27 MAY 2016
Aileen Robertson – ACQA board member
Sue Ferres – CHSA Riverland Mallee Coorong Region
Bridgette Van Den Brink & Kristi Luneta – Jallarah Homes Inc
Kathy Fahey – CHSA
Tania Woolford – Mt View Homes Inc,
Leanne Wood – Star of the Sea Aged Care Wallaroo
Louise Cooper – Barmera Aged Care
Laura Mudge & Kerri Ingham – CHSA Eudunda Hospital & Senior Citizens Hostel
Rachele Keon – CHSA Kapunda Homes
Marlene Durdin – Wheatfields Inc
Matt Kowald – Barossa Village
Tania Drever – CHSA

Gail Harding – Wheatfields Inc
Dawn Hilditch, Maggie Hayward and Di Adams – Hamley Bridge Hospital

General Business
On behalf of the ACQA board Aileen welcomed everyone present, explaining the Matt would be joining the meeting later. Gail is currently on leave from Wheatfields and travelling interstate, as part of her road trip she is doing presentations at 5 locations in Victoria and NSW to inform other facilities of the work ACQA does and the advantages for the members.

The ACQA board is planning on holding a conference later this year and Matt will talk about this more later in the meeting.

More interstate road trips have been discussed with Gail volunteering to visit Tasmania and Matt going to Queensland.

Steven Charman will be here in July to meet with representatives from Country Health SA. There will be details of a software update released in a few months’ time.

Aileen then asked for feedback from those present how ACQA is useful to them.

Sue- The audits help to meet expected outcomes for the agency, especially when you have an unannounced visit.

Bridgette- finds the website easy to use compared to other websites for Continuous Improvement.

Rachele Keen- If the person responsible for entering information into the ACQA site is on leave it is very easy for their replacement to pick it up, very little training is required.

Kathy- Networking is great, it’s a shame not more people use it. It’s good to share what works for your facility. People working alone developing resources and this duplicates effort.
Benchmarking and trends for organisations with multiple sites.

Sue- great support from Active QMS (excellent response within a day).
Likes the Graphing & Reports.
As its web based staff can work from home on it allowing for more staff flexibility.
Recent accreditation audits have focused on Continuous Improvements and want to see step by step documentation including evaluations.

Matt- At Barossa village they are using the Australian Unity Wellbeing Index for every admission and again at the care plan evaluation. In Leecare Matt has added a link in Emotional Wellbeing screen and will send the schema pathway to anyone that would like it.

In relation to the aged care industry we all need to change our thinking from care to cruise ship. To reflect what is offered to our clients.

Google ‘Ted Talk’ on blood taking- good for staff to watch. Kapunda Homes have included this in mandatory education.

Item 2: Audit Review Information Management
Update review date

Policy, Procedure and/or Guidelines
2. Remove this question.
3. Does the home have a policy, procedure and/or guideline on the appropriate use of Information Technology (IT) including the use of devices and social media? (EO 1.8)
4. Remove this question.
6. Remove this question.
8. Remove this question.

Clinical Documentation Principles
4. Are food allergies and sensitivities recorded on all dietary information? (EO1.8)
5. Are clinical notes stored securely? (EO1.8)

Information Technology
New questions to replace current questions.
1. On the day of the audit are staff aware of the IT policy, procedures /guidelines regarding the use of social media and mobile devices? (EO 1.3 & 1.8)
2. Have staff received computer training appropriate to their role? (EO 1.3)
3. On the day of the audit were staff satisfied that they were competent in the use of the home’s current IT systems, appropriate to their roles? (EO 1.3, 1.6 & 1.8)

Review of Information System
1. Are all minutes of meetings recorded, completed and accurate? (EO 1.8)
2. Are hazards reported, recorded, completed and accurate? (EO 1.8)
3. Are all staff incidents reported, recorded, completed and accurate? (EO 4.5)
5. Has all feedback information (CCI’s) been collated, actioned and fed back to relevant consumers as per organisations policy, procedure / guidelines? (EO 1.1, 2.1, 3.1 & 4.1)

Care Recipient Information
5. Was the information provided to the care recipients understandable to them? (EO 1.8)

Item 3 Audit review Medication Management Audit
Update review date

Relevant Guidelines: The link to ‘Guiding Principles for Medication management in residential aged care facilities’ doesn’t work

3. The link to ‘Responding to issues of restraint in Aged Care’ doesn’t work

Medication Management
1. Does the organisation have a medication policy, procedure and/or guidelines that reflects the organisations current medication system and process? (EO 2.2)
2. Does this policy, procedure and/or guidelines clearly identify which categories of staff can administer different types of high rick medications? (EO 2.2)
3. Does the home have a clear policy, procedure and/or guidelines for the administration of nurse initiated medications? (EO 2.2)
4. Remove this question.
5. Does the home have a policy, procedure and/or guidelines on the safe use of complementary or alternative medications used by Care Recipients? (EO 2.2)
6. Is there a policy, procedure and/or guideline in place for the management of Imprest medications? (EO 2.2)
7. Is there a current policy, procedure and/or guideline to ensure disposal of medications and medication administration equipment appropriately?
9. Have all medication incidents as outlined in the mediation policy, procedure and/or guidelines been reported via the home’s clinical incident reporting system for this audit period? (EO 2.4)
10. Are medication incident trends identified , monitored and tabled at relevant meetings in accordance with the home’s medication policy, procedure and/or guideline? (EO 2.2)

Staff Training
1. Are medications administered by appropriate skilled staff in accordance with the home’s medication policy, procedure and/or guidelines and current legislation? (EO2.3)

Best Practice Guidelines
2. Have external medication reviews including “Quality of Use of Medications” been conducted by an appropriately skilled pharmacist in accordance with the home’s medication policy, procedure and/or guidelines? (Draft guiding principle No 3) (EO 2.7)
3. Does the home have a Medication Advisory Committee? (Draft guiding principle No 1) (EO 2.7)

Administration of medication
2. If a medication is not administered is the reason documented on the medication chart? (EO 1.8)
3. If a medication is not administered is the reason documented in the Care Recipient’s progress notes? (EO 1.8)

Care Recipients who self-mediate
New question- 1. Does the home have a medication management policy, procedure and/or guideline for care recipients who wish to self-medicate? (EO2.4)
2. Have all Care Recipients who self-medicate any medication, been assessed safe to do so in accordance with the organisations policy, procedure and/or guidelines? (EO 2.4)
3. Do care recipients who self-administer their medicines have a current ‘Patient Medication profile’ supplied by their pharmacist? (EO 2.7)
3. Remove this question- Have all medications been provided in accordance with these orders? (EO 2.7)

Infection Control
3. On the day of the audit was equipment used for altering the form of medications cleaned between use as per guidelines? (EO 4.7)

Medication supply and disposal
2. Have all medications been disposed of in accordance with the home’s medication policy, procedure and/or guidelines? (EO 2.7)
3. All medications in use are within their expiry date? (EO 2.7)

Continuous Improvement
1. Is systematic evaluation of medication management in the home conducted regularly in consultation with the MAC? (EO 2.1)

Item 4 Round table
Matt – the ACQA board is proposing to hold a conference possibly on the 4th November it would be an all-day event.
Some locations discussed were the Arkabar or Ridges.
Aiming for an attendance of 100 to make it cost effective, possibly be $75 for members and $150 for non-members.
Some suggestions for presenters / topics include Quality of Life- Wellbeing, Pinnacle HR- Social media issues, Hamley Bridge Memorial Hospital – Lessons learnt from the Pinery Bushfire, Sarah Molineke – Pressure injuries.

Tanya W – In a previous program staff could enter an improvement and at a later date transfer it to the Continuous Improvement plan without having to re-enter the information. This has been brought up before and hopefully will be included in the next software release.

Bridgette – Drop down boxes don’t always print out on audits. If Chrome or Firefox are used they print out okay.

Tanya D – Suggested that the Hand Hygiene only be done twice a year. All agreed that this was a good idea.

Confident Care rep Amanda Lake (0414 011 706) will present free education on Oral care, (and can supply fingernail kits)

Marlene – The Privacy audit was removed from the website ?for review, is it required? Matt suggested that it be discussed at the next meeting.

Could we have an area on the audits to record who conducted the audit currently it only records who enters the audit?

Item 5 Audit review Leisure, Health and Wellbeing Audit
Update review date

3. The link to Decision making tool: ‘Responding to issues of restraint in Aged Care’ doesn’t work
5. The link to ‘Outcomes of National Workshops on draft revised Accreditation Standards for residential aged care (May 2011) doesn’t work.

Assessment and Planning
3. Have all Care Recipients had a social and leisure profile completed as part of their admission process?
4. Delete this question.
6. Is there evidence of care plan reviews of all Care Recipients’ individual leisure, health and wellbeing plans based on their current needs, in accordance with the home’s policy, procedure and/or guidelines?
7. Have all Care Recipients’ individualised leisure, health and well-being needs, goals & strategies been identified and documented?
8. Delete this question.
9. Delete this question.
10. Delete this question.
11. Is there evidence that the home has a policy, procedure and/or guidelines for the delivery of the Leisure & Lifestyle program?
12. Is the leisure, health and well-being interventions incorporated into all aspects of care?

Is there evidence within the individualized care plan of support needs related to the following areas, as determined by individual need. Delete this section.

Audit Criteria – Identifying individual’s Support Needs (EO 2.4,3.2, 3.5, 3.6, 3.7, 3.8 & 3.9)
Further Explanation Q7
Based on the Decision Making Tool; Responding to issues of restraint in Aged Care this link doesn’t work

Identification of Support Needs
1. Have all Care recipients’ past and current cultural (nationality) needs and preferences been identified and incorporated into their leisure, health and well-being plans?
Remove nationality.
3. Have all Care Recipients’ past and current spiritual (focused on the self) needs and preferences been identified and incorporated into their leisure, health and well-being plans? Remove focused on the self.
7. Is there evidence of leisure, health and well-being strategies being exhausted before Restraint is initiated? Change to restraint.

Remove this entire section.
Is there evidence of a policy, procedure and/or guideline designed to support the individual in the following areas?
1. Privacy, Dignity & Confidentiality
2. Choice & control of their own lives (inclusive of language & literacy needs)
3. Physical Independence
4. Cognitive health support
5. Mental health support
6. Lifestyle independence.

Audit Criteria – Leisure, Health and Wellbeing Programs (EO 3.7)
Guidelines for Q1 to Q8 – This section of the audit concentrates on the Leisure Activities program within the home.

Leisure, Health and wellbeing Programs
3. Are objectives and session plans set for all programmed activities in accordance with your policy, procedure and/or guidelines?
4. Has a risk assessment been completed for programmed activities?
8. Are staff responsible for assessment and planning the leisure, health and well-being program appropriately trained?
Audit Criteria – System and Process regarding Risk Management & WH&S (EO 1.8, 3.1 & 4.5)
Guidelines for Q1 to Q8 – This section of the audit reflects internal systems & processes.
‘Risk management process’ refers to the identification of risks & strategies in place to negate or minimise the level of risk. WH&S and risk management processes should comply with the home’s internal systems & processes.
System and Process
Insert a new question as number 1
1. Do staff other than lifestyle staff participate in leisure, health and wellbeing programs?
2. Do staff other than lifestyle staff participate in care recipients’ leisure, health and wellbeing documentation including exceptional reporting?
3. Is there a detailed program of leisure, health and wellbeing activities available in advance, to care recipients?
Delete the current Q7. Is there evidence of risk management within WH&S processes built into the leisure, health and well-being program activities and care recipients?

Meeting closed 3pm

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