Forest Lodge Residential Aged Care
RACS ID: 3825
Approved provider: Great Oaks Pty Ltd
Home address: 23 Forest Drive Frankston North VIC 3200
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 July 2020.We made our decision on 24 May 2017.
The audit was conducted on 18 April 2017 to 19 April 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
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.
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
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: Forest Lodge Residential Aged Care Dates of audit: 18 April 2017 to 19 April 2017
RACS ID: 3825 6
Audit Report
Name of home: Forest Lodge Residential Aged Care
RACS ID: 3825
Approved provider: Great Oaks Pty Ltd
Introduction
This is the report of a Re-accreditation Audit from 18 April 2017 to 19 April 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 18 April 2017 to 19 April 2017.
The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of four 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: 180
Number of care recipients during audit: 178
Number of care recipients receiving high care during audit: 168
Special needs catered for: Memory support
Audit trail
The assessment team spent two days on site and gathered information from the following:
Interviews
Position title / Number /General manager / 1
Human resources business partner / 1
Chief quality and risk officer / 1
Regional operations manager / 1
Wellbeing services manager / 1
Clinical/care staff / 15
Wellbeing coordinator / 1
Health and safety manager / 1
Admission coordinator / 1
Physiotherapy staff / 2
Care recipients/representatives / 32
Administration assistants / 2
Catering management/staff / 2
Cleaning/laundry management/staff / 4
Maintenance management/staff / 2
Contractor / 1
Sampled documents
Document type / Number /Care recipients’ files and care plans / 23
Medication charts / 22
Personnel files / 5
Care recipients’ agreements / 14
Other documents reviewed
The team also reviewed:
· Allied health referral and communication folders
· Audit and survey schedule summary, audit evaluation and monthly quality audit report
· Care recipients’ information package and handbook
· Cleaning and laundry documentation including schedules and sling register
· Continuous quality improvement plan
· Contractor documentation
· Dietary needs, supplement and preference documentation
· Education documentation including calendar and attendance records
· Emergency manual and flip chart
· Feedback forms
· Food safety program, audits and menu
· Handover sheets and diagnosis reports
· Human resources documentation including police record and registration registers, rosters, orientation records, recruitment system and human resource monitoring reports
· Incident forms including adverse event registers
· Infection data
· Maintenance and essential services schedules, records and reports
· Mandatory reporting documentation/folder
· Meal and dining experience survey and feedback forms
· Newsletter
· Operations bulletin, meeting minutes and schedule
· Palliative care related clinical documentation including end of life care pathway
· Policies and procedures
· Purchasing, supply documentation and supplier evaluation
· Self-assessment documentation
· Statement of choices form
· Wellbeing documentation including activities program, cultural events calendar and cultural catering theme day calendar.
Observations
The team observed the following:
· Activities in progress, equipment and resources
· Cleaning, laundry and maintenance in progress
· Emergency and firefighting equipment, evacuation kit, maps and egress pathways
· Equipment and supply storage areas including signage and safety data sheets
· Feedback forms, brochures, external complaints information in languages other than English and locked lodgement box
· Hearing impairment icon on care recipient name plates
· Interactions between staff and care recipients
· Living environment including café, medical clinic and gymnasium
· Meal and refreshment service
· Mission and values statements displayed
· Noticeboards and electronic information and menu displays
· Palliative care kit
· Personal protective equipment, infection control resources and processes
· Security processes in operation
· Storage and administration of medications
· The ‘Charter of care recipients’ rights and responsibilities – residential care’ on display
· Waste processing, storage and disposal.
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 organisation actively pursues continuous improvement and shows improvements across the Accreditation Standards. Management collect and collate data and information to identify opportunities for improvement from sources including improvement logs, verbal feedback from stakeholders, meetings, audits, hazard and risk identification and clinical data. Management register opportunities for improvement on the continuous quality improvement database which documents actions and supports the monitoring of progress towards desired outcomes. Established processes guide evaluation and management keep stakeholders informed through a range of communication strategies. Care recipients, representatives and staff are satisfied ongoing improvements occur.
Examples of recent improvement initiatives in relation to Standard 1 Management systems, staffing and organisational development include:
· To assist in communication by reducing the number of emails within the home and to ensure consistent communication of information, organisational human resource management introduced ‘Operational Bulletins’. The bulletin is produced weekly and informs managers of any changes to legislation, policies and procedures, forms/templates, issues and organisational changes. The manager disseminates the information as required. The home now has access to consistent, relevant information.
· To improve the feedback system, organisational management reviewed the feedback policy and procedure and reinforced the process of responding to compliments, comments and complaints. This includes monthly analysis of feedback forms submitted. The analysis results are displayed in the staff room in a graph format for staff review. Staff are more aware of the feedback system and encourage care recipients and representatives to complete when required.
· To enhance transparency and accessibility of human resource documents for the home and head office, management are incorporating staff details onto the electronic system. Following education in the process, designated staff are scanning all hardcopy employee files into the system.
1.2 Regulatory 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
Management with the support of the organisation have systems to ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines. Information from sources such as legislative update services, government websites and sector resources are communicated to management with relevant changes identified and any required action. Policies and procedures are developed, reviewed and updated according to required changes. Staff discuss regulatory compliance at relevant meetings and management disseminates information through email, meeting minutes and education. Monitoring of ongoing compliance is through the quality management system. Staff said they are informed of regulatory changes.
Examples of regulatory compliance in relation to Standard 1 Management systems, staffing and organisational development include the following:
· Management ensured the notification of all stakeholders about the re-accreditation audit within the required timeframe.
· Confidential documentation is stored and destroyed securely.
· There is a system to ensure all staff, volunteers and appropriate service providers have current criminal history checks and appropriate credentials.
1.3 Education 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 have a system to ensure all staff have appropriate knowledge and skills to perform their roles effectively. Organisational management develop an annual education calendar and provide other education and training opportunities as identified. Topics delivered or training provided may be as a result of regulatory requirements, observations, staff feedback, in response to quality activities and/or care recipients’ current and changing needs. There is an annual mandatory training program and education is provided during induction. There are a range of delivery methods which include in-house and external sessions, workshops, competency evaluation, online and self-directed learning. Staff evaluate sessions attended and key personnel maintain an electronic data base of education completed. Management and staff are satisfied with the learning opportunities offered to them. Care recipients are satisfied with the knowledge and skills of staff.
Examples of education and training provided in relation to Standard 1 Management systems, staffing and organisational development include:
· ‘ACFI’ training
· bullying and harassment training
· customer service training
· electronic documentation system training.
1.4 Comments 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 complaint mechanisms. Management ensure internal and external complaint information is accessible and provided in languages common to care recipients in the home. Management convey information about ways to comment and complain in information handbooks for care recipients and representatives, during orientation, at meetings and during informal contact. There are feedback forms and a locked suggestion box is available for anonymous input. The manager responds to suggestions and concerns and is available to all stakeholders. Meetings are conducted regularly and provide stakeholders with an opportunity to raise concerns. Staff assist care recipients or representatives to utilise the feedback mechanisms available, if required. Care recipients and representatives feel confident in using the comments and complaints processes available.