Estia Health Craigmore

RACS ID6948
150 Adams Road
CRAIGMORE SA 5114

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 May 2020.

We made our decision on 08 March 2017.

The audit was conducted on 06 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
1.1Continuousimprovement / 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 Craigmore
RACS ID: 69481Dates of audit: 06 February 2017 to 08 February 2017

Audit Report

Estia Health Craigmore 6948

Approved provider: Estia Investments Pty Ltd

Introduction

This is the report of a Re-accreditation Audit from 06 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 06 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: 135

Number of care recipients during audit: 132

Number of care recipients receiving high care during audit: 125

Special needs catered for: Care recipients living with dementia and related disorders.

Audit trail

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

Interviews

Position title / Number
Management, including corporate management / 3
Care recipients/representatives / 14
Clinical staff / 8
Care and lifestyle staff / 9
Hospitality staff / 5
Administration assistant / 1
Maintenance staff / 1
Allied health / 1

Sampled documents

Document type / Number
Care recipient files / 14
Summary/quick reference care plans / 5
Medication charts / 14

Observations

The team observed the following:

Activities in progress
Archive room
Charter of care recipients’ rights and responsibilities on display
Confidential feedback stations and forms
Equipment and supply storage areas
Infection control stations
Interactions between staff and care recipients
Living environment
Meal service
Medication round in progress
Noticeboards
Online quality management system
Outbreak kit
Service and maintenance areas
Short group observation in the memory support unit
Staff room
Storage of medications
Various aged care information and advocacy pamphlets

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

Estia Health Craigmore is supported by an overarching corporate continuous improvement system which assists the home to actively pursue continuous improvement and monitor their performance against the Accreditation Standards. The home uses feedback from stakeholders, audits, surveys, clinical indicators, incident, hazard and environmental audits/inspections to identify improvement opportunities. These are logged electronically onto the plan for continuous improvement where they are monitored, evaluated and tracked until completed. Continuous improvement activities are discussed at meetings; results show the home’s systems are identifying improvement opportunities. Care recipients, representatives and staff are satisfied the home pursues continuous improvement.

Examples of continuous improvement activities undertaken by the home in the last 12 months include:

The organisation has acquired through growth, a number of existing quality systems; corporate management identified the need to consolidate all three quality systems into one quality management system. The new quality management system was introduced; this is an online organisational structure for the home’s policies and procedures, forms/templates, manuals and other relevant documentation. It also enables staff to log-on and access human resource information, the online training component and other care and work health and safety systems. Management and staff feedback confirms the system is effective and information is easy to find.
To improve communication processes in the home and help staff understand and improve on the home’s systems, a staff newsletter has been introduced. This contains information on continuous improvement activities, compliance information, mandatory reporting obligations, up-and-coming education and a range of relevant information about the home. Staff feedback confirms the newsletter is informative and helps them to understand the home’s systems.

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 systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Corporate management received legislative updates from key professional business and aged care industry groups and notify management through the newly established online quality management system. Staff are provided information relevant to their role through established communication processes. Policies and procedures form part of the new system, these are reviewed regularly and updated as required. Legislative updates are a standard agenda item at all meetings. Results show the home has systems to meet their legislative responsibilities. Management and staff interviewed said they are advised of relevant legislative updates. Care recipients and representatives said they were notified of the Re-accreditation audit.

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

Professional registrations are monitored for nursing staff.
Criminal history checks for staff, community volunteers and contracted employees.

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 has systems to provide management and staff with the appropriate knowledge and skills to perform their roles effectively. Staff skills and knowledge are supported by extensive corporate recruitment and selection processes, including an online education system and core mandatory training topics. Education is based on feedback from staff, care recipient acuity and clinical incidents. Education is monitored through the newly established quality management system and staff are supported to attend mandatory training sessions. Results show there are processes to follow-up on non-attendance and staff are offered a range of education and undertake monthly pledges as commitment to their ongoing professional development. Staff interviewed said they have access to a wide range of education and are satisfied with the training provided. Care recipients and representatives interviewed are satisfied staff have the required knowledge and skills to provide care and services.

Examples of education staff have completed in Standard 1 Management systems, staffing and organisational development include:

Online computer education
Continuous improvement
Bullying and harassment

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

Care recipients and representatives have access to, and are informed about internal and external complaints mechanisms. Entry processes, resident meetings, newsletters, the handbook and brochures on external complaints and advocacy services are available and displayed to assist care recipients to understand how they can raise any suggestions, compliments or concerns. There are confidential boxes and feedback forms available for care recipients, representatives and staff to provide feedback. Feedback is logged electronically and monitored for trends and continuous improvement opportunities. The home monitors care recipient and representative satisfaction with the complaints processes through feedback and the annual survey. Results show the home is responsive to feedback with additional feedback stations set-up in each area of the home. Staff interviewed said they are aware of their responsibility for assisting care recipients to raise any ideas, suggestions or concerns. Care recipients and representatives interviewed are satisfied with the complaints process.

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 ‘Our Purpose, Our Ambition and Our Estia Code’ is documented throughout all official documents and displayed in the home. The ‘Our Purpose’ is based on one family where everyone belongs. The ‘Our Ambition’ is based on providing families with access to quality local residential health care in a supportive and trusted environment where everyone belongs. The ‘Our Estia Code’ is based on creating happiness, always being approachable, doing my daily best and pushing our limits, and see something and say something. This is supported by Estia’s eight keys to good customer service: a positive attitude ‘can do’, keep your promise, listen to your customer, delight your customer, trust your customer ‘give trust and you’ll get double in return’ and work as a team ‘ work smarter’.

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 systems to monitor staff are appropriately skilled and qualified. The home is guided by corporate recruitment processes, including a range of online education and training that ensures staff are selected based on the required skills and qualifications. Staffing levels are monitored and based on the assessed needs of the care recipients and feedback from staff. Agency staff are utilised for shifts not filled by permanent part-time and regular casual staff. Results show management is responsive to changes in care recipients’ care needs, with two additional care shifts recently added to the roster. Staff interviewed said they have enough time to complete their duties, are provided with ongoing education and feel supported by management. Care recipients and representatives interviewed are complimentary of care and services provided by staff.

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 has systems for identifying that stocks of appropriate goods and equipment for quality service delivery are available. A new quality management system has improved the online ordering system for goods and equipment supplies; designated staff monitor imprest stock levels, including the rotation of perishable items. A preventative maintenance calendar which includes in-house servicing, outsourced services and reportable essential services guides staff and external contractors in the cleaning, servicing and maintenance of equipment. The asset register and external contractor inspection reports assist maintenance staff to monitor equipment to ensure it is fit for use. The home monitors care recipients and staff have enough goods and equipment through feedback, the maintenance program and incidents and hazards. Results show equipment is serviced regularly, stored appropriately and stock levels are maintained. Staff interviews, observations and documentation viewed confirm adequate supplies of goods and equipment are available. Care recipients and representatives interviewed are satisfied with the goods and equipment supplied.

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 systems to enable management and staff to perform their roles and ensure care recipients and representatives have access to current information. Admission processes, resident meetings, newsletters and care and lifestyle reviews provide care recipients and their authorised representatives with information to make decisions about the care and services they receive. Established communication processes, including electronic alerts, handover, communication books, memoranda and care and lifestyle reviews provide staff with sufficient and relevant information to perform their roles. Management collate and analyse key information which is discussed at site and corporate meetings. Confidential information is stored securely, archived and destroyed off-site according to legislative requirements. Electronic information is password protected with varying levels of access to designated staff and backed up regularly. There are established processes to monitor the information management system. Results show the home has effective processes in place and has recently implemented a new quality management system and staff newsletter. Staff, care recipients and representatives are satisfied they are provided with enough information.

Estia Health Craigmore