Estia Health Keysborough

RACS ID3582
15 Stanley Road
KEYSBOROUGH VIC 3173

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 11 May 2020.

We made our decision on 07 March 2017.

The audit was conducted on 14 February 2017 to 15 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 Keysborough
RACS ID: 35821Dates of audit: 14 February 2017 to 15 February 2017

Audit Report

Estia Health Keysborough 3582

Approved provider: Estia Investments Pty Ltd

Introduction

This is the report of a re-accreditation audit from 14 February 2017 to 15 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.

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 14 February 2017 to 15 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.

Assessment team

Team leader: / Jenny Salmond
Team member/s: / Gillian Walster

Approved provider details

Approved provider: / Estia Investments Pty Ltd

Details of home

Name of home: / Estia Health Keysborough
RACS ID: / 3582
Total number of allocated places: / 60
Number of care recipients during audit: / 52
Number of care recipients receiving high care during audit: / 50
Special needs catered for: / None identified
Street: / 15 Stanley Road
City/Town: / KEYSBOROUGH
State: / VIC
Postcode: / 3173
Phone number: / 03 8788 2700
Facsimile: / 03 8788 2750
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
Care director / 1
National lifestyle manager / 1
Victorian quality manager / 1
Regional property services manager / 1
Registered nurses and care staff / 4
Care recipients / 7
Lifestyle assistant / 1
Catering staff / 2
Cleaning staff / 1
Laundry staff / 1
Maintenance staff / 1

Sampled documents

Category / Number
Care recipients’ clinical related files / 5
Care recipients’ lifestyle related files / 6
Care recipients administration files / 6
External service contacts / 6
Medication charts / 9
Smoking assessments, care plans and review / 2
Personnel files / 6

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. A schedule of internal and external audits and surveys guide management assessment of the home’s level of performance against the Accreditation Standards. The identification of additional improvement opportunities occur through a variety of established processes which include informal and formal stakeholder feedback, scheduled stakeholder meetings, the monitoring of performance indicators and management observation. The plan for continuous improvement documents actions and supports the monitoring of progress towards desired outcomes. Established informal and formal processes guide evaluation and management keep stakeholders informed through a range of communication strategies. Care recipients, and staff feel comfortable in providing feedback and suggestions and are satisfied with their involvement in continuous improvement activities within the home.

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

As a result of an organisational initiative, an online learning system was introduced in September 2015. Each training module involves completion of the online module, questionnaire and evaluation. Administrative staff monitors the completion, by all staff, of their individually allocated program within the specified time frame. Staff are satisfied with the greater personal convenience the system affords them in completing their mandatory training requirements and their access to a library of additional topics. Supplementary face to face and toolbox sessions continue and management stated they are satisfied the online learning system affords all staff a greater opportunity to be involved in a broader range of education topics.
In response to a review of staff duty statements in January 2017, management identified limited time was available to support staff breaks on the morning shift. As a result, one of the care staffs’ short shifts was increased by an hour. Management is satisfied this additional time has provided the flexibility required for all staff to have their required break. Evaluation is ongoing.
Ongoing consideration of staff feedback and management observation has resulted in enhancements to available staff hours. These have included the:

–Appointment of a maintenance officer, who works at the home three days a week. Stakeholder feedback has been positive about the responsiveness to maintenance requests. Management stated this initiative has resulted in more timely maintenance and the refurbishment of rooms as they become vacant. As a consequence of their involvement in the home, the maintenance office has taken on projects that include the renovation of garden areas.

–Implementation of lifestyle support over the weekends. Stakeholder feedback has been positive and management is satisfied the provision of four hours on both Saturday and Sunday enhances the engagement of care recipients through a variety of scheduled activities.

–Implementation of laundry hours over the weekend. Management is satisfied this initiative has effectively reduced the backlog of laundry needing to be undertaken on a Monday. Care recipients receive their clean personal items in a more timely fashion and staff feedback on their access to more clean linen early in the week has been positive.

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 has systems to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Organisational management monitor legislative and regulatory changes and information received from government, a legislative update service and professional associations. Established processes ensure the communication of this information to relevant staff through the home’s manager and formal policies and procedures are updated as required. Communication strategies employed by management include identifying changes in the weekly e-newsletter available to all staff, regular stakeholder meetings, education sessions, noticeboard displays and memoranda. Management and staff demonstrated awareness of their obligations in relation to regulatory compliance.

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

A documentation system ensures the monitoring of current professional registrations.
Confidential documents are stored securely and destroyed as scheduled.
Information about internal and external complaints mechanisms and advocacy services are readily available.
Management follows an established process to ensure all staff, volunteers and appropriate service providers and contractors have current police checks, statutory declarations and appropriate credentials.
Management notified all stakeholders of the re-accreditation audit within the required timeframe.

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 in relation to the Accreditation Standards. Management use a training needs analysis to identify education opportunities and provide a training calendar with organisational and home specific education. Education and training provided is in response to care recipients’ needs, staff requests, audits, incidents, performance review and changes to regulations. The range of delivery methods includes on-line learning, in-house and external sessions, competencies, self-directed learning and is supported by the organisational clinical educator. The organisation encourages and supports professional development opportunities. Staff complete evaluations of sessions attended. Management monitor and evaluate the effectiveness of the program through feedback, observations and in response to quality activities. Management and staff are satisfied with the education and training opportunities provided.

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

aged care funding instrument
health metrics
clinical documentation.

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

Each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms. Information about internal and external feedback mechanisms is included in orientation programs and stakeholder information. Pamphlets outlining external complaints and advocacy services are readily available within the home. A range of established informal and formal communication processes are used by management to engage all stakeholders in the provision of feedback. These strategies include management being available to receive and reply to feedback and their scheduled attendance at stakeholder meetings. Staff and family members support care recipients who are less able to express their feedback independently. Monitoring of actions to address identified issues occurs through the continuous improvement system. Care recipients and staff are comfortable in using established feedback mechanisms.

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’s purpose, ambition and family code statements and commitment to continuous improvement underpins the work practices of all stakeholders. These statements and the ‘Charter of care recipients’ rights and responsibilities – residential care’ are displayed within the home and reinforced through a range of established communication processes.

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

There are appropriately skilled and qualified staff sufficient to ensure services are delivered in accordance with these standards and the residential care service’s vision and values statements. An established organisational system guides the recruitment, selection and orientation of new staff. Position descriptions, duty lists, the staff information handbook, mandatory training, orientation and ‘buddy’ shifts define the role related responsibilities of new staff. Management monitor staff rosters to ensure the maintenance of appropriate personnel levels. Registered nurses are on duty to support care on all shifts. To support continuity of care, internal staffing resources are used where possible to fill vacant shifts. Staff are satisfied with the current staffing levels and the support provided by management to address identified issues. Care recipients expressed satisfaction with the quality and timeliness of staff support.