Juniper Numbala Nunga

RACS ID7426
37 Sutherland Street
DERBY WA 6728

Approved provider:Uniting Church Homes

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 18 February 2020.

We made our decision on 13 December 2016.

The audit was conducted on 15 November 2016 to 16 November 2016. 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: Juniper Numbala Nunga
RACS ID: 74261Dates of audit: 15 November 2016 to 16 November 2016

Audit Report

Juniper Numbala Nunga 7426

Approved provider: Uniting Church Homes

Introduction

This is the report of a re-accreditation audit from 15 November 2016 to 16 November 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.

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 15 November 2016 to 16 November 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.

Assessment team

Team leader: / Philippa Brittain
Team member: / Shirley Latham

Approved provider details

Approved provider: / Uniting Church Homes

Details of home

Name of home: / Juniper Numbala Nunga
RACS ID: / 7426
Total number of allocated places: / 26
Number of care recipients during audit: / 20
Number of care recipients receiving high care during audit: / 20
Special needs catered for: / Nil specified
Street: / 37 Sutherland Street
Town: / DERBY
State: / WA
Postcode: / 6728
Phone number: / 08 9191 1402
Facsimile: / 08 9193 1105
E-mail address: / Nil

Audit trail

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

Interviews

Category / Number
Management team / 3
Registered nurses / 2
Care staff / 5
Physiotherapist/medical practitioner / 2
Care recipients/representatives / 10
Occupational therapy assistant / 1
Catering, laundry, cleaning staff / 5

Sampled documents

Category / Number
Care recipient files, assessments, care plans and progress notes / 6
Leisure interests and activity care plans and interventions / 6
Service agreement / 2
Medication charts / 7
Personnel files / 4

Other documents reviewed

The team also reviewed:

  • Accident, incident and hazard records
  • Activity calendar and activity records
  • Archiving system and asset register
  • Audits and staff and care recipient surveys
  • Care recipient and staff information handbooks
  • Cleaning programs and schedules
  • Clinical indicators, including monthly reports
  • Communication books, handover notes and diaries
  • Complaints, compliments and ideas file
  • Continuous improvement forms and plan
  • Duty statements, rosters and staff allocation lists
  • Essential and preventative maintenance schedule, maintenance book and requests
  • Fire and safety equipment maintenance reports
  • Food safety program, diet analysis assessments and drinks list, menu and dietary information, temperature records and local shire inspection report
  • Gastroenteritis and infection control guidelines
  • Imprest stock and nurse-initiated medication files
  • Influenza vaccination records
  • Mandatory reporting file
  • Matrix used to monitor currency of performance appraisals, police certificates, professional staff registrations, training matrix and competencies
  • Medication self-administration consent forms
  • Meeting minutes, newsletters and staff memoranda
  • Policies and procedures and guidelines
  • Register of drugs of addiction
  • Regulatory compliance file and safety data sheets
  • Site induction and orientation documentation.

Observations

The team observed the following:

  • Activities in progress
  • Antibacterial gels and handwashing facilities
  • Archive records and store room
  • Charter of Care Recipients’ Rights and Responsibilities, the organisation’s mission statement and values on display within the home
  • Cleaning equipment and locked chemical rooms
  • Equipment and supply storage areas
  • Evacuation bag and current care recipient mobility list
  • External and internal complaints information displayed in lobby
  • Interactions between staff and care recipients
  • Living environment
  • Safety signage and security surveillance cameras
  • Short group observation of church service with local indigenous guitar players in the communal area
  • Storage and administration of medications
  • Water coolers.

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 meets this expected outcome

The organisation actively pursues continuous improvement. Ideas for improvement originate from external and internal sources and from within the organisation. The home ensures all stakeholders are aware of, and can contribute to, improving care and services. Mechanisms feeding into the improvement process and where appropriate the continuous improvement plan, include feedback forms, accidents and incidents, hazards, feedback from meetings, results of audits and clinical data. Clinical indicators and other feedback are analysed and trends noted, staff are informed of results through memoranda and at meetings and data is discussed at corporate meetings. Staff, care recipients and representatives reported awareness of the continuous improvement process and provided feedback on completed improvements.

Improvement initiatives implemented by the home over the last 12 months in relation to Standard 1 – Management systems, staffing and organisational development are described below:

  • Staff and management noted the communication system was not effective as staff and care recipients could only take calls in the nursing home (Numbla Nunga, NN). In response, management installed an intercom system and cordless telephones, which staff reported has improved the information flow and timeliness of information received. In addition, staff and care recipients stated, the hostel (Ngamang Bawoona, NB) personnel no longer need to visit the nursing home to take telephone calls and the home’s main telephone line is not constantly in use as it was before. Care recipients reported satisfaction with the new system reporting the new telephones are more accessible.
  • A staff survey showed staff wanted more opportunities to be recognised for their work. As a result, a staff recognition scheme has been developed by the organisation and introduced in the home. Management stated there are now opportunities for peer selection of an employee of the month and year including prizes and cash rewards for nominate and winners of the awards. Staff reported being satisfied with the scheme and said it provided them with incentives and recognition.
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 ensure the home complies with relevant legislation, regulatory requirements, professional standards and guidelines. The organisation receives updates on legislative and regulatory changes from the industry peak body and government sources. Head office is notified of any changes, and staff can obtain information as required via emails, memoranda, notices, at meetings and training sessions. Changes to procedures in line with legislation occur as required. The home ensures the provision and monitoring of statutory declarations and police certification for new and existing staff, volunteers and contracted professionals. Management monitors staff registrations. Staff and care recipients advised they receive information concerning compliance requirements as needed and complied with these. Care recipients reported management informed them of the re-accreditation audit.

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 organisation ensures management and staff have the knowledge and skills to perform their roles effectively. An interview process, orientation, education, job descriptions, employee handbook and staff appraisals support recruitment processes. Mandatory training is undertaken and a training schedule is developed from information gathered through questionnaires, appraisals, feedback from meetings, staff suggestions, care recipient feedback and in response to regulatory requirements. Staff reported satisfaction with training and are confident they have the skills to perform their roles effectively. Care recipients and representatives reported management and staff are skilled, knowledgeable and effective in their roles.

Examples of education and training related to Standard 1 – Management systems, staffing and organisational development are listed below:

  • Bullying and harassment
  • Continuous improvement
  • Employee assistance 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

There are processes to ensure that care recipients and their representatives have access to internal and external complaints mechanisms. General feedback forms are accessible in the lobby and wings of the home, as are brochures for external complaints processes. Care recipient information packs and agreements outline avenues for complaint and care recipient meetings encourage feedback from care recipients and representatives. Staff demonstrated their awareness of the complaints mechanisms and outlined ways they could assist care recipients to complain or make a suggestion. Most care recipients interviewed reported they use complaints mechanisms and were satisfied with the response. All care recipients and representatives interviewed reported satisfaction with access to comments and complaints 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 home displays its vision, mission values and commitment to quality statement in the home. Care recipients receive this information when moving into the home via the agreement and information pack. Staff introduction to the organisation’s vision, mission and values occurs during induction and through performance appraisals.

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 processes to ensure employment of appropriately skilled and qualified staff sufficient to meet the needs of the care recipients. The residential manager maintains staffing and skills mix at levels designed to meet the care recipients’ changing care needs. Monitoring and review of staffing levels is through care recipient and staff feedback, audits and surveys and care recipients’ assessed needs. New staff receive orientation to the home’s systems, receive mandatory training and are initially ‘buddied’ with a more experienced staff member. Monitoring of staff practice is through performance appraisals and care recipient feedback. Staff reported they generally have enough time to do their work depending on other staff performing their duties and that management is receptive to feedback concerning workloads. Care recipients stated their satisfaction with the staff skills and support 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 home has systems to maintain stocks of appropriate goods and equipment for quality service delivery. Designated staff complete orders for supplies to maintain optimal levels of stock and regulate stock rotation. The home uses regular suppliers to maintain the quality of products and services. Staff are consulted about new equipment based on care recipient needs. New equipment is trialled to ensure quality and safety, and staff are trained in the use of all new equipment. A preventative and corrective maintenance program is in place for maintaining and checking equipment. Staff stated they have access to appropriate goods and equipment to provide clinical and lifestyle care. Care recipients reported the home provides goods and equipment necessary to meet care recipients’ needs.

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. Policies and procedures guide staff in the use, disclosure, storage, back-up, retrieval and destruction of information. The use of memoranda, clinical information, duty statements, handovers, emails, communication books, notices and meetings ensure effective communication. Management uses information from collated clinical data, hazards and audits to inform staff and improve services. Staff reported they are educated regarding information management and confidentiality at orientation, and they have access to sufficient information to guide their work. Care recipients reported their satisfaction with the home’s information systems.

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

The organisation has systems and processes to ensure externally sourced services meet the needs and goals of the home. A preferred provider list and organisation of contractors is carried out centrally to ensure the organisation has its requirements met by service providers. There are processes to monitor indemnity insurance and professional registrations. Management monitors the quality of services via various feedback mechanisms and reported service providers meet outlined expectations. Staff and care recipients reported satisfaction with the standard of externally sourced services.