Uniting Banks Lodge Peakhurst

RACS ID: 0232

Approved provider: The Uniting Church in Australia Property Trust (NSW)

Home address: 93 Baumans Road Peakhurst NSW 2210

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 22 December 2020.
We made our decision on 08 November 2017.
The audit was conducted on 27 September 2017 to 29 September 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: Uniting Banks Lodge Peakhurst Date/s of audit: 27 September 2017 to 29 September 2017

RACS ID: 0232 20

Audit Report

Name of home: Uniting Banks Lodge Peakhurst

RACS ID: 0232

Approved provider: The Uniting Church in Australia Property Trust (NSW)

Introduction

This is the report of a Re-accreditation Audit from 27 September 2017 to 29 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 27 September 2017 to 29 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: 114

Number of care recipients during audit: 106

Number of care recipients receiving high care during audit: 88

Special needs catered for: Memory support unit accommodating 27 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 / 21
Representatives / 5
Head of residential operations Sydney South Regional Hub / 1
Service manager / 1
Deputy service manager / 1
Quality improvement manager learning and development (Regional hub) / 1
Clinical nurse educator / 1
Residential business lead manager (Regional hub) / 1
Business services officer / 1
Registered nurses / 4
Endorsed enrolled nurse / 1
Care staff / 10
Physiotherapists / 2
Memory and lifestyle support officer (Regional hub) / 1
Recreational activities officers / 2
Transport manager (Regional hub) / 1
Chaplains (Regional hub) / 2
Pastoral care staff / 2
Beautician / 1
Volunteers / 2
Administration assistant / 1
Client admission officer / 1
Assets officer / 1
Chef / 1
Catering staff / 2
Laundry staff / 1
Cleaning coordinator and rosters officer / 1
Cleaning staff / 1
Area maintenance supervisor / 1
Maintenance staff / 1

Sampled documents

Document type / Number /
Care recipients’ files (assessments, progress notes, care and lifestyle plans and associated documentation) / 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, wandering ‘resident’ check list

·  Catering, cleaning and laundry: food safety records, cleaning schedules (including laundry and kitchen)

·  Clinical monitoring records: care plan review schedule, clinical care needs spreadsheet, care and clinical admission and review procedure, anticoagulant therapy, blood glucose levels, blood pressure, neurological observations, pain, hygiene and pressure relief turning charts, clinical indicator monitoring data, case conference records

·  Comments, complaints and compliments register (electronic)

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

·  Continuous improvement: audits, continuous improvement plan and outcomes

·  Emergency plan

·  Human resources: job descriptions, electronic personnel files, recruitment policies and procedures, rosters, education records (mandatory and professional development), education matrix, learning and development calendar and learning campus (electronic)

·  Infection control: staff and care recipient fluvax register, outbreak management guidelines, Public Health Unit line listings, infection incident reports, infection surveillance monitoring data

·  Information management: communication diaries, memoranda, minutes of meetings, care recipient, staff and volunteers information handbooks, policies and procedures, care recipients’ information package, surveys and agreements

·  Lifestyle management: lifestyle past history , leisure and spiritual assessments, activity plans, attendance records, activity evaluations, newsletters, consent forms, communication cue cards

·  Maintenance records: maintenance plans (preventative and reactive), contractors folder and handbook, assets register

·  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, professional signatures register, self-medication assessments/authorisations

·  Mobility: mobility assessments, physiotherapy care plans, individual exercise, massage, heat pack therapy and transcutaneous electrical nerve stimulation attendance records, hip protector list, safe footwear checklist

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

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

·  Regulatory compliance: police certificates and statutory declarations register, professional registrations, consolidated register and incident and hazards reporting records

·  Self-assessment report for reaccreditation and associated documentation

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

·  Work, Health and Safety materials

Observations

The team observed the following:

·  Activities in progress

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

·  Chemicals storage and safety system including safety data sheets

·  Complaints (internal and external) forms, materials and brochures

·  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 certificate, fire equipment, exits and evacuation plans

·  Hairdresser and beautician in attendance

·  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

·  Information noticeboards including Work, Health and Safety

·  Interactions between staff, care recipients and representatives

·  Living environment

·  Menu and menu boards (including electronic in foyer)

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

·  NSW Food Safety certificate A rating

·  Pampering room and memory areas/boxes

·  Re-accreditation audit notice on display

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

·  Secure storage of medications and oxygen; medication administration

·  Short group observation in memory support unit lounge

·  Sign in/out registers, internal swipe and key pad access, closed circuit television monitoring systems

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

·  Vision, Mission and Philosophy statements and Charter of Care Recipients' Rights and Responsibilities displayed

·  Wound management trolley and resources

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 home demonstrated it has a robust continuous improvement system with a range of continuous activities across the Accreditation Standards. Uniting, the organisation, has developed consistent systems and processes designed to capture and analyse information relevant to continuous improvement activities. The home’s management demonstrated it applies these to its continuous improvement program. Staff, care recipients, representatives and other stake holders are actively encouraged to contribute to continuous improvement. Improvements are also drawn from analysis of information such as clinical and incident data, audits, surveys, meeting minutes, comments, complaints and compliments. The organisation’s Practice and Quality team work closely with the home’s management to support continuous improvement. Improvements are evaluated for effectiveness. Care recipients and staff were able to describe a range of recent improvements and their satisfaction with these.

Continuous improvements related to Standard One include the following:

·  Following care recipient feedback regarding staff sufficiency, management conducted a review of staffing numbers across the home. The review identified an increase in care recipient needs leading to a targeted increase in staffing levels. This included a registered nurse position being introduced overnight. A floating care staff position has been added to both the morning and afternoon shifts. Further to this a leisure and lifestyle office was introduced on weekends in the memory support unit to better support the management of behaviours. The service manager and deputy acknowledged these changes have been successful andthey are continuing to monitor the sufficiency of staff. Including the plan to introduce an additional floater position to assist with strategies in fall prevention.

·  Uniting has recently undergone a major review and restructure. Building on its model of inspired care it is rolling out in residential care a first person/household model. This will lead to creating smaller clusters (or households) within the home; each with its own kitchen, dining room, activity area and small, cosy, homely spaces. The home’s management is beginning to integrate this approach into Banks Lodge. Key staff have attended training on applying the model and recent refurbishments within the home reflect this (see Continuous improvement Standard Three for more information on this). Management recognise the need to change the work culture to achieve this outcome and provide person first care and services and are actively applying this to their current recruitment requirements. Management are actively working to empower staff to be a self-led team and make work decisions appropriate to their designation. Solution orientated community circles are being used for care recipients/representatives and staff to discuss and problem solve issues and concerns. Care recipients and staff said they are inspired by the changes that are taking place through this improvement.