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Residents, Partners, Carers & Families Update – Australian Aged Care Quality Agency Processes, Report and Decision

Dear Residents of St John’s, Partners, Carers & Families,

Firstly thank you to those of you who provided feedback at our recent Residents, Partners, Carers and Families Consultation Meeting on Friday 10 November, 5:30pm to 6:30pm. I appreciate you taking the time to discuss with myself and the others who attended your thoughts on the work to date by the Infection Control Response & Quality Working Group and our staff. A Q&A Sheet from this meeting will be distributed shortly.

It was discussed at this Consultation Meeting that St John’s Village had received notification from the Australian Aged Care Quality Agency (ACCQA) that the report of AACQA surveyor’s (the Review Audit Report) and the final decision (Review Audit Decision) would be published today, Monday 13 November 2017.

These documents have now been published by the AACQA. The Review Audit Decision shows the decision maker in the AACQA has determined that St John’s Village does not meet 13 of the 44 Expected Outcomes in the Accreditation Standards. The AACQA has told St John’s Village that the not met Expected Outcomes and most of the issues identified by the surveyors occurred in the specific context of the influenza outbreak.

While noting the unique circumstances arising from this year’s influenza outbreak, St John’s Village fully recognises the need to ensure that it has systems and procedures in place which can withstand such challenges. St John’s Village is therefore committed to rectifying gaps identified in the report as a matter of urgency. As discussed at our two Consultation Meetings significant progress has already been made by St John’s Village in addressing the concerns of the AACQA and the results of St John’s Village’s internal review. This progress is due in no small part to the hard work and dedication of our nurses and carers on the floor.

Included with this letter is a more detailed discussion of the AACQA process, report and decision (Attachment A). I will shortly advise of the date and time for a third Consultation Meeting to discuss the AACQA decision and further progress on the improvements being undertaken at St John’s Village.

St John’s Village remains an accredited facility under the Accreditation Standards and the Board and management of St John’s Village are strongly committed to providing quality care to our residents. I am confident this is also at the core of what our staff do everyday.

Given past media interest in the influenza outbreak and the results of the Review Audit Report St John’s Village expects there will be further media reporting about the organisation and ACCQA decision. Should this media reporting or the contents of the Review Audit Report or Review Audit Decision generate any further questions please do not hesitate to contact Paul MacDonald (Facility Manager), Michelle Harcourt (Nurse Advisor) or myself.

Yours in God,
Bishop John Parkes, Executive Director & Chairman, St John’s Village

Contacts

Paul MacDonald, Facility Manager

Michelle Harcourt, Nurse Advisor

Bishop John Parkes, Executive Director & Chairman

info@stjohnsvillage.com.au

Phone: 03 5721 4214

Attachment A – Australian Aged Care Quality Agency Processes, Report & Decision

Influenza Outbreak & AACQA Review Audit

Today the Australian Aged Care Quality Agency (AACQA) will publish on its website the Review Audit Report and Review Audit Decision. The Review Audit Report is based on the review audit the AACQA surveyors conducted between 19 September and 4 October, 2017. Many of the staff were involved in interviews with the surveyors during this review.

The Review Audit Report is a recommendation from the surveyors who attended St John’s Village to the decision maker in the AACQA about whether St John’s Village meets the 44 Expected Outcomes in the Accreditation Standards (part of the Aged Care Act 1997). The decision maker in AACQA (also referred to as the Delegate) makes the final decision (Review Audit Decision) on whether St John’s Village meets the 44 Expected Outcomes in the Accreditation Standards.

This review audit was requested by the Minister for Ageing Ken Wyatt because the influenza outbreak that occurred at St John’s Village in mid August to early September. During this influenza outbreak 10 residents at St Johns Village who had contracted influenza died. Nine residents who died had tested positive to Influenza A, one resident who died had tested positive to parainfluenza.

Many of the residents who contracted influenza during the outbreak already had significant medical issues and were clinically compromised. Under the very difficult circumstances of the influenza outbreak I am confident that all staff rose to the challenge of providing quality care to the residents of St John’s Village during this time and particularly those residents who were very ill.

While noting the unique circumstances arising from this year’s influenza outbreak, St John’s Village fully recognises the need to ensure that it has systems and procedures in place which can withstand such challenges. St John’s Village is therefore committed to rectifying gaps identified in the report as a matter of urgency. As discussed at our two Consultation Meetings to date, significant progress has already been made by St John’s Village in addressing the concerns of the AACQA and the results of St John’s Village’s internal review. This progress is due in no small part to the hard work and dedication of our nurses and carers on the floor.

AACQA Review Audit Report & Decision

As previously indicated the Review Audit Decision will be published today and shows the decision maker in AACQA has determined that St John’s Village does not meet 13 of the 44 Expected Outcomes in the Accreditation Standards. AACQA has told St John’s Village that the not met Expected Outcomes and most of the issues identified by the surveyors occurred in the specific context of the influenza outbreak.

Given past media interest in the influenza outbreak and the results of the Review Audit Report, St John’s Village expects there will be further media reporting on the organisation and the AACQA decision.

It is important to understand that some of the information contained in the Review Audit Report and published on the AACQA website has been successfully challenged by St John’s Village and deemed incorrect. However Australian Government legislation requires it still to be published.

In the Review Audit Report the surveyors recommended that 17 Expected Outcomes be not met for the Nursing Home and 14 Expected Outcomes be not met for the Hostel. Among others, the surveyors recommended that Expected Outcomes ‘2.8 Pain Management’ and ‘2.11 Skin Care’ be found to be not met in respect of the Nursing Home.

A comprehensive submission to challenge the surveyors’ recommendations was prepared by St John’s Village for the AACQA decision maker. As part of this, we provided the decision-maker with evidence about the care provided to residents at St John’s Village.

The AACQA decision-maker ultimately found that St John’s Village did meet Expected Outcomes ‘2.8 Pain Management’ and ‘2.11 Skin Care’ which require that:

  • “all care recipients are as free as possible from pain”; and
  • “care recipients’ skin integrity is consistent with their general health”.

In other words, information provided to the AACQA decision-maker satisfied her that residents did not die in pain, and that residents did receive appropriate wound care. The statements in the published Review Audit Report relating to these Expected Outcomes were proved to be inaccurate and not reflective of the care provided to our residents.

In addition to overturning the surveyors’ recommendations in relation to Expected Outcomes ‘2.8 Pain Management’ and ‘2.11 Skin Care’, the decision-maker also found that St John’s Village was compliant in relation to Expected Outcomes ‘1.3 Education and Staff Development’ and ‘1.8 Information Management’.

The decision-maker concluded that there are 13 Expected Outcomes not met for the Nursing Home and 12 Expected Outcomes not met for the Hostel. In total there are 13 Expected Outcomes not met for the organisation as there are 12 not mets that are common to both the Nursing Home and Hostel.

St John’s Village remains an accredited facility under the Accreditation Standards. St John’s Village will undergo a re-accreditation audit, this is scheduled for mid-December 2017 with the exact dates to be confirmed shortly. The Board and management of St John’s Village are confident with the current structures in place, that we will be able to achieve a positive re-accreditation audit in December.

Notification to Australian Health Practitioner Regulation Agency

The Board of St John’s Village has reported the previous Acting Care Services Manager to the Australian Health Practitioner Regulation Agency (AHPRA) under its mandatory reporting obligations. The Board has been provided with advice that the conduct of the previous Acting Care Services Manager disclosed during the review audit and reported in the Review Audit Report is notifiable conduct. St John’s Village will fully co-operate with any investigation by AHPRA if requested. Any decision in relation to the previous Acting Care Services Manager’s conduct is a decision for AHPRA and the Nursing and Midwifery Board of Australia.

Thank You & Further Information

The Board and management of St John’s Village remain committed to providing quality care to our residents and I am confident this is also at the core of what our staff do everyday.

If you have any concerns or questions about the media reports, Review Audit Report or Review Audit Decision please do not hesitate to speak to either Paul MacDonald (Facility Manager) or Michelle Harcourt (Nurse Advisor). You should also feel free to raise any concerns directly with myself Bishop John Parkes. Contact details are provided in the covering letter to this attachment.

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