Halls Creek Peoples Church Frail Aged Hostel

RACS ID7178
440 Neighbour Street
HALLS CREEK WA 6770

Approved provider:Halls Creek Peoples Church Incorporated

Following a review audit conducted on 29 November to 9 December 2016, the Quality Agency decided the home met 37 of the 44 expected outcomes of the Accreditation Standards.

The assessment team’s review audit report is attached.

After considering the submission from the home including actions taken by the home, we decided that the home does meet expected outcome 1.2 Regulatory compliance.

Decision on period of accreditation

The Quality Agency made a decision on 21 December 2016 to vary this home’s accreditation period to expire in six months. The home is now accredited until 21 June 2017. The period of accreditation will allow the home the opportunity to demonstrate the recent improvements in care and services are sustainable, and will mean the home will be assessed against the Accreditation Standards at a full audit within a relatively short period of time.

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 / Not met
1.2Regulatorycompliance / Met
1.3Education and staffdevelopment / Met
1.4Comments andcomplaints / Met
1.5Planning andleadership / Met
1.6Human resourcemanagement / Not met
1.7Inventory andequipment / Met
1.8Informationsystems / Not 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 / Not 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 / Not 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 / Not met
4.2Regulatorycompliance / Not 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: Halls Creek Peoples Church Frail Aged Hostel
RACS ID: 71781Dates of audit: 29 November 2016 to 09 December 2016

Audit Report

Halls Creek Peoples Church Frail Aged Hostel 7178

Approved provider: Halls Creek Peoples Church Incorporated

Introduction

This is the report of a Review Audit from 29 November 2016 to 09 December 2016 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:

36/44 expected outcomes

The information obtained through the audit of the home indicates the home does not meet the following expected outcomes:

1.1, 2.1, 3.1 and 4.1 Continuous improvement
1.2 and 4.2 Regulatory compliance
1.6 Human resource management
1.8 Information systems

Scope of this document

An assessment team appointed by the Quality Agency conducted the Review Audit from 29 November 2016 to 09 December 2016.

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: 28

Number of care recipients during audit: 19

Number of care recipients receiving high care during audit: 13

Special needs catered for: Nil specified

Audit trail

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

Interviews

Category / Number
Manager / 1
Clinical care coordinator / 1
Registered nurses / 2
Care staff / 8
Cleaning staff / 1
Cook / 1
Care recipients/representatives / 9
Volunteers / 1
General practitioner / 1
Laundry staff / 1
Kitchen assistants / 2
Gardener / 1

Sampled documents

Category / Number
Care recipients’ files / 9
Care plans / 10
Medication charts / 8
Personnel files / 11

Observations

The team observed the following:

Activities in progress
Cleaning in progress and cleaning equipment
Clinical equipment and supplies, including dry goods, continence products, chemicals
Fire and safety equipment including fire blanket, extinguishers, exit signs
Food safety program file
GP visiting care recipients
Interactions between staff and care recipients
Kitchen area with white board, menu, colour coded equipment and various thermometers
Laundry
Living environment including outdoor area and rooms cooled with fans or air-conditioners
Meal service with staff assisting care recipients
Medication storage and administration
Noticeboards for care recipients and staff including brochures regarding complaint mechanisms and advocacy services
Short group observation in the outdoor area
Staff assisting care recipients with mobility and transfers and using personal protective equipment
Staff incidents and hazards file
‘Tell us what you think’ feedback forms, secure suggestion box and hazard forms.

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 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 does not meet this expected outcome

The home does not have a continuous improvement system to identify improvement opportunities and monitor performance against the Accreditation Standards. The home has no examples of improvement activities based on systematic evaluation of the services. The home is not using a framework to identify goals, actions, timeframes or monitoring and evaluation processes. The home is not following their policies and procedures for continuous improvement and does not use information from audits, surveys, incident reporting or training analyses to identify opportunities for improvement. Continuous improvement is not included on meeting agendas and is not discussed at care recipient or staff meetings. Staff reported they are not aware of any improvements and are not aware of the process. Care recipients were not aware of any improvements being made at the home.

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 does not meet this expected outcome

The home is not ensuring policies and procedures are being followed to ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. While the home has regulatory compliance policies and procedures, these policies are not followed to ensure all rostered staff have a current criminal record check which they have passed. The management team reported they are not fully aware of the requirements but have recently discussed the issue with the Quality Agency.

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 a training program to ensure management and staff have the knowledge and skills to perform their roles effectively. A training matrix is used to monitor that mandatory and other training is provided. Training is provided by external agencies and clinical staff, and evaluated for effectiveness. Staff report they attend external courses and are undertaking a certificate to provide them with skills, or they have experience in caring for elderly or frail care recipients.

Examples of education and training provided in 2016 and related to Standard 1 – Management systems, staffing and organisational development are listed below.

Compulsory reporting
Roles and responsibilities.

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 mechanisms for internal and external comments and complaints. Information regarding internal, external complaint mechanisms and advocacy services is provided to care recipients when they move into the home through the resident agreement and handbook. Feedback forms for comments, complaints and suggestions (Tell us what you think) are accessible, including a secure suggestion box for confidential complaints. Management reported other opportunities for feedback are provided through care recipient meetings and informal or formal meetings with the manager. Staff interviewed are aware of the internal and external feedback system and care recipients and representatives reported they have no complaints and tell staff when they are not satisfied.

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

Yura Yungi Medical Services Council has documents that outline the home’s vision, mission and commitment to quality. The statements are displayed in the home and are included in the resident agreement and resident and staff handbooks.

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 does not meet this expected outcome

The home is not following a system or process to ensure the residential care service’s philosophy and objectives are met. Staff were unable to demonstrate they are working within, or are aware of, the home’s philosophies regarding the code of conduct, cultural awareness, communication or teamwork. Systems to manage human resources, including recruitment and orientation, are not followed to ensure support and care staff have the required skills and knowledge for their role. Staff skills are not monitored and all relevant staff do not have a criminal record check which they have passed. While registered nurses address clinical care effectively, care staff reported new care and support staff are not always supervised when there are insufficient staff, and orientation is not always completed. Care recipients interviewed said they are satisfied with the care 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

There are processes to ensure adequate stocks of appropriate goods and equipment are available for quality service delivery. Designated staff are responsible for stock control, rotation processes and the purchasing of goods and equipment. The home utilises products from preferred suppliers. Preventative and corrective maintenance systems ensure equipment is maintained, repaired and replaced as needed. Equipment is stored safely with secure storage of chemicals. Management advised additional goods are being ordered due to the potential risk of depleted supplies during the wet season. Staff interviewed advised they have adequate equipment for their role and care recipients reported satisfaction with the maintenance.

1.8Information systems

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

Team’s findings

The home does not meet this expected outcome

The home does not have an effective information management system. Management are not able to access accurate and current information to help them perform their roles and the home’s policies and procedures for gathering of information are not followed. The collection of key information is not used to identify the needs of staff or care recipients. While there are processes for the storage and archiving of information and clinical information is securely stored, feedback systems and daily clinical care processes are not used to record information.

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

Externally sourced services are provided in a way that meets the home’s needs and service quality goals. Appropriate insurance policies are completed and updated and external providers service the home. Information regarding external service providers and the month of servicing is filed. Contractors sign in and out of the home. Management staff interviewed reported satisfaction with the quality of service they receive from external service providers.

Standard 2 – Health and personal care

Principle: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.

2.1Continuous improvement

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

Team’s findings

The home does not meet this expected outcome

Refer to expected outcome 1.1 Continuous improvement for an overview of the home’s continuous improvement system.

In relation to Standard 2 – Health and personal care, staff record care recipient accidents and incidents which are followed up. Clinical audits are conducted to measure and review the clinical care systems, however, results are not collated or analysed to identify improvements opportunities. Care recipients, representatives and staff are satisfied the organisation actively promotes and improves care recipients’ physical and mental health. However, the home does not have a systematic process that demonstrates a framework of continuous improvement that is goal oriented, planned, actioned and tracked to ensure sustainable improvement.

2.2Regulatory compliance

Halls Creek Peoples Church Frail Aged Hostel