IRT Kangara Waters

RACS ID: 2939

Approved provider: Illawarra Retirement Trust

Home address: 2 Joy Cummings Place BELCONNEN ACT 2617

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 20 August 2020.
We made our decision on 13 July 2017.
The audit was conducted on 30 May 2017 to 01 June 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: IRT Kangara Waters Date/s of audit: 30 May 2017 to 01 June 2017

RACS ID: 2939 2

Audit Report

Name of home: IRT Kangara Waters

RACS ID: 2939

Approved provider: Illawarra Retirement Trust

Introduction

This is the report of a Re-accreditation Audit from 30 May 2017 to 01 June 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 30 May 2017 to 01 June 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: 100

Number of care recipients during audit: 98

Number of care recipients receiving high care during audit: 89

Special needs catered for: Wattle: 16 Bed secure unit for care recipients living with dementia

Audit trail

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

Interviews

Position title / Number /
Care recipients / 20
Representatives / 13
Business manager / 1
Care manager / 1
Registered nurses / 3
Clinical educator / 1
Registered nurse/Infection control co-ordinator / 1
Infection control officer / 1
Care staff / 6
Lifestyle co-ordinator / 1
Medical officer / 1
Nurse practitioner / 1
Physiotherapist / 1
Pharmacist / 1
Administration assistant / 1
Administration assistant/ site safety representative / 1
Hospitality manager / 1
Catering staff / 1
Laundry staff / 1
Cleaning staff / 2
Maintenance supervisor / 1
Head of quality and systems review / 1
Administration support officer quality and systems / 1
Structural designer / 1
Business manager IRT College / 1
Facilities manager – Southern / 1
Senior fire officer / 1
Head of procurement / 1
Category managers (procurement) / 2
Sales consultant / 1
Human resources business partner – Care / 1
IT systems people and culture / 1
Subject matter expert – Platinum / 1

Sampled documents

Document type / Number /
Care recipients’ files / 12
Medication charts / 10

Other documents reviewed

The team also reviewed:

·  Accident and incident reports

·  Behaviour management: behaviour assessments, monitoring charts, behaviour management plans, psychogeriatric and mental health team referrals and reports, behaviour incident reports, bed rail restraint authorisations

·  Catering, cleaning and laundry: audits, menu, dietary report, food safety records and program, cleaning records and schedules, audits, resident food comments books, survey

·  Clinical monitoring records: anticoagulant therapy, blood glucose levels, blood pressure, neurological observations and pressure relief turning charts

·  Comments and complaints: feedback forms, computerised entry of compliments and complaints

·  Continence management: continence assessments, continence management plans, daily bowel monitoring records, continence aid allocation list, complex health care directives indwelling catheter care, catheter management report

·  Continuous improvement: plan for continuous improvement, continuous improvement logs, audits and audit results, survey results, external benchmarking results, IRT Culture plan, safety net review

·  Education and staff development: attendance records, medication competencies, IRT College course calendar, training evaluations, monthly education calendars, on line training modules

·  Fire, security and other emergencies: fire training attendance records, care recipient mobility list, internal fire audits, disaster and evacuation management plan, emergency and response procedures, fire safety statement, maintenance service records

·  Human resource management: position descriptions and duty lists, master rosters and allocation sheets, staff medication competency list, annual performance reviews schedule, performance review and planning document, probationary reviews, roster, example of human resource staff file, call point report

·  Infection control: pest control records, Legionella test report, staff and care recipient fluvax register

·  Information systems: meeting minutes, policies and procedures, monthly care manager report, communication and appointment diaries, clinical handover documents

·  Inventory and equipment and external services: examples of agreements including allied health service agreements, draft contractor handbook, online supplier system, preferred supplier list

·  Lifestyle management: lifestyle past history , leisure and spiritual assessments, activity plans, attendance records, activity evaluations

·  Living environment: preventative maintenance manual, warm water temperature monitoring and system maintenance records, work orders, electrical tagging records

·  Medication management: medication administration plans, signing sheets, PRN medication (whenever necessary) evaluations, clinical refrigerator temperature monitoring records, therapeutic monitoring guidelines and anti-coagulant therapy care plans, oxygen therapy care plans, medication incident reports, nurse initiated medication forms, Drugs of addiction registers, complex health care directives diabetic management, diabetes management report, self-medication assessments/authorisations

·  Mobility: mobility assessments, physiotherapy care plans, individual exercise, massage, and heat pack therapy records

·  Nutrition and hydration: nutritional preferences assessments, weight monitoring records, dietitian reviews/management plans, speech pathologist reviews/reports, nutrition and hydration list and supplements list

·  Occupational health and safety: safety data sheets and alert system, work health and safety committee member list, safe work procedures, toolbox talks, safety improvement funding requests, incidental and one to one training log, hazard register, weekly safety reports

·  Pain management and palliative care: pain assessments, pain management plans, advanced care plan directives, palliative specialised nursing care plans, end of life clinical pathways

·  Planning and leadership: mission and values

·  Regulatory compliance: self-assessment report for reaccreditation, food business registration, mandatory reporting register, staff, contractor and volunteer police check monitoring systems, professional registrations, annual fire safety statement, work health and safety systems, privacy statement

·  Security of tenure: interim occupation agreement, resident agreements for residential care, resident guide (book), key feature statements

·  Skin integrity: wound assessments and management plans, photographic wound monitoring records, pressure care directives , podiatry assessments and reports

Observations

The team observed the following:

·  Australian Aged Care Quality Agency re-accreditation audit notice displayed

·  Care recipients participating in activities,

·  Care recipients utilising pressure relieving and hip and limb protection equipment

·  Chemical stocks and storage

·  Dining environment during midday meal service and morning and afternoon teas including staff serving meals, supervision and assisting care recipients

·  Equipment and supply storage areas

·  Fire monitoring and firefighting equipment and signage, evacuation information, sprinkler system, emergency evacuation back pack, disaster response supplies

·  Infection control resources including hand washing facilities, hand sanitising gel, colour coded and personal protective equipment, sharps containers, spills kits, outbreak management supplies, pest control and waste management systems

·  Interactions between staff ,care recipients and representatives

·  Internal and external complaints information available, suggestion boxes accessible to care recipients/stakeholders for secure lodgement

·  Living environment

·  Menu on display

·  Mobility and manual handling equipment in use and in storage

·  Mobility equipment in use including mechanical lifters, walk belts, wheel chairs, shower chairs, low-low beds, hand rails in corridors and internal lift access

·  Nurse call system and response by staff

·  Secure storage of care recipients' clinical files and confidential staff handover

·  Secure storage of medications and oxygen; medication administration

·  Short group observation in Wattle lounge

·  Sign in/out registers, security measures

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

·  Vision, Mission statements displayed

·  Welcome pack for new care recipients

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

IRT Kangara Waters has a quality framework, which assists in the active pursuit of continuous improvement across all four Accreditation Standards. The quality framework supports the identification, implementation and evaluation of improvement opportunities and activities. The identification of areas for improvement occurs through scheduled audits, analysis of incidents and clinical indicators, and regular meetings for care recipients, their representatives, management and staff. The comments and complaints system, surveys and direct feedback from care recipients, their representatives and staff also contribute to the home’s quality framework. Strategies are developed, documented, monitored and evaluated to ensure satisfactory outcomes are achieved. Staff are aware of the systems for continuous improvement and confirm they are involved in continuous improvement activities. Interviews with care recipients, representatives and staff confirm feedback has resulted in improvements for care recipients. Recent improvements relating to Accreditation Standard One include:

·  An IRT staff survey identified staff have felt unappreciated. An organisation wide project, ‘Call out a champion’ to improve staff morale is now in place. Staff are able to recognise one another through sending thank you cards on line. The computerised system keeps records of thank you cards for each staff member, points can be awarded to staff which they are able to redeem for cash or a gift card. Staff report the recognition of work well done “feels good”.

·  To support succession planning, staff leadership roles are being reviewed as opportunities arise for staff to act in more senior roles. Staff are being included in senior management meetings to assist in their development. Additional training in frontline management has been made available for those in leadership roles.

·  In response to feedback from care recipient’s representatives about ways to improve communication, the home has commenced compiling an email contact list for representatives. Email notifications for care recipient/representative meetings are being sent to representatives and this has resulted in increased attendance at the meeting.