Garrawarra Centre

RACS ID: 1456

Approved provider: NSW State Government (NSW Ministry of Health)

Home address: 1810 Old Princes Highway WATERFALL NSW 2233

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for one year until 14 December 2018.
We made our decision on 16 October 2017.
The audit was conducted on 04 September 2017 to 06 September 2017. The assessment team’s report is attached.
The period of accreditation will allow the home the opportunity to demonstrate that the recent improvements in care standards are sustainable, and will mean that the home is subject to another 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.

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: Garrawarra Centre Date/s of audit: 04 September 2017 to 06 September 2017

RACS ID: 1456 29

Audit Report

Name of home: Garrawarra Centre

RACS ID: 1456

Approved provider: NSW State Government (NSW Ministry of Health)

Introduction

This is the report of a Re-accreditation Audit from 04 September 2017 to 06 September 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 04 September 2017 to 06 September 2017.

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: 120

Number of care recipients during audit: 99

Number of care recipients receiving high care during audit: 99

Special needs catered for: Care recipients with dementia and behavioural and psychological symptoms of dementia

Audit trail

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

Interviews

Position title / Number /
Deputy chief executive – local health district / 1
General manager/nurse manager / 1
Nurse unit managers / 4
Registered nurses/endorsed enrolled nurses / 6
Administration assistant / 1
Business quality manager / 1
Advisor/Administrator / 2
Clinical advisor / 1
Clinical nurse consultant – infection control / 1
Clinical nurse educator / 1
Registered nurse/clinical nurse consultant / 1
Nurse educators / 2
Physiotherapist / 1
Oral hygiene, footcare and music and memory coordinator / 1
Diversional therapist / 1
Care staff / 9
Geriatrician / 1
Care recipients/ representatives / 22
Hotel services Manager / 1
Work health and safety officer (SESLHD) / 1
Rehabilitation case manager (SESLHD) / 1
Administration staff / 1
Cleaning staff / 1
Laundry staff / 2
Hospitality staff / 4
Security staff / 1
Medical officer / 1

Sampled documents

Document type / Number /
Care recipients’ files / 12
Incident investigation reports / 12
Medication charts / 12
Wound assessments and management plans / 14
Personnel files / 8

Other documents reviewed

The team also reviewed:

·  Care recipient information pack, handbook, resident and accommodation agreement

·  Care recipient room listing

·  Cleaning and maintenance schedules

·  Clinical management committee terms of reference and meeting minutes, clinical policies and procedures, flowcharts, handover sheets

·  Comments and complaints register, compliments

·  Continuous improvement: continuous improvement action work plan, audit schedule and results, monthly incident and infection control reports - trend analysis

·  Diabetes review

·  Email to nurse unit managers and nurses re documentation of behaviour management

·  Equipment checklists

·  External contractors: contracts and service agreements, contractor insurance details, preferred contractor/service supplier list, equipment service reports

·  Fire security and other emergencies: fire safety equipment, fire safety audits, fire officer monthly checklists, evacuation plans, emergency procedures manual, disaster management plan

·  Food safety program: daily record sheets - food and equipment temperatures, NSW food authority audit results

·  Human resource management: induction checklist, staff handbook, statutory declarations, confidentially agreements, position descriptions, duty statements, rosters, staff allocation sheets, performance appraisals and schedule

·  Incident report summary – resident abuse (consolidated register of incidents)

·  Infection control; infection surveillance program, infection control results, infection control data collection sheets, needle stick and sharp object injury report, blood and body fluid exposure report, influenza outbreak documentation, refrigeration temperature monitoring, pest control service reports, Legionella testing reports

·  Information and communication systems: policies and procedures, memoranda, communication diaries, shift handover report forms, organisational chart, committee meeting agendas and minutes - workplace health and safety/infection control/food/safety/ continuous quality improvement, management, registered/enrolled nurses, staff, residents/relatives

·  Inventory and equipment: equipment register and lists, maintenance requests, internal and external preventative maintenance schedule, equipment service records; thermostatic mixing valve testing records, electrical test tagging

·  Medication management; Medication advisory committee terms of reference and meeting minutes, ward registers of drugs of addiction, refrigerated medication storage records, medication management – principles of safe medication management, medication policies and procedures, emergency and PRN medications

·  Memo re update of the IIMS system sticker for progress notes – investigation of incidents

·  Monthly aggression review August 2017

·  Monthly falls review August 2017

·  NSW Health and Aged Care Quality and Governance Taskforce agenda

·  Nutrition and hydration; food preference lists, specialised dietary requirements, seasonal menus, dietician review

·  Nutritional supplement charts

·  Procedure for resident post fall management

·  Regulatory compliance; consolidated incident reporting register, unexplained care recipient absences, staff and contractors police certificate checks, professional registrations - registered nurses, general practitioners, allied health

·  Self-assessment report for re-accreditation and associated documentation

·  Staff education; orientation program, monthly education calendar, mandatory and non-mandatory attendance record, staff qualifications, competency assessments

·  Sunshine leisure and lifestyle program for AIN trial June/July 2017

·  Use of restraint policy

Observations

The team observed the following:

·  Activities and entertainment in progress, activities programs on display

·  Aged Care Complaints Commissioner and advocacy information on display

·  Archive room

·  Cleaning in progress, trolleys and supplies, wet floor signage in use

·  Clinical equipment and supplies

·  Clinical information noticeboards in treatment rooms

·  Dining environments during midday meal services, morning and afternoon tea, staff serving/supervising

·  Displayed notices; Quality Agency re-accreditation audit notices, Charter of care recipients’ rights and responsibilities, mission statement

·  Diversional therapy information whiteboard

·  Duress pendants in use by staff

·  Electronic and hardcopy documentation systems

·  Equipment and supply storage areas including linen, continence and medical supplies

·  Feedback forms - ‘Tell us want you think”’ and comments/complaints, locked suggestion boxes

·  Firefighting equipment checked and tagged, fire indicator panel, sprinkler system, evacuation diagrams, evacuation resources

·  Hairdressing salon, café,

·  Handover report meeting

·  Infection control resources: hand washing facilities, hand sanitisers, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies, locked clinical medication bins, infectious laundry handling, waste management

·  Information noticeboards, electronic boards

·  Interactions between staff and care recipients/relatives/visitors during meal service and lifestyle activities

·  Kitchen and serveries, NSW food authority licence on display

·  Laundry, personal laundry, heat seal labelling machine

·  Leisure and lifestyle activities in progress

·  Leisure and lifestyle program displayed

·  Living environment internal and external

·  Medical officer onsite

·  Medication administration and storage

·  Menu on display

·  Mobile dental clinic onsite

·  Mobility and manual handling equipment in use and in storage

·  Nail care box

·  Nurse call system and timely response by staff

·  Photographs of care recipients participating in exercise and lifestyle programs

·  Safe chemical and oxygen storage, safety data sheets (SDS) at point of use

·  Secure storage of care recipients’ clinical information and staff information

·  Short group observation

·  Sign in/out registers, keypad access, closed circuit television (CCTV) security cameras

·  Staff handover

·  Staff noticeboards

·  Staff work practices and work areas

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

Garrawarra Centre has a continuous improvement system to identify and implement improvements across the four Accreditation Standards. The home’s quality management system identifies improvement opportunities from a range of sources that include scheduled audit results; surveys; incident and clinical indicator trend analysis reporting; meetings and feedback mechanisms. Management develops a continuous improvement action work plan to enable identified areas for improvement to be prioritised, actioned and evaluated. Meetings are held to progress initiatives. Care recipients/representatives and staff are encouraged to make suggestions and stated they are aware of improvements undertaken in the home. Examples of recent improvements implemented in relation to Accreditation Standard One include:

·  The home specialises in the management of care recipients with dementia and mental illness. A more formalised approach to consultation of service was required to meet the needs of the care recipients. A meeting was conducted with District Executive team and, as a result, an increased specialist resources was made available to attend the home on a regular basis to assist with the management of care recipients at risk. The services of the Sutherland Hospital (TSH) clinical nurse consultant (CNC) dementia/mental health and a Geriatrician specialising in psychogeriatric care have been utilised to provide assessment of care recipients throughout the Garrawarra Centre. The improvement has been successful in ensuring there are clear clinical pathways and support to manage aggression and the specialised needs of the care recipients at the home.

·  The Programs and Performance Director identified many of the clinical and corporate supports between TSH and the Garrawarra Centre needed to be strengthened. A decision was made to combine the management and leadership of Garrawarra Centre with the management of TSH. The advantage of this restructure to Garrawarra Centre will include: