ACQA Network Meeting Minutes
25th August 2017
Gail Harding Wheatfields Inc,
Elsbeth Marich Wheatfields Inc,
Sue Ferris CHSA Riverland Mallee and Coorong,
Bridgette Van Der Brink Jallarah Homes,
Jenny Fairey Barossa Village,
Dawn Hilditch Hamley Bridge,
Joe Tutty Hamley Bridge,
Tina Garrard Hamley Beidge.
Tania Woolford Mt View Homes,
Lesley Hawker West Wimmera Health Service.
Gail Harding welcomed all attendees.

Discussion on Accreditation Visits.
Spot visits

Wheatfields: Had an unannounced visit and Assessment and Care planning was assessed.

Issues were: Call Bells, Complaints, Electronic Signatures for Scripts Log in for Doctors, Scripts acceptable to be processed.

If you are using an electronic medication system and the Agency staff query the doctors’ signature because it is not hand written, let them know Log in is the electronic signature and it is acceptable.

Hamley Bridge: Compulsory Reporting, 3.2, Discression of not to report behaviours due to cognitively impaired Residents.

They have recently completed Elder Abuse Training, Aged Care Channel, Updated Policies, Compulsory Reporting, Flow Charts.

Recommend that you are able to get a Compulsory Reporting Online Package from Compliance SA get Package sent out.

Fridge Temps- Looking into purchasing Medisafe Unit to Record Fridge Temperatures.

Recently were involved in the random assessment for Work Safe SA audits on manual handling in Aged Care Facilities. Theylooked at Manual Handling, Pre Assessments, Purchases, Equipment Register daily by Carers, Batteries Charged, and Sling register.

It is recommended to have slings appropriately tested with a contractor registered to complete weight tests.

Tanunda: Pinnacle HR Visit, Changes – Cultures, Staffing – Biggest Issues covering shifts.

Like everywhere the staff are under pressure anad have lots of demands on them.

Jallarah: Staffing and culture within the workplace could be improved as well as everyone is under the pump.

Mannum: Organise Meetings about being a team for Management and Staff to work together, and the ability for Staff to feel comfortable to communicate with Management.

Areas of Concern from Assessors – Recommendation for Residents to have meals in the dining areas to build better Culture within the facility.

Gail: New Accreditation standards coming in as from the 1st of July 2018, if Accredited on 1st July will be at new standards.

Standards coming out in October for review, 7 standards 35 Outcomes. There will be a new Standards Meeting in 6 Locations of CHSA throughout the year this has been requested by CHSA.

Auditors are asked to talk to Management about the Audits and find the gaps. Need to meet with management and they need to set aside time to see the gaps.

ACQA developing new platform for the new Standards, package will have ability to Audit homecare, not just for Residential so if you manage home care packages you can use the one tool in ACQA. Let Gail Harding know if you will be using it for Home care and we can set you up for that.

If you are due for accreditation just after July 2018 it may be worthwhile to forgo a few months and apply to be accredited early under the old standards. Worthwhile thinking about.

Active Manager Steven Charman has produced graphs of non-compliance and these were discussed to assist facilities in meeting the most common areas of non-compliance.

Audits – Non-compliance Medications

How can we improve on PRNS recorded in Progress Notes?

Hamley Bridge: Specific PRN Order, check if there has been entry, Medication Chart Check.

Give out PRN, write it on whiteboard, and make sure it is kept private.

Medication Refusal Recorded on Progress Notes

Note in Communication book
Need Separate Audit on this.
Create tick sheet, Have all Medications been given and signed?
Systematic evaluation of Medication Management (MAC) should be done on Admission.

Do all Medication charts include the dates of the next scheduled review?

Have excel spread sheet, put formula in for whatever your process is, once a month look at who needs to be added to the chart. Nursing Responsibility. Med Charts include Admin Records.

Do Medication Charts include administration records?


Do all medication charts include PRN Section?

Make up Stamps with the reason meds are given very quick and staff will use it., Anxiety, Pain etc.

Care Recipients living Environment
Do all care reciepients have ADC’s recorded

Write in “no Care Directives”, do not have to have advanced Care Plan, needs an independent Audit which would lower the score.

If Audit score is lower than the last Audit re schedule that audit to monitor it and pick out areas that were less and make a plan around it.

Have Care Recipient Clinical Care needs been met?

Change schedule and update care plans when specialists comes in, look at Policy if less than 6 months old change Policy.

Whole Care plan review in 6 months, if your policy says 3 months change it to review 6 monthly. Repeat fallers must have a very precise plan around it.

Clinical Incident
Change or remove question in Clinical Incident audit, staff names and designation all together as CHSA allow for anonymity.

Look at Organisational Improvements to reduce on going incidents.

What we would want for the Residents.


Regularity Compliance
Have all performance appraisals been completed in accordance with Schedule?

Have all completed improvements been evaluated?

Incident Report – Has not been updated Talk to Steven about this. Minutes from a previous meeting outline the changes needed.

Behaviour Incident Report – Misspelling of word “Result”

Printing out of Audits no drop boxes.

Continuous Improvement plan, do not like how it prints out.

Meeting closed at 4.00pm with Gail thanking all for their attendance.

Similar Posts