Estia Health Mudgeeraba

RACS ID5991
21-25 Old Coach Road
MUDGEERABA QLD 4213

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 05 May 2020.

We made our decision on 08 March 2017.

The audit was conducted on 31 January 2017 to 02 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 Mudgeeraba
RACS ID: 59911Dates of audit: 31 January 2017 to 02 February 2017

Audit Report

Estia Health Mudgeeraba 5991

Approved provider: Estia Investments Pty Ltd

Introduction

This is the report of a Re-accreditation Audit from 31 January 2017 to 02 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 31 January 2017 to 02 February 2017.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of three 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: 167

Number of care recipients during audit: 140

Number of care recipients receiving high care during audit: 129

Special needs catered for: Care recipients with dementia related disorders

Audit trail

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

Interviews

Position title / Number
Executive Director / 1
Regional support team / 2
Care Director / 1
Clinical Care Coordinator / 1
Registered/enrolled nurses / 5
Care staff / 8
Physiotherapy assistant / 1
Administration assistant / 1
Chef / 1
Care recipients/representatives / 22
Maintenance staff / 2
Environment services staff / 5
Diversional therapy staff / 3

Sampled documents

Document type / Number
Care recipients’ files / 15
Summary/quick reference care plans / 18
Medication charts / 25
Personnel files / 5

Observations

The team observed the following:

Activities in progress
Advocacy information on display
Archiving room
Charter of care recipient rights and responsibilities
Chemical storage
Cleaning in progress
Confidential feedback box
Equipment and supply storage areas
Hand washing facilities and personal protective equipment in use
Interactions between staff and care recipients
Internal and external complaints information displayed
Internal and external living environment
Kits for infection and spill control
Laundry and kitchen environment
Meal and beverage service
Medication administration and storage
Noticeboards and notices on display
Palliative care kits
Podiatry services
Short group observation
Sign in/out register
Staff work practices
Storage of medications
Vision and values statements

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 Mudgereeba (the home) continues to pursue continuous improvement and has implemented improvements in response to the changing needs of care recipients, their representatives, staff and the organisation to meet the requirements of the Accreditation Standards. An annual audit schedule, satisfaction surveys and reporting processes for clinical indicators, hazards, incidents and complaints are used to monitor systems and processes. Improvement actions raised through audits are recorded and discussed at meetings, while a plan for continuous improvement is implemented to track improvement actions and improvement activities to completion. Regular meetings for all levels of management, staff and care recipients are used to communicate information about improvements and to evaluate the effectiveness of improvement activities. Ongoing staff education and monitoring of staff practices ensures staff understand and implement relevant changes and improvements to the home’s processes. Care recipients and staff are satisfied improvements are being implemented at the home.

Examples of recent improvements relating to management systems, staffing and organisational development include the following:

The home encourages and supports staff to enhance their skills and qualifications and has a number of staff enrolled in nursing studies. A graduate nurse program was implemented in 2016 to provide improved career development for existing staff and to further enhance staff skills and retention rates for the home. The program includes induction, immersion study days, leadership development and clinical specialist training. The program was successfully completed by one graduate nurse in 2016 and is planned to recommence in February 2017 with another staff member.
A centralised requisition management system has been introduced to streamline ordering and invoice approval processes. The web-based system has been implemented progressively, with medical, office and equipment supplies being effectively managed through the portal. As a result, the organisation has improved reporting, tracking and reconciliation processes.

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 monitors changes to legislation and regulations and provides information and regular updates to policies and procedures to staff via the organisation’s intranet and electronic care information system. Legislative changes and relevant changes to policies and procedures are discussed at meetings and communicated through the intranet, memoranda and monthly meetings to staff at all levels. Meetings and email communications are used to disseminate relevant information to volunteers and care recipients/representatives where relevant. Compliance with relevant requirements is monitored through the annual audit schedule, third party reviews, and electronic reports for monitoring criminal history clearance, registration requirements, mandatory training and competency assessment of staff. Policies and procedures are reflective of legislative requirements, professional standards and guidelines.

In relation to Standard 1, Management systems, staffing and organisational development, for example:

Care recipients are informed of planned re-accreditation audits by the Australian Aged Care Quality Agency.
Processes are established that ensure staff, volunteers and relevant contractors have a current police certificate.
Professional staff’s registrations are monitored in accordance with the Australian Health Practitioner Regulation Agency (AHPRA).

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 accesses organisational educational resources and programs through the intranet and on-line portal. In addition, expert speakers are invited to deliver specialised training as required and opportunities to attend conferences and external education are offered to management and staff via a staff development request process. Position descriptions describe the qualifications, skills and experience for each position. Staff are required to maintain mandatory and specific role-related qualifications and skills. Competency assessments are conducted for key processes; attendance at education sessions is monitored and evaluated. Staff training and education is identified through direct feedback from staff, the changing needs of care recipients, observation of practice, audits and surveys. Staff are satisfied that education provided is relevant to their work and that management is responsive to requests for additional training needs.

Staff have the opportunity to undertake a variety of training programs relating to Standard 1 Management systems, staffing and organisational development, including for example:

training in the use of the organisation’s electronic information systems, and
attendance by management at national internal and external aged care conferences and events.

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 home has a system to capture complaints, compliments and suggestions from care recipients/representatives, staff and other interested parties. Management receives feedback and conducts ongoing monitoring of care recipients satisfaction via blue feedback forms, surveys, meetings and an ‘open-door’ approach. The Executive Director (ED) investigates all complaints to ensure an appropriate response is made. Monthly reports and trending of comments and complaints are maintained and tabled at Continuous Quality Improvement (CQI) meetings. Information relating to internal and external complaints mechanisms and advocacy services are included in the care recipients’ handbook and is on display throughout the home. The advocacy service is invited to attend the home as requested by care recipients/representatives. Feedback forms and suggestion boxes are available in each part of the home for confidential feedback.Care recipients /representatives are familiar with the various ways to raise a concern and are comfortable approaching staff with their concerns.

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 vision, values, philosophy and commitment to quality are documented in publications provided to care recipients/representatives and staff and in documents on display in the home.

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 Executive Director manages day-to-day operation of the home and a clinical leadership team oversees clinical care. Staff with appropriate skills and qualifications are employed to facilitate consistent care and services. Sufficiency of staff is monitored through care recipient and staff feedback and adjustments are made as indicated. Short-term contract staff are contracted as required to ensure a full staff complement each shift. Staff are employed based on their skills, experiences, qualifications relevant to the position and positive reference checks. New staff are orientated to the organisation and the home’s policies and procedures, values and philosophy, and supported by an experienced staff member until they are comfortable in their role. Position descriptions and duty guidelines are documented to guide staff practice. Ongoing education is provided across a range of topics and staff skills are monitored through observation, competency assessments and performance appraisals. Care recipients/representatives expressed satisfaction that staff are prompt and courteous when attending 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 uses the organisation’s centralised procurement processes including approved suppliers and electronic ordering processes to ensure that adequate stocks of key supplies (linen, food products, clinical supplies, chemicals, consumables and continence aids) are available. Orders are checked at the time of delivery to ensure product quality and deficiencies are followed up with suppliers and reported to management where appropriate. Stocks of goods held on site are appropriately and securely stored. Equipment is purchased through preferred suppliers to provide a consistent approach across the organisation and ensure equipment is fit for purpose. Equipment is maintained by appropriately qualified personnel and contractors through reactive and preventative maintenance. Staff and care recipients/representatives are satisfied with the availability of goods and equipment at the home and that equipment is well maintained.

1.8Information systems

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

Team’s findings

The home meets this expected outcome

Electronic and paper-based records are maintained by the home. Information is stored securely and electronic records are password protected and electronic permissions are relevant to staff roles. Staff sign an agreement to maintain confidentiality when handling care recipient information and locked rooms and cupboards are used to store confidential information. There is a process for the archiving and disposal of obsolete records. The home collects and analyses key information and data to assist with ongoing improvement of care and services. Policies, procedures, assessments and care plans are regularly reviewed and updated. Care recipients, representatives and staff are generally informed of changes relevant to their needs through meetings, memos, electronic mail, newsletters, communication diaries, whiteboards and verbal feedback.Care recipients/representatives are satisfied they are kept informed.

Estia Health Mudgeeraba