Bupa Calwell - RACS ID 2948 - 43 Were Street

Bupa Calwell - RACS ID 2948 - 43 Were Street

Bupa Calwell RACS ID 2948 43 Were Street CALWELL ACT 2905 Approved provider: Bupa Care Services Pty Limited 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 01 October 2019. We made our decision on 24 August 2016. The audit was conducted on 12 July 2016 to 14 July 2016. The assessment team’s report is attached. We will continue to monitor the performance of the home including through unannounced visits.

Home name: Bupa Calwell RACS ID: 2948 2 Dates of audit: 12 July 2016 to 14 July 2016 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.

Expected outcome Quality Agency decision 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

Home name: Bupa Calwell RACS ID: 2948 3 Dates of audit: 12 July 2016 to 14 July 2016 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. Expected outcome Quality Agency decision 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

Home name: Bupa Calwell RACS ID: 2948 4 Dates of audit: 12 July 2016 to 14 July 2016 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 service and in the community. Expected outcome Quality Agency decision 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.

Expected outcome Quality Agency decision 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: Bupa Calwell RACS ID: 2948 1 Dates of audit: 12 July 2016 to 14 July 2016 Audit Report Bupa Calwell 2948 Approved provider: Bupa Care Services Pty Limited Introduction This is the report of a re-accreditation audit from 12 July 2016 to 14 July 2016 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. 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

Home name: Bupa Calwell RACS ID: 2948 2 Dates of audit: 12 July 2016 to 14 July 2016 Scope of audit An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 12 July 2016 to 14 July 2016. 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.

Assessment team Team leader: Jennifer Morrow Team member/s: Carol Lowe Approved provider details Approved provider: Bupa Care Services Pty Limited Details of home Name of home: Bupa Calwell RACS ID: 2948 Total number of allocated places: 144 Number of care recipients during audit: 111 Number of care recipients receiving high care during audit: 107 Special needs catered for: 36 secure dementia care beds Street/PO Box: 43 Were Street City/Town: CALWELL State: ACT Postcode: 2905 Phone number: 02 6298 5400 Facsimile: Nil E-mail address: Nil

Home name: Bupa Calwell RACS ID: 2948 3 Dates of audit: 12 July 2016 to 14 July 2016 Audit trail The assessment team spent three days on site and gathered information from the following: Interviews Category Number General manager 1 Regional support manager 1 Business administration manager 1 Business administrator 1 Care managers 3 Registered nurses 5 Care staff 6 Recreational activities officer/work health and safety committee chairperson 1 General practitioner 1 Care recipients/representatives 16 Physiotherapy aide 1 Laundry staff 3 Cleaning staff 4 Maintenance staff 2 Chef 1 Catering staff 2 Recreational activities officers 3 Sampled documents Category Number Care recipients’ files 14 Education folders (2015 and 2016) 2 Personnel files 10 Medication charts 12 Audit folders (Accreditation Standards 1-4 and medication) 6 Cleaning folders 5

Home name: Bupa Calwell RACS ID: 2948 4 Dates of audit: 12 July 2016 to 14 July 2016 Other documents reviewed The team also reviewed:  Bupa Calwell – resident handbook and pamphlet  Bupa Care Services resident handbook  Care plan schedule, handover, communication diary’s,  Care plans, assessments allied health specialist referral, care folders and charts including pain management, wound treatments, food and nutrition documents, continence care, behaviour logs, physiotherapy and rehabilitation instructions  Care recipients’ information handbook  Catering information including: dietary information, temperature records for thedelivery, storage, preparation and serving of meals, cleaning records, menu  Commissioning education program powerpoint presentation  Complaints on computer system and confidential improvement log folder  Consent to use personal information, display name, consent for treatment and procedures  Daily staffing sheets, staffing availability forms and roster  E-learning education program on computer system  Emergency procedure flipchart  Employee handbook  Guide to incident reporting flipchart  Induction guide – new employee and induction checklist  Infection control: manual, outbreak information/records, vaccination records, infection data, and fridge temperature records  Job description and duty statement folder  Legislative information including: ACT Government – Health Food Business Registration (20 October 2015 to 22 October 2016), mandatory reporting register – computer printout, volunteers police check information and registered nurses and allied health professional registrations folder , staff police check information on computer system and visa information, log books for the sprinkler system, emergency warning system, emergency intercom system, fire detection and alarm systems, passive fire and smoke systems and fire hydrant systems  Leisure and lifestyle: weekly program and calendar, attendance records, lifestyle assessments, photographs

Home name: Bupa Calwell RACS ID: 2948 5 Dates of audit: 12 July 2016 to 14 July 2016  Maintenance program including: reactive maintenance folders in the care offices, preventative maintenance program, sign off sheets, schedule for the preventative maintenance program with external companies, work instructions for the maintenance system, microbial sampling (warm water system), preferred contractors and suppliers telephone listing, service reports on equipment, chemical register, product safety data sheets  Medication management: policy, pharmacy folder, medication charts, medication sign charts, doctor’s orders, incident reports, controlled drugs register  Meeting minutes folder  Resident and accommodation agreement Observations The team observed the following:  Activities in progress  Certificate of completion of a structure - 23 October 2015  Charter of residents’ (care recipients’) rights and responsibilities on display at front entrance  Continuous improvement log folder, cleaning log folder, complaints and advocacy information pamphlets on display at front entrance  Dining rooms during meal service, staff assisting care recipients as needed  Displayed notices including re-accreditation audit notices, advocacy brochures, education and activities calendars meeting minutes and menus  Emergency evacuation plans and emergency kits  Equipment and supply storage areas  Infection control spill kits, sharps containers, outbreak management kits, personal protective equipment, colour coded cleaning equipment, hand sanitiser throughout the home, waste disposal facilities  Interactions between staff, care recipients and representatives  Living environment  Short group observation in Hilly Oaks lounge/dining/activities room  Storage of medications  Value statement on display at front entrance and various locations around the home  Visitors registers and security measures

Home name: Bupa Calwell RACS ID: 2948 6 Dates of audit: 12 July 2016 to 14 July 2016 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 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 This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings The home meets this expected outcome Bupa Calwell (the home) opened in late 2015 and participates in a program of organisational audits to review and monitor the quality of service delivery. An audit schedule guides the management team with the program of audits to be conducted across a range of clinical, environmental and administrative areas. The audits results are entered onto the home’s continuous improvement plan as well as a computerised system which enables senior management at the organisation’s head office to monitor any audit trends as well as ensuring audits are being completed.

Additional audits can be undertaken if issues are identified and external audit teams from within the organisation can be called in to conduct audits on specific topics if required. Improvements are also sourced via continuous improvement logs, confidential continuous improvement logs and verbal complaints. Feedback is also sought through the staff, care recipient and representative meetings. A sample of improvements relating to Standard One includes the following:  The general manager advised that some staff files had come to the home when these staff members had been transferred from other homes within the group.

A review of the personnel files identified information was not always filed in a consistent manner and some key information was missing from files. Follow-up has been undertaken with the human resource recruitment centre to track down missing documents. Administration staff have been progressively working through staff files to ensure information is filed appropriately to enable management to track information when needed. The general manager advised the administration staff now have a work instruction to guide them with filing requirements.

 The general manager advised that the home undertook a review of the work instruction for the education program and identified that the instructions were not being followed. A training needs analysis was issued to staff to enable them to record their training and education requests. This information was then entered into a matrix to identify the most popular requests for education topics as well as their preferred form of education delivery. This information is now being used to further develop the education program. Pre and post education evaluation forms are being reviewed to glean any information which can be used to develop and improve the education sessions.