Page 00 - The Local Paper - Wednesday, July 11, 2018
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Special Report
Facts about Kellock’s merger partner ■ Anglican Bishop John Parkes wants to merge Alexandra’s Kellock Lodge aged residential care centre with his organisation’s St John’s Village at Wangaratta. Mergers and acquisitions, and business takeovers, are almost always accompanied by ‘due diligence’ studies. “Due diligence” is defined as “a comprehensive appraisal of a business undertaken by a prospective buyer, especially to establish its assets and liabilities and evaluate its commercial potential”. In July last year year a proposed merger between St John’s Village with Anglican Aged Care Service’s Benetas failed after both parties “mutually agreed” not to proceed after agreement could not be reached on “commercial terms”, the Wangaratta Chronicle reported. In December 2016 Bishop John Parkes had told residents the merger was necessary “to ensure the longterm viability of our services”, the Wangaratta newspaper reported. The Australian Aged Care Quality Agency conducts regular appraisals of centres around the nation. In an accreditation review conducted late last year, AACQA found that St John’s Retirement Village Nursing Home failed to meet 13 of the 44 expected outcomes of the Accreditation Standards. St John’s is operated by the “approved provider”, Trustees of the Anglican Diocese of Wangaratta. ACQA says a number of areas of performance at St John’s were “not met”: Management systems, staffing and organisational development ■ Continuous improvement, ■ Regulatory compliance, ■ Comments and complaints, ■ Human resource management, Health and personal care ■ Continuous improvement, ■ Regulatory compliance, ■ Clinical care, Care recipient lifestyle ■ Regulatory compliance, Physical environment and safe systems ■ Continuous improvement, Health and personal care ■ Regulatory compliance, ■ Education and staff development, ■ Infection control, ■ Catering, cleaning and laundry services. The damning 30-page report says that managers under the supervision of Trustees of the Anglican Diocese
PHOTO BY JAY TOWN
Failure Failure after after failure failure at at St St John’s John’s
● Bishop John Parkes at St John’s Village Wangaratta. Photo courtesy: Herald Sun. of Wangaratta (headed by Bishop “Management did not ensure staff consistently prepared or equipped Parkes) were not clear they had re- reported allegations of elder abuse with the appropriate knowledge and sponsibility for quality systems. skills in relation to use of the home's in a timely manner. The AACQA report said staff gen“Management did not ensure the electronic risk management system. erally did not know how to use a new respiratory outbreak case list was “Management and staff knowlelectronic risk management pro- complete and reflected all deaths and edge and skills were inconsistent in gram. relation to reporting or actioning inhospitalisations. “Management did not identify the “Management did not ensure all cidents and infections and commuissues with documenting improve- deaths and hospitalisations related to nicating about the health status of ment suggestions and were not ac- the influenza and respiratory out- care recipients. tively engaged with the continuous break of August 2017 and Septem“While the home has an onsite improvement system.” ber 2017 were consistently notified registered training organisation that AACQA was scathing about the to the Department of Health and provides staff education, the program St John’s leadership: Human Services in a timely manner does not always identify and respond to staff training needs. “The organisation’s manage- within 24 hours. “Staff said management did not ment does not have an effective sys“Management did not have system to identify and promote compli- tems to ensure management and provide timely information and eduance with all relevant legislation, staff followed all relevant guidelines cation to support the containment and regulatory requirements, professional in identifying, actioning and moni- management of the respiratory outstandards and guidelines. toring the influenza and respiratory break. “During the review audit, stake“Regulatory compliance across outbreak in a timely manner from the the Accreditation Standards was not onset of symptoms,” the Agency said holders raised concerns about staffing levels, skin care, pain manageeffectively monitored. of St John’s. “Management and staff did not “Management and staff cannot ment, continence and clinical care ensure the home was actively pur- demonstrate they had the appropri- during the influenza and respiratory suing continuous improvement ate knowledge and skills to identify, outbreak in August 2017 and Sepacross the Accreditation Standards. contain and manage the influenza tember 2017. “In addition, they raised concerns “Management were not aware and respiratory outbreak of August about infection control, cleaning and staff were working outside their 2017 and September 2017. scope of practice in relation to veri“These skill and knowledge defi- the level of communication during fication of death, management of cits impacted negatively on care re- that time. “A representative of a deceased syringe drivers and controlled medi- cipients. cation. “Management and staff were not care recipient who contracted respiratory illness said they did not receive a call to inform them of the outbreak. “They received a letter about the outbreak after their relative had died. “The organisation did not maintain a sufficient number of appropriately skilled and qualified staff during the influenza and respiratory outbreak of August 2017 and September 2017. “A total of 58 staff across the organisation were affected during the outbreak and were absent from work at various periods. “There was no staffing contingency plan for the outbreak to ensure types and numbers of staff were maintained “Replacement staff were not always able to be sourced from permanent staff, the staff pool or a nursing agency. No additional staff worked during the outbreak,” the Agency found. ● Continued on next page ● Peter Rice was one of the Alexandra residents featured on WIN News last week.
10 deaths at St John’s ■ “A fatal flu outbreak at a Wangaratta nursing home, where 10 residents died of influenza and two others from respiratory illness, was worsened by serious management failures, a scathing government audit has found,” was how The Age late last year reported on St John’s Village at Wangaratta. Three of the 10 residents who died were not referred to a doctor when they first started showing symptoms, and others had to wait five days for swabs to be taken, the report by the Aged Care Quality Agency found, The Age said. "Management were not aware of their responsibilities in relation to the reporting of the hospitalisation of care recipients with influenza or respiratory illness within 24 hours and did not comply with these requirements," the agency said. "On occasions there was no registered nurse on duty and the nurse manager on call was not always available to come in when requested after hours." "Except for hand hygiene training prior to the outbreak, management could not show broader infection control practices training for all staff." "The home's infection control co-ordinator was on planned leave from August 31, 2017 until September 25, 2017". “The ‘environmental services supervisor’, who was in charge of cleaning, also went on leave, which left the home's ‘leisure and lifestyle co-ordinator’, who had no recent infection control training, in charge of the cleaners. “A number of cleaning staff were home sick, and "existing numbers ... were not increased to undertake infectious cleaning processes,” The Age said.
Turnover of managers ■ St John’s Village Chief Executive Officer Glenn Phelps resigned last year in the wake of an investigation into the influenza deaths at the facility. Care manager Neale Morris was also stood aside, the Wangaratta Chronicle reported. Mr Phelps was the fourth CEO or acting CEO at the aged care centre in less than three years. Previously, Rob Hankins decided not to extend his contract in that position after just six months in the role. Peter Hill left St John’s in February 2015 after two years in the job. In November 2016 St John’s had to repay a couple at the retirement village their share of at least $300,000 wrongly charged to residents for more than a decade. Bishop John Parkes was Acting CEO for a time, the Wangaratta Chronicle said.
Page 00 - The Local Paper - Wednesday, July 11, 2018
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Special Report ● From previous page The Australain Aged Care Quality Agency continued with its detailed criticisms of the deficient standards at St John’s Retirement Village Nursing Home under the providers, the Trusteesof the Anglican Diocese of Wangaratta: “There was not always a registered nurse on duty and the on call nurse did not always come in when requested after hours. “The infection control coordinator was on planned leave during the outbreak and the role was not replaced. “The leisure and lifestyle coordinator supervised environmental services staff during the outbreak when their supervisor was on approved leave. “Management did not effectively monitor and action staffing levels and skill mix during the outbreak and did not monitor staff knowledge, skills and staff practice. “Management did not effectively identify the services and actions to be provided by staff during the outbreak and communicate them to staff in a timely manner. “Management said they were not satisfied with staffing levels during the outbreak. “Staff were not satisfied staffing numbers, types and skills during the outbreak were sufficient and said they did not have adequate time to attend to care recipients' clinical care needs. “Staff said they were not adequately supported by management during the outbreak and they are dissatisfied with the level of current support. “Replacement staff were not always able to be sourced from permanent staff, the staff pool or a nursing agency. “No additional staff worked during the outbreak and staff worked short on many shifts resulting in care recipients not consistently receiving appropriate clinical and personal care. “Over half of care recipients and representatives interviewed were not satisfied the home was adequately staffed during the respiratory outbreak. “Not all care recipients and representatives were satisfied there are sufficient, appropriately qualified and responsive staff to meet care and service needs,” the Agency said. AACQA said St John’s Village failed to meet standards regarding information systems: “The home does not meet this expected outcome “The organisation cannot demonstrate their information systems during the recent respiratory outbreak of August 2017 and September 2017 were effective. “The home's policies and procedures do not assist management and staff in identifying and responding to an outbreak. “The policies, procedures and flowchart do not reflect current Australian Government and Victorian Government infection control guidelines. “Organisational outbreak policies and procedures define an outbreak as three or more care recipients and/ or staff showing newly acquired respiratory symptoms within a seven day period. “This is not in line with current infection control guidelines that define a respiratory outbreak as three or more care recipients and/or staff showing symptoms within the same three day period. “Management did not provide timely information about the influenza and respiratory outbreak to care
● WIN News reporter Renee Arndt interviews Kellock Lodge stalwart Maurie Pawsey at the Grant St pop-up shop being used by the Friends of Kellock Lodge. You can view the TV report at www.LocalPaper.com.au recipients and representatives. Sev"The organisation does not have show ongoing improved results in enteen of 35 care recipients and rep- an effective system to identify ongo- Standard 2 Health and personal resentatives were dissatisfied with ing improvement opportunities re- care,” AACQA concluded. the level of communication they re- lated to Standard 2 Health and perSt John’s Village failed regulaceived during the outbreak. sonal care. tory compliance standards: “Thirteen staff were not satisfied “New improvement processes “The home does not have an efwith information provision in rela- were implemented in April 2017 and fective system to identify regulatory tion to the respiratory and influenza consistent processes for gathering compliance obligations and to ensure outbreak and said they were not al- improvement suggestions from compliance with regulations, guideways informed about who was af- stakeholders in relation to health and lines and professional standards in fected with respiratory illness. personal care are not established. relation to health and personal care. “The respiratory outbreak case “Clinical monitoring and report“Management did not ensure list used to provide accurate infor- ing mechanisms are ineffective and qualified staff were always available mation to the Department of Health management cannot show key per- and responsible for assessing and and Human Services was incom- formance data that exceeded speci- monitoring care recipients' clinical plete and did not reflect all care re- fied risk thresholds has been care needs during the influenza and cipients' hospitalisations and deaths. actioned, for example, falls, hydra- respiratory outbreak of August 2017 “Clinical care documentation was tion status and number of medica- and September 2017. not updated to reflect the health sta- tions prescribed. “Staff did not always work actus and increasing needs of care re“Management cannot interpret cording to legislative requirements cipients who contracted influenza clinical monitoring data or explain or within their scope of practice in how it is used to improve care and relation to verification of death, manand respiratory illness. “The documentation did not in- service provision. Incidents are not agement of syringe drivers and conclude current pain management and consistently documented, investi- trolled medication. skin care needs and wound dressing gated, actioned and closed. “For example, we identified that “For example, a care recipient on two occasions the enrolled nurses requirements. “Staff and representatives said who showed symptoms of respira- worked outside their scope of practhey were not provided with updated tory illness and passed away during tice by assessing and verifying the clinical information when care re- the outbreak had a fall five days be- deaths of two care recipients. fore their death. “On one occasion, staff said they cipients clinically deteriorated. “Staff were unable to determine contacted the on call nurse three “Staff could not consistently operate the risk management system any head strike but noted the care times about a care recipient who was in recording infections and incidents, recipient had difficulty straightening dying but they were unavailable. “The care services manager including follow up actions, evalua- their knee and they were unable to stand. No incident form is on file. working as the on call registered tions and closing off incidents. “Data from incidents is not effec- nurse was called about a death howOf Health and Personal Care outcomes, St John's Village failed to tively collated and analysed for ever, they came to the home hours meet continuous improvement re- trends to minimise preventable re- after a care recipient's body had been taken by the undertaker. quirements, according to the Ac- currences. “:Management and staff could not “Management said personal care creditation Team:
● Bishop John Parkes has been Acting CEO of St John’s Retirement Village at Wangaratta. Photo courtesy: Wangaratta Chronicle
assistants are permitted only to record if the battery light is flashing on a syringe driver, which indicates the machine is working. However, we identified a personal care assistant recorded monitoring information that is the responsibility of an endorsed enrolled or registered nurse. “Management said two registered nurses or one registered nurse and an endorsed enrolled nurse have authority to take telephone medication orders. “However, we noted a telephone order for controlled medication was taken and the medication was administered on August 22, 2017, by an endorsed enrolled nurse and a personal care assistant. This order was not signed by the medical officer.” AACQA said St John’s failed clinical care standards: “During the influenza and respiratory outbreak in August 2017 and September 2017 a number of care recipients did not receive appropriate clinical care. “Three of 10 care recipients who died with influenza or respiratory illness were not referred to a medical officer at the onset of their illness. “Care recipients with influenza or respiratory illness were reported as displaying symptoms of fever, lethargy, loss of appetite, pain, cough and breathing difficulties. “Management cannot demonstrate they received timely notification of care recipients who were identified as having symptoms of influenza or respiratory illness. “Staff said they were not always able to attend to care recipients' hygiene, pain relief, skin care and hydration needs, due to the increased acuity and extended care needs of care recipients. “We identified between April 6, 2017, and September 22, 2017, a total of 290 incidents entered in the risk management system have not been followed up by management and are unresolved. “This includes but is not limited to, medication, skin trauma, pressure areas, behaviours and falls. “Not all representatives said staff contacted them in a timely manner when informing them about their relatives' declining conditions.” There were deficiencies in the pain management standards at St John’s Village: “Care recipients' pain was not effectively managed during the respiratory and influenza outbreak of August 2017 and September 2017. “Staff said care recipients who were unwell during the outbreak died in pain because they could not provide timely repositioning and pain management resources were not always available. “Pain relief medication was not always available for care recipients and pain charting was not always completed in order to evaluate the effectiveness of pain relief measures. “Care plans were not always updated to reflect the increasing pain experience and management strategies as care recipients deteriorated, to guide appropriate staff practice. “Five care recipients and several staff said care recipients' pain is not effectively managed.” There were deficiencies with skin care management: “During the influenza and respiratory outbreak of August 2017 and September 2017 a number of care recipients did not receive appropriate skin care. Seven of ten care recipients who died with respiratory illness had outdated information in assessments and care plans impacting on the delivery of care recipients' skin care needs,” the report said