews with care recipients /representatives and staff confirm feedback has resulted in improvements for care recipients. Recent improvements relating to Accreditation Standard One include:

·  The need for a contemporary computerised documentation system was identified to improve the assessment of care recipients and the recording and monitoring of their care. A suitable program was identified, computer hardware and software installed and staff training provided. Staff are comfortable with using the system and care recipient care is clearly documented and monitored.

·  It was identified that staff files were unorganised making it difficult to find information and as a result not all staff files were complete. A new filing system has been introduced and the files have been sorted and audited to ensure the necessary paper work is complete for all staff.

1.2 Regulatory 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 all relevant legislation, regulatory requirements, professional standards and guidelines. The director of nursing monitor’s legislation, regulations and guidelines and updates policies and procedures in response to changes. The home has access to information directly from an industry peak body, the Department of Health and through a subscription to an information service. The home's management team monitors the implementation of regulatory changes and adherence to regulatory requirements through audit processes, staff competency assessments and observation of staff practice. Communication to staff about changes in policy and procedure occurs through meetings, memoranda and staff education programs. Examples of compliance with regulatory requirements specific to Accreditation Standard One - Management systems, staffing and organisational development include: