Estia Health Werribee

RACS ID3644
8 Russell Street
WERRIBEE VIC 3030

Approved provider:Estia Investments 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 06 April 2020.

We made our decision on 07 February 2017.

The audit was conducted on 10 January 2017 to 11 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: Estia Health Werribee
RACS ID: 36441Dates of audit: 10 January 2017 to 11 January 2017

Audit Report

Estia Health Werribee 3644

Approved provider: Estia Investments Pty Ltd

Introduction

This is the report of a re-accreditation audit from 10 January 2017 to 11 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.

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 10 January 2017 to 11 January 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.

Assessment team

Team leader: / Doris Hamilton
Team member/s: / Ann De Pellegrin

Approved provider details

Approved provider: / Estia Investments Pty Ltd

Details of home

Name of home: / Estia Health Werribee
RACS ID: / 3644
Total number of allocated places: / 80
Number of care recipients during audit: / 64
Number of care recipients receiving high care during audit: / 64
Special needs catered for: / Care recipients living with dementia
Street/PO Box: / 8 Russell Street
City/Town: / WERRIBEE
State: / VIC
Postcode: / 3030
Phone number: / 03 9749 8000
Facsimile: / 03 9974 0279
E-mail address: /

Audit trail

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

Interviews

Category / Number
Executive director / 1
Visiting executive director / 1
Care director / 1
Care staff / 5
Administration assistants / 2
Registered/enrolled nurses / 4
Lifestyle staff / 2
Workplace health and safety officers / 2
Care recipients / 7
Representatives / 4
Laundry staff / 1
Cleaning staff / 2
Catering staff / 3
Property services consultant / 1
Maintenance staff / 1

Sampled documents

Category / Number
Care recipients’ files / 12
External services contracts / 5
Residential agreements / 6
Medication charts / 10
Personnel files / 5

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

The organisation actively pursues continuous improvement across the four Accreditation Standards. Care recipients, staff and stakeholder suggestions, comments and complaints, data analysis, incidents, management initiatives, quality activities and external reviews feed into the continuous improvement process. Management document all improvements on the continuous improvement plan which include the action taken, nominated staff involved, outcomes and feedback provided. Organisational and site management monitors and review the continuous improvement program regularly to ensure timely response and additional actions as required. Care recipients, staff and other stakeholders discuss continuous improvement at relevant meetings and management disseminate information through meetings, noticeboard displays, newsletters and through informal interaction. Care recipients, representatives and staff are satisfied the home actively pursues continuous improvement.

Recent improvements in relation to Standard 1 Management systems, staffing and organisational development include:

In response to staff feedback, management introduced an additional weekend shift 7:00am to 1:00pm in line with the same weekday shift for an enrolled nurse. This enables the weekend registered nurse in a supernumerary role to focus on clinical monitoring instead of administering medications. Management developed a task list which includes responding to queries and concerns and staff education. Management said they have received positive comments from care recipients, representatives and staff.
Following the review of education and staff completion of mandatory topics, corporate management sourced additional learning programs. An online education platform was introduced with electronic program ambassadors trained to assist fellow staff and additional electronic tablets provided. The program generates various reports for staff and management to access. Management said staff are now completing required and additional topics which are incorporated in staff practise.

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 organisation’s management has a system to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines in relation to the Accreditation Standards. The organisation receives updates and relevant information from government, industry, professional and peak-body associations. Relevant committee groups review changes, develop or modify policies and procedures and arrange education to ensure alignment with changes. Site management utilise orientation, information handbooks, education, meetings and other communication mechanisms to flag specific regulatory compliance changes or issues. Compliance with relevant legislation is monitored through the quality system and reporting processes. Staff said they receive information regarding regulatory compliance relevant to their roles and demonstrated knowledge of regulatory requirements.

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

The home has a plan for continuous improvement which identifies current improvements.
A system for ensuring the currency of police certificates and statutory declarations as appropriate for staff, volunteers and contractors.
A system to monitor the currency of professional registrations.
Stakeholders are provided with and have access to information regarding advocacy services and the internal and external complaint mechanisms.
Appropriate and secure information storage and destruction systems at the home.
Management notified care recipients and/or their representatives of the re-accreditation assessment within the required time frame.

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

Management and staff have appropriate knowledge and skills to perform their roles effectively. Management develop an annual education program combining sessions mandatory for all staff, competencies, staff feedback and training needs analysis. External providers, management and staff conduct responsive education for topics identified through feedback, audits, specific care recipient needs and preferences and incident reports. Staff have monthly education calendars and an electronic education program accessible from their homes or onsite. Staff said they are satisfied with education and the manner in which it is provided. Management evaluate the effectiveness of education. Care recipients and representatives expressed satisfaction with management and staff knowledge and skills.

Education provided to staff relating to Standard 1 Management systems, staffing and organisational development includes:

Accurate documentation
Continuous improvement
Electronic education 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

The organisation ensures care recipients and other interested parties have access to the internal and external complaints mechanisms. Management highlight this information in residential agreements, education, orientation, information handbooks and brochures, which are available in languages relevant to the cultural background of care recipients at the home. Feedback mechanisms include comment forms, stakeholder meetings, surveys, informal interaction and through management’s open door approach.Secure suggestion boxes are available for the lodgement of documented comments and to ensure anonymity if desired. Management and staff respond to comments and complaints at the time, document actions and/or response on feedback forms and the comments and complaints register which may link to other relevant documentation such a confidential file or the continuous improvement plan. Documentation shows timely response and outcomes. Corporate and site management generate reports to identify trends or service gaps.Staff are clear about their responsibilities when responding to complaints. Care recipients, representatives and staff are aware of the comment and complaints process and feel comfortable in raising concerns with staff or management directly.

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 home has documented the organisation’s purpose, ambition and family code throughout the service.

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 a system to ensure staff are appropriately skilled and sufficient in numbers to meet care recipients’ requirements. Organisational human resource management processes support management and staff. Formal recruitment, selection and induction processes are used and staff receive orientation. Position descriptions, handbooks, policies and procedures and other relevant resources support staff in their roles. Ongoing monitoring of staff practice occurs and includes monthly goals, observation, competency testing, audits and incident reports. Staff said they have sufficient time and skills to perform their roles. Care recipients and representatives spoke positively of staff at the home and expressed satisfaction with the care and services provided.

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 organisation has a system to ensure stocks of appropriate goods and equipment are available for quality service delivery. Designated staff at the home regularly monitor and order clinical and non-clinical supplies through preferred and approved suppliers. Staff rotate stock where required and goods are stored in clean, tidy and secure storage areas. There are processes for the purchase of new and replacement equipment that includes trial, risk assessment and staff training. The goods and equipment provided reflect the identified needs of care recipients. A preventative and corrective maintenance program ensures equipment is in good working order with regular and scheduled cleaning of equipment. Management monitors the stock of appropriate goods and equipment through quality activities and feedback mechanisms to ensure quality service delivery. Care recipients, representatives and staff are satisfied there are sufficient, appropriately maintained stocks of goods 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 home has effective information management system. Care recipients and representatives have information regarding the care and services provided by the home through residential agreements, handbooks, information displays and meetings. Staff have access to information regarding policies and procedures and clinical care and lifestyle management through electronic data bases. Management conduct staff meetings to discuss and receive information. The home ensures electronic and paper based information is secure and retained according to legislative requirements. Care recipients, representatives and staff said they are satisfied with the information system of the home.

1.9External services

This expected outcome requires that "all externally sourced services are provided in a way that meets the residential care service’s needs and service quality goals".

Team’s findings

The home meets this expected outcome