BaptistCare Kularoo Centre

RACS ID: 0255

Approved provider: BaptistCare NSW & ACT

Home address: Cnr Kularoo Drive & Boundary St FORSTER NSW 2428

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 19 January 2021.
We made our decision on 17 November 2017.
The audit was conducted on 10 October 2017 to 12 October 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.

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met

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.

2.1 Continuous improvement Met

2.2 Regulatory compliance Met

2.3 Education and staff development Met

2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep 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.

3.1 Continuous improvement Met

3.2 Regulatory compliance Met

3.3 Education and staff development Met

3.4 Emotional Support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors

4.1 Continuous improvement Met

4.2 Regulatory compliance Met

4.3 Education and staff development Met

4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met

Home name: BaptistCare Kularoo Centre Date/s of audit: 10 October 2017 to 12 October 2017

RACS ID: 0255 29

Audit Report

Name of home: BaptistCare Kularoo Centre

RACS ID: 0255

Approved provider: BaptistCare NSW & ACT

Introduction

This is the report of a Re-accreditation Audit from 10 October 2017 to 12 October 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 10 October 2017 to 12 October 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: 160

Number of care recipients during audit: 152

Number of care recipients receiving high care during audit: 135

Special needs catered for: Dementia

Audit trail

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

Interviews

Position title / Number /
Care Team Manager / 2
Leisure and lifestyle coordinator / 1
Education coordinator / 1
Maintenance supervisor / 1
Administration Manager / 1
Hotel services manager / 2
Safety, Quality & Risk Coordinator / 1
IT support manager / 1
Cleaning staff / 4
Care recipients / 29
Residential manager / 1
Fire officer / 1
Chaplain / 1
Administration staff / 1
Property officer / 1
Operations manager / 1
Volunteer / 1
Recreational Activities Officers / 4
Catering staff / 3
Hotel service managers / 3
Laundry staff / 3
Registered nurses / 5
Care staff / 11
Work Health and Safety consultant / 1
Nurse consultant palliative care / 1
Physiotherapist / 1
Occupational therapists / 1
Medical officers / 2

Sampled documents

Document type / Number /
Medication charts / 8
Personnel files / 6
Care recipients' files / 19

Other documents reviewed

The team also reviewed:

·  Accident, incident documentation and hazard documentation - care recipients and staff

·  Activities program and calendar

·  Activity descriptions and work instructions

·  Admission checklist

·  Advocacy information

·  Approved supplier list

·  Archive room and documentation

·  Assessments, care plans and progress notes

·  Audit reports and documentation

·  Audit schedules

·  Care recipient admission checklist

·  Care recipient and accommodation agreement

·  Care recipient and staff survey results

·  Care recipient and visitor sign in/out books

·  Care recipient dietary requirements

·  Care recipient list

·  Care recipients' admission pack

·  Care recipients' information package and handbook

·  Clinical care records including care plans, care plan summaries assessments, progress notes, care recipient dietary and menu choices, clinical observation charts including weights, continence, behaviours, personal hygiene, sleep, skin integrity, pain, mobility, falls risk, toileting, oral health, wound assessments, pain charts, blood glucose levels and ranges set by medical practitioner, resident of the day, case conference records, clinical incident reports

·  Comments and complaints documentation

·  Communication emails/memoranda

·  Competency assessments

·  Compliments, complaint register and correspondence

·  Computer based information systems

·  Computerised care management system documentation

·  Consent forms

·  Consistent assignment model of care

·  Continence aid allocation lists

·  Continuous improvement plan

·  Contracted services documentation

·  Contractor agreements

·  Corporate newsletters

·  Education calendars and documentation

·  Education needs analysis and records

·  Education notices on education board

·  Electrical test and tag records

·  Emergency flip charts

·  Environmental records

·  Feedback forms

·  Fire Certificate documentation

·  Fire safety statements

·  Food Authority licence and audit report

·  Four hour repositioning guide and shower calendar (care recipient rooms)

·  Handbook - resident/care recipient

·  Handbook – staff and volunteer

·  Handover documentation

·  Hazards, incidents and accident reports and actions

·  Infection control policies, procedures, infection surveillance data, outbreak management plans, staff and care recipients vaccination consent and records

·  Legislative information

·  Leisure and lifestyle documentation including assessments, plan, activity and lifestyle profiles; leisure and lifestyle policies and procedures; activity calendars; newsletters; feedback forms.

·  LGBTI documentation

·  Medical/ health practitioner feedback forms

·  Medication management documents including medication incident reports, medication directives, signing registers, dangerous drug register, primary medication and signing charts, fridge temperatures, nurse initiated medications, medication reviews,

·  Meeting minutes including care recipient and relative; work, health and safety committee, clinical, executive, facility staff, medical advisory

·  Menu and care recipient dietary information

·  My care and services folder

·  Newsletters and other publications

·  Nutrition and hydration care recipient dietary requirement and preference sheets, menu, thickened fluids and supplements and weight records

·  Organisation chart

·  Palliative care resource folder and end of life care pathway

·  Policies and procedures

·  Preventative and corrective maintenance program and work records

·  Professional registrations and monitoring system

·  Regulatory compliance documentation

·  Residential and respite service agreements

·  Restraint documentation

·  Security of tenure information signed consent to relocate documentation.

·  Self-assessment documentation

·  Staff Handbook

·  Team quality plan

·  Training information/attendance records/evaluations

·  Training matrix

·  Trend data analysis

·  Vision, values and mission statements

·  Work Health and Safety records including policies and procedures; safety and assessment checklists; safety guidebook; hazard and incident reports; fire safety, infection control and manual handling training records.

Observations

The team observed the following:

·  Activities in progress including reading, group exercises, bingo, craft and concerts given by external entertainers

·  Activities program on display

·  Archive room

·  Care recipients in residence

·  Care staff handover

·  Catering areas including the main kitchen

·  Chapel

·  Charter of care recipients’ rights and responsibilities on display

·  Cleaning in progress

·  Clinical equipment in use

·  Colour coded equipment

·  Computers with Wi-Fi available for care recipients and visitors

·  Dining environments during lunch and beverage services with staff assistance, morning and afternoon tea, including care recipients seating, staff serving/supervising

·  Equipment, archive and supply storage areas

·  Evacuation egresses

·  Evacuation signs and diagrams

·  Falls management program ‘on your feet’

·  Feedback mechanisms – Internal and external

·  Fire evacuation diagrams

·  Fire indicator panel

·  Fire safety systems and equipment including unobstructed emergency exits, emergency evacuation information, current fire safety certification.

·  Hairdresser in attendance

·  Hand hygiene facilities

·  Infection control resources: hand washing facilities, hand sanitisers, sharps containers, spills kits, outbreak management supplies, waste disposal systems

·  Key pad locks

·  Laundry environment

·  Living environment - internal and external (including private sitting and garden areas)

·  Medication storage and administration

·  Mission and values statement on display

·  Mobility and manual handling equipment in use and in storage

·  Notice boards – General and staff (containing posters, photographs, activity calendars, brochures and forms displayed. Poster advising of reaccreditation audit visit

·  NSW Food Authority licence - current

·  Nurse call system and timely response by staff

·  Offices

·  Reception

·  Secure storage of confidential care recipient and staff information – electronic and hardcopy

·  Short observation secure dementia unit

·  Sprinkler system

·  Staff practise and courteous interactions between staff, care recipients, and representatives’

·  Staff toolbox education information

·  Staff work areas and work practices including administrative, clinical, cleaning, laundry, catering and maintenance

·  Suggestion box and feedback forms

·  Vision Mission statement and customer service commitment

·  Visitors’ resources including puzzles, games and books

·  Wheeled walkers

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.

1.1 Continuous improvement

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

Team's findings

The home meets this expected outcome

The continuous improvement program includes processes for identifying areas for improvement, implementing change, monitoring and evaluating the effectiveness of improvements. Feedback is sought from care recipients, representatives, staff and other stakeholders to direct improvement activities. Improvement activities are documented on the plan for continuous improvement. Management uses a range of monitoring processes such as audits and quality indicators to monitor the performance of the home's quality management systems. Outcomes are evaluated for effectiveness and ongoing monitoring of new processes occurs. Care recipients, representatives, staff and other personnel are provided with feedback about improvements. During this accreditation period the organisation has implemented initiatives to improve the quality of care and services it provides. Recent examples of improvements in Standard 1 Management systems, staffing and organisational development are:

·  Consistent Assignment is the foundation for high quality individual care and effective team work that was introduced in June 2017. All BaptistCare facilities are moving towards introducing this. As a precursor to the introduction of this model of care the home reviewed its staffing systems and the management of rosters. The master roster was rewritten. Staff were placed on permanent contracts and were permanently attached to one unit where they became part of a team. Benefits to date include a reduction in overtime, absenteeism and sick leave. The home also reviewed staffing in all areas including the dementia unit. Staffing there was increased significantly. For example, Certificate IV staff now work a full six hour shift daily. Continuity of care and teamwork has improved for care recipients and staff. The outcomes of this project are measured in various ways including through the staff feedback survey, the care recipient satisfaction survey and a new tool that is enabling the manager to closely monitor care requirements and staffing on an ongoing basis.