25 Qld nursing homes to breach federal standards
Magpies at dining tables, stingy meals, dirty pads or fractured bones untreated – these are the recent failures inside Queensland nursing homes. SEARCH THE INTERACTIVE
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Twenty-five nursing homes in Queensland have failed to comply with federal health and safety standards since May.
The breaches by some homes included forcing a resident to wear incontinence pads by tying them on to the person’s legs, failing to administer drugs on time or skimping on meal portions.
Another home allowed residents to smoke in corridors near their rooms because bird poop covered outdoor furniture in the designated smoking area.
One facility restrained residents without their consent while others told residents to use incontinence pads instead of the toilet because staff were too busy.
One nursing home also failed to take a resident for X-rays and to hospital for 13 days after she fell over and fractured her neck.
A Brisbane-based home failed standards because magpies were found inside the facility causing mealtime disruption.
The performance assessments come as the federal government marks the first year of its innovative star-rating review process, which is a separate measure of nursing home performance.
Under the system, no Queensland institute received the lowest rating of one out of five in the latest published figures and only one scored a rating of two.
According to the government’s public register which displays information for each aged care home, Queensland’s worst overall performer under the star ratings for the three months to August was Anglicare’s SQ Abri Home for the Aged, run by the Corporation of the Synod of the Diocese of Brisbane.
The not-for-profit, which operates at Bauer St, Southport, is home to 55 residents.
It recorded an overall rating of 2, the lowest in the state.
It received one out of five for staffing and a low two out of five for meeting quality measures.
Residents gave it three out of five and it received three out of five for compliance.
Of the 465 Queensland nursing homes surveyed and ranked for the government’s My Aged Care website, 208 received an overall rating of three stars with 226 receiving four stars and 11 hitting the top ranking of five stars.
Only one nursing home, Redcliffe’s Peninsula Palms Retirement Village at Morris Rd, Rothwell, managed to receive a score of five stars out of five across each of the four categories.
Nursing homes are also assessed by the Aged Care Quality and Safety Commission with onsite assessments and performance reports.
Homes are assessed under eight national standards for provision of consumer dignity and choice; how they provide clinical care; ongoing planning; how they help residents maintain personal care; quality and quantity of support for daily living, human resources and organisational governance.
All the Aged Care Quality and Safety Commissioner’s findings are published in performance reviews on the commission’s website for the public to see.
Here are 25 nursing homes which recorded breaches in meeting the eight national standards expected of aged care facilities in the three months to August this year, and the published findings of the Commissioner.
Akooramak Care of Older Persons
Warwick Benevolent Society Inc
267-269 Wood St, Warwick
★★★
One of Warwick’s oldest operating aged care homes, Akooramak, was found by the commissioner to have been skimping on meals and serving up small portions of dishes that did not meet residents’ preferences during an assessment in July and a performance report in August.
The home was found to have breached Standard 4: “Services and supports for daily living” in the performance report.
The home breached one of the eight federal standards, in an August performance report by a delegate of the Aged Care Quality and Safety Commissioner.
Hospitality staff at the facility, which was founded in 1876 and has 98 residents, backed up complaints from “several residents” who claimed the service frequently ran out of food and the menu often changed due to lack of ingredients.
The catering manager said the menu did not cater for residents’ tastes or requests and residents had little input into what they ate.
Assessors who visited the site in July were also told there were no options for residents requiring gluten-free or lactose-free snacks.
In its defence, Akooramak management said it had taken steps to regularly review the menu with input from residents and hired a new chef in August.
The nursing home said it had also reviewed and updated each resident’s dietary profile and interviewed individuals to find out what they would like to see on the menu.
A local supplier has been hired to ensure adequate ingredients are always available and to minimise last-minute changes to the menu.
Photographic spot checks of dishes have also been used to monitor appropriate meal presentation.
The commissioner’s report said Akooramak had taken immediate action to address the menu issues and was committed to rectifying any issues.
Blue Care Gracemere Aged Care Facility
The Uniting Church in Australia Property Trust
Conaghan St, Gracemere
★★★
An Aged Care Quality and Safety Commission performance report, published in October, found Blue Care Gracemere Aged Care Facility was non-compliant in one of the eight standards and did not have an effective risk management plan in place.
The home was found to have breached Standard 8: “Organisational governance”.
The report found the facility, 10km west of Rockhampton, failed to report a “wandering” resident with “changed behaviours” taking off their incontinence pad and undressing in other residents’ rooms.
The performance report said management believed the resident’s behaviour was not serious enough to warrant being recorded as an incident, and had not implemented strategies to prevent, monitor or reduce similar incidents.
The review also said a “restrictive garment” was tied around the resident’s legs to stop the man taking off the incontinence pad, despite management telling staff to stop the practice.
The performance review said the use of the garment was a mechanical restraint and found the facility in breach of obtaining the relevant consent.
“This treatment of the consumer had not been considered by the service as an incident of neglect and consequently had not been reported to the Serious incident response scheme,” the report said.
Since the report, Blue Care staff have again been advised not to use the restraint and are being monitored to ensure they abide by the organisation’s code of conduct and the national code of conduct for aged care workers.
The resident was assessed by a dementia advisory service in September and male nightshirts have been ordered and special underwear is being trialled.
The report also noted that the facility, which charges $89.98 a day or $403,000 lump sum, failed to lodge a report after a resident was injured after falling out of a wheelchair on a bus trip.
However, a copy of an incident report was provided while the assessment team was on site.
In its defence, Blue Care said the resident had unbuckled their seatbelt while the bus was in motion, and a physiotherapy review would be undertaken to determine the most appropriate harness for the person on the next bus trip.
The report also found Blue Care had failed to document the case of a resident who had been touching another consumer without consent.
The report said Blue Care had acted to improve compliance since the site assessment in September but the measures had not been tested for their effectiveness.
Blue Care Ingham Bluehaven Aged Care Facility
The Uniting Church in Australia Property Trust (Q.)
58 Cassidy St, Ingham
★★★
A performance report published in September found Blue Care Ingham needed to monitor staff to address instances where interactions with residents “are not kind, caring or respectful”.
The report found the facility was non-compliant in two standards that governed personal and clinical care and with human resources guidelines.
The home was found to have breached Standard 3: “Personal care and clinical care” and Standard 7: “Human resources”.
A site assessment in August found no behaviour support plans were in place for two residents who had complex behavioural problems.
The report documented the case of a resident who had multiple bruises on their arms as a result of staff being unable to control the person.
Several residents and their families expressed concerns about staff interactions and gave examples of where staff had been disrespectful, rough in providing care, and failed to respect individual preferences and privacy.
Some of the concerns were reported to staff or management in May but the assessment team found the issues were ongoing.
“Management and registered staff did not have a clear understanding of restrictive practices,” the performance review said.
“The assessment team observed various instances of staff being disrespectful towards consumers, disrespectful language in consumers’ care documentation, and multiple bruises on both arms of a consumer.”
Blue Care management said they were aware of interaction issues, acknowledged that some staff did not always treat residents in a kind and caring manner and noted that not all staff had completed manual handling training.
Management said a staff member was being performance-managed for rough treatment of residents and planned to discuss workforce interactions with staff.
Management also expressed regret that some residents had not felt respected and said service management met with some residents and their families and apologised.
Blue Care said it would step up monitoring of staff interactions and supervision of staff under performance management.
Since the site assessment, Blue Care has spoken with residents and families and updated all behavioural plans and drawn up individualised strategies.
Blue Care Kallangur Pilgrim Aged Care Facility
The Uniting Church in Australia Property Trust (Q.)
40 Narangba Rd, Kallangur
★★★
Two complaints in May about a patient’s wound management and clinical deterioration after a resident fell over in January formed part of an assessment into Blue Care Kallangur.
A performance report published in June, based on site visits, found the nursing home had breached two national standards following reports of a serious incident.
The home was found to have breached Standard 3: “Personal care and clinical care” and Standard 8: “Organisational governance”.
The assessment team found the nursing home had made improvements to the way it managed wound and pain care since the January incident but its clinical monitoring was not following best practice.
The performance report identified three instances where clinical monitoring of residents’ falls was not completed in line with best practice or the service’s management policy.
“Neurological and vital sign observations, and the effectiveness of pain management strategies were not consistently completed,” the report said.
“Management advised there were gaps in registered staffs’ knowledge of post-fall management.
“Whilst the approved provider’s response to the Assessment Contact Report identified actions to address the deficiencies and improve clinical monitoring, actions have either not been fully implemented and/or not been tested for effectiveness and sustainability.”
The performance report also found the nursing home failed to report two incidents to the Serious Incident Response Scheme in line with legislative requirements.
Management was unsure why these incidents had not been accurately reported.
The report also found registered and enrolled nurses had completed training on the service’s incident management system, but the service had not provided training on incident management and reporting.
Blue Care acknowledged the findings and provided an action plan to address deficiencies.
Blue Care Kirra Aged Care Facility
The Uniting Church in Australia Property Trust
5 Appel St, Coolangatta
Blue Care Kirra Aged Care facility was found to be non-compliant in three national standards after a site assessment in September.
A performance report published in October found the nursing home was not ensuring safe and effective care when using catheters, or for wound and pressure injuries, falls, restrictive practices or behaviour management.
The home was found to have breached Standard 3: “Personal care and clinical care”, Standard 6: “Feedback and complaints” and Standard 7: “Human resources”.
The report also found consumers’ care plans did not include complete or accurate information to guide staff.
One resident had no catheter care plan and the wound care documentation did not include relevant information about the wound status or give guidance on ongoing care.
The report said staff were not repositioning the resident and there was no process for ensuring the resident would be repositioned.
The type of mechanical restraint and management of that restraint was not accurately identified in the resident’s documentation.
The report also said staff had also failed to update details about a resident who fell over and there had been no documented investigation into incidents of physical aggression by a resident to identify contributing factors or strategies to minimise a recurrence.
In its defence, management said the organisation had identified deficiencies in care planning documentation and incident investigation.
Management acknowledged the findings in the assessment report and provided evidence of improvements taken and planned.
The report also found Blue Care’s complaints process was ineffective, action was not taken in response to complaints and open disclosure was not used when things went wrong.
Management identified improvements to the service’s complaints processes including reinstating staff and resident meetings and including discussion about feedback and complaints processes.
The nursing home also improved its feedback register, consulted the affected resident along with stepping up staff education.
Blue Care Mackay Homefield Aged Care Facility
The Uniting Church in Australia Property Trust
87-95 George St, Mackay
Blue Care Mackay was found to have breached six out of eight national standards including humiliating and embarrassing three residents by telling them to go to the toilet in their incontinence pad instead of the toilet.
The findings were made in an Aged Care Quality and Safety Commissioner report in June after a site assessment in May.
The home was found to have breached Standard 1: “Consumer dignity and choice”; Standard 2: “Ongoing assessment and planning with consumers”, Standard 3: “Personal care and clinical care”, Standard 6: “Feedback and complaints”, Standard 7: “Human resources”, Standard 8: and “Organisational governance”.
The report also found there were lengthy delays in changing soiled pads and delays in toileting assistance causing incontinence.
A fourth resident said staff were kind and caring but felt they were not treated with dignity as staff drew their curtains and turned off their television which was against their wishes.
Staff confirmed there were delays in providing care due to a lack of staff.
Management said they were saddened by the reports and have had meetings to apologise to three of the five affected to discuss ways to address individual concerns and rebuild trust.
The bell system was reviewed to ensure its effectiveness and daily reports have been generated with an investigation into any call bell response times over 10 minutes.
A memo was sent to all staff in May alerting them to call bell monitoring.
Three residents said they were not consulted when decisions were made to put on bed rails and the facility could not provide documentation to show discussions had been held to authorise restraints.
Management reviewed all residents who are subjected to mechanical restraints and found that two out of 13 had assessments to determine their decision-making capacity.
Blue Care said appropriate assessment, consent, and authorisation processes were not consistently demonstrated and instigated a review.
Behaviour support plans were noted to be ineffective in guiding staff when managing consumers with challenging behaviours.
Staff reported they were unsure how to manage one resident’s aggressive behaviours and would generally ask registered staff to administer antipsychotic medication in the form of chemical restraint.
The resident had four incidents of unreasonable force in six weeks and progress notes indicated the interventions were ineffective.
The report also found that planning and use of restrictive practices was not always best practice or tailored to a resident’s needs.
Another resident had 13 falls between February and April 2023, but prevention strategies such as sensor mats, regular observations and toileting monitoring were ineffective.
Unsafe footwear was identified as a factor but staff had not always ensured the consumer consistently wore safe shoes, the report said.
Another resident sustained four falls between January and May, while going to the toilet unaided as staff had not arrived to help, the report said.
A comprehensive analysis was being undertaken into the circumstances leading to the death of one of the residents who had experienced multiple falls.
Falls education was provided to staff in June and clinical leadership team meetings were re-established.
The service did not demonstrate that staffing was planned, and the mix of staff did not deliver safe and quality care and services.
Five residents and seven family members said the service was understaffed, and residents provided examples.
Call bell data also showed extensive delays.
A roster and staff review was undertaken and additional registered nurses and four personal care staff also started in June.
Training records confirmed 30 per cent of staff were not up to date with mandatory training.
All staff confirmed they had not received performance reviews.
The report also found the service was unable to show ways it actively reduced inappropriate antibiotic usage.
Blue Care Mareeba Aged Care Facility
The Uniting Church in Australia Property Trust (Q.)
7 MacRae St, Mareeba
A site assessment in June found Blue Care Mareeba had breached one of the national standards and found it had deficiencies in effective information management systems.
The report said the facility had effective organisation-wide governance systems but found it failed to communicate changes to residents’ needs and complaints regarding care were not being adequately recorded.
The home was found to have breached Standard 8: “Organisational governance”.
The site audit report also found deficits in some audits which failed to include a review of information management.
The site audit report found staff did not have a clear understanding of principles of neglect with some incidents which had the potential to cause harm not reported under the serious incidents code.
Management acknowledged the issues that had arisen and instigated a review of daily progress notes, updating staff returning from leave and starting weekly clinical risk meetings.
Management also acknowledged inconsistent monitoring and identification of serious incidents and instigated staff education on serious incidents.
Blue Care Toowoomba Residential Aged Care Facility
The Uniting Church in Australia Property Trust (Q.)
256 Stenner St, Toowoomba
A site assessment in August found the way high impact and high prevalent risks were handled was ineffective and reported the home had breached one of the eight national standards.
The home was found to have breached Standard 3: “Personal care and clinical care”.
Residents who fell were not monitored appropriately to ascertain if they had sustained an injury and time-sensitive medication was not administered as prescribed, a performance report in August found.
Two residents assessed as at high risk of falls and had hit their heads in a fall were not monitored.
One resident who had lacerations and bruising to their face after a fall in July did not have any neurological observations taken as per the service’s fall prevention guidelines, according to the report.
A regime of neurological observations was to be taken up to three days after the fall, however this did not occur, the report said.
Despite physiotherapy interventions made following a review of the consumer after their fall, these interventions were not in place when the consumer was observed by the assessment team.
Management acknowledged the service was unable to consistently show effective management of post falls monitoring and noted their own clinical monitoring processes identified deficits in staff following procedure.
Residents prescribed time-sensitive medication were receiving their drugs late and not as prescribed. Charts revealed 20 occasions where two residents with Parkinson’s disease received their time sensitive medication late.
Bolton Clarke Fairways
RSL Care RDNS Limited
59 Hanbury St, Bundaberg North
Residents and their representatives interviewed by the assessment team in August acknowledged they received the personal and clinical care they needed.
However, an assessment site report found the home breached one of the eight federal standards.
The home was found to have breached Standard 3: “Personal care and clinical care”.
A performance report in September said the home’s behaviour support plans for residents with “changed” or aggressive behaviours were incomplete and did not include individualised strategies.
It said staff lacked knowledge of strategies to help manage consumers with aggressive behaviour and residents’ wound care and diabetes management were not consistently documented.
Care documentation did not record details about completed wound care or include measurements or photographs.
Documentation also did not consistently record blood glucose levels, according to the report.
Restrictive restraining practices were not identified and documented in line with regulatory requirements.
Management acknowledged the findings and advised of continuous improvements to address all areas including a daily review of wound care documentation.
Bolton Clarke Fernhill
RSL Care RDNS Limited
103 King St, Caboolture
A performance report in October found the home did not comply with three federal standards.
The report said residents were not treated with dignity and respect.
The home was found to have breached Standard 1: “Consumer dignity and choice”, Standard 3: “Personal care and clinical care” and Standard 7: “Human resources”.
A resident who preferred a vegetarian diet, was provided a meal labelled for another consumer which contained two types of meat. It was noted in the report that the meal was left uneaten.
The lack of staff assistance, according to the report, impacted on the dignity of consumers including delays in hygiene care provision, including timely change of incontinence pads and mobility assistance.
One resident said they experienced pain from being left in bed for extended periods of time, including up to 12 hours overnight.
Another resident said they preferred going to bed at 9.30pm and rising at 6.30am but notes submitted for assessment showed those preferences were not followed and on one occasion their personal hygiene care was completed at 4.30am.
One another occasion, according to the report, no assistance was delivered in a timely manner and therefore the person did not have a shower.
Care staff provided feedback that it was difficult to ensure tasks were completed daily and often care was delayed or missed due to a lack of staff or busy work schedules.
Registered staff said the facility was often understaffed, according to the report.
Six residents or their family members said their dignity had been affected by some practices.
Churches of Christ Bribie Aged Care Service
Churches of Christ in Queensland
12-40 Foley St, Bongaree
★★★
A site assessment in August found that the 119-bed Churches of Christ Bribie Aged Care Service breached one of the eight standards for management of wound care and pain.
The home was found to have breached Standard 3: “Personal care and clinical care”.
A performance report, published in September, said clinical oversight of wound care and pain management was poor and the facility had not had a wound specialist since March.
It said residents had experienced lengthy delays in wound healing and referrals to health specialists, including wound care experts, had not occurred in a timely manner.
“Pain has not been excluded as a reason some consumers may be exhibiting challenging behaviours and refusing care,” the report said.
The report mentioned four cases where patients’ wounds, which included chronic ulcers, skin tears and pressure wounds on heels, had not been documented correctly or tended to in a timely manner.
Management said residents had regular medical reviews with their doctors and it had referred one to a dietitian and taken steps to alleviate pain in all cases.
The report said a resident with a serious pressure injury to their sacrum had incomplete pain management documentation and staff were not following guidelines for heat pack use, and were not filling out pain flow charts.
The report said photos showed the wound had deteriorated since March, when the resident was last seen by the wound specialist.
The assessment team was told the resident had been hospitalised for infections and subsequent pressure injuries had developed.
A referral to a wound care specialist was made and a Telehealth review was completed in September.
Churches of Christ Golden Age Aged Care Service
Churches of Christ in Queensland
60 Ridgeway Ave, Southport
★★★
A performance report published in June found the home did not comply with two national standards.
An assessment in May found that the facility had taken steps to improve the way residents were treated after a performance report in August 2022 found the service non-compliant.
The home was found to have breached Standard 1: “Consumer dignity and choice”.
The assessment in May also found the service had conducted elder abuse training to help identify and recognise instances of inappropriate behaviour and cases of abuse.
However, the assessment team report in May found residents still described instances of feeling disrespected and gave examples.
One resident became emotional after speaking about a complaint of staff misconduct.
A June performance report said staff left the door open while a resident was partially undressed with lower pants and continence pad showing.
The report said an investigation was held into the incident.
Complaints also included that the shower temperature was not adjusted on request.
Management said one of the staff members no longer worked at the facility.
“Staff did not demonstrate understanding of respectful or kind interactions with consumers and one staff member reported knowingly not reporting unkind treatment of a consumer,” the June performance report said.
“Consumers described examples of disrespectful and rough treatment by staff.
“Whilst the service was able to demonstrate that they have addressed the deficiency related to staff performance appraisals, the service was unable to demonstrate effective monitoring and review of staff members when performance issues are raised.”
Churches of Christ Stanthorpe Aged Care Service
Churches of Christ in Queensland
9-15 Alice St, Stanthorpe
★★★★
A performance report in September found the Stanthorpe home did not comply with one of the eight federal standards and found areas in which improvements must be made to ensure compliance with standards governing restraining residents.
The home was found to have breached Standard 3: “Personal care and clinical care”.
The report found effective systems and processes were not in place to manage residents with “changing behaviours” who needed restraining.
The report said behaviour support plans did not include individual strategies to deal with physical and verbal aggression from residents.
“Where restrictive practices were applied, the service did not demonstrate, for five named consumers, any alternatives that were trialled prior to the administration of a chemical restraint,” the report said.
“Staff were unable to demonstrate strategies to manage consumers with changing behaviours, apart from administering chemical restraint.”
Management said it had consulted with one resident and their representatives and the resident was transferred to a behaviour support unit for a review.
Staff education was also provided by Dementia Support Australia.
Garden City Retirement Home
Alzheimer’s Association of Queensland Inc
33 Tryon St, Upper Mount Gravatt
★★★★
A performance report in August found the facility had breached two federal standards and was not ensuring care and services were reviewed regularly for effectiveness, or updated when circumstances changed or incidents occurred.
The home was found to have breached Standard 2: “Ongoing assessment and planning with consumers” and Standard 3: “Personal care and clinical care”.
The report said management acknowledged regular review and update of consumers’ care plans had not occurred every three months in line with the facility’s policy.
Management set up a schedule to complete 42 care plans which had no overall reviews.
New management and clinical staff were to be appointed and more staff education undertaken along with a review of quality and compliance processes.
Glenella Care
Annimaci Pty Ltd
35 Davey St, Glenella
★★★
Glenella Care was found to be non-compliant with one of the eight federal standards after a June assessment.
The home was found to have breached Standard 3: “Personal care and clinical care”.
A performance report published in July found the service did not demonstrate timely identification, management, and evaluation of residents needing restraining.
The report found documentation was inaccurate for those subjected to restrictive practices and monitoring processes were not effective to ensure accurate records were maintained.
The facility had been found non-compliant at a site audit in September 2022, but the latest assessment said corrective actions had not been effective to ensure accurate documentation for restrictive practices.
It found eight residents did not have accurate and up-to-date restraint records and there had been no authorisations or consent for the residents to be restrained.
“The service had policies and procedures in line with the current legislative requirements, however, they were not followed by staff in relation to restrictive practices,” the latest report said.
“The service also provided education for all staff to complete online training in restrictive practice and it is now an annual mandatory requirement.”
Management said it had undertaken an assessment of all consumers following the October 2022 visit to determine their decision making capacity, and the process has been embedded into the assessment for all new residents.
The facility has also remodelled its Register of Psychotropic Medication Assessment form using a new electronic care system.
McLean Care Yallambee
McLean Care Ltd
34-40 Margaret St, Millmerran
★★★★
The service was found to be non-compliant in one of the eight federal standards relating to managing restraining practices in a performance report published in August.
The home was found to have breached Standard 3: “Personal care and clinical care”.
The report found the facility did not optimise consumers’ health and wellbeing, was not using best practice and was not aligned with legislative requirements.
An assessment team, which visited the site, found staff did not have a shared understanding of what constituted a restrictive practice.
The assessment also found the facility’s register did not accurately record the administration of chemical restraint medications.
Perimeter restraint, for those restrained from leaving a secure area, was not identified as a form of restrictive practice and a number of residents did not have access to the code to exit the locked front door or could not operate the keypad independently, the report said.
“The assessment team observed staff using a form of mechanical restraint to prevent a consumer (resident) who had a high risk of falls from mobilising unaided,” the report said.
“Consent for this type of restrictive practice had not been discussed with or provided by the representative.
“Charting associated with the use of restrictive practice was incomplete and for some consumers (residents) failed to detail alternative strategies.
“While the service had policies and procedures in relation to the management of restrictive practices, including using the least restrictive form as a last resort, in practice this was not occurring.”
In its defence, management said an assessment of perimeter restraints was completed and identified residents who were restrained without consent.
“The front door to the service was being adjusted to open automatically; additionally, assessments were being conducted, behaviour support plans developed and consent sought where a need was identified,” management said in the performance report.
“A behaviour management specialist had been engaged to assist management in reviewing care plans and developing behaviour support plans to reflect individual needs.
“Staff education was conducted during the site audit with plans developed for further ongoing education sessions.”
Merrimac Park Private Care
Superior Care Group Pty Ltd
50-52 Macadie Way, Merrimac
★★★
The nursing home failed to meet two federal standards after a site assessment in June, with the breaches reported in a performance review in July.
An assessment team found a resident, who required a catheter, had to wait an hour for their catheter to be flushed and reviewed by a registered nurse after experiencing blood clotting. Directives had been included in the resident’s care plan for hourly monitoring, which the report claimed did not occur between June 10-13.
The home was found to have breached Standard 3: “Personal care and clinical care” and Standard 7: “Human resources”.
The performance review also found clinical observations were not recorded at the time blood clots were noted and the resident was not referred to a medical officer after the catheter became blocked.
“Inconsistent monitoring of the consumer’s observations occurred despite assurances by clinical staff this would occur,” the report found.
“The consumer (resident) was noted to be pale, drowsy, and struggling to talk on June 15.
“Clinical observations were taken which were noted to be outside normal limits and the consumer was transferred to hospital.”
Another resident who has a pressure injury on her buttocks complained that she was not repositioned often enough in bed to manage the pain from the sore.
The management said it had undertaken a plan for continuous improvement to ensure registered staff monitor and fill out all charts throughout the shift.
The diabetic management plan for a resident who required insulin to manage diabetes did not contain instructions for when blood glucose levels were not within recommended ranges, the report said.
After the assessment, management submitted a diabetic management plan with instructions completed by a medical officer on June 30.
The nursing home did not show that its staff were able to deliver safe and quality care due to vacant senior clinical positions and lack of a training co-ordinator, the report said.
Residents expressed concern with high numbers of inexperienced new staff and agency staff, and call bell response times, the report said.
The assessment team noted 67 instances of call bell response times exceeding 30 minutes between June 1-14.
The assessors also reported a resident in the dementia ward lying sideways on a bed with an incontinence pad overflowing with faecal matter.
Management said call bell response times would be monitored daily and discussed at clinical meetings.
Recruitment would continue with a new Head of Care starting work in June and an additional clinical nurse consultant in July.
Ozcare Mackay
Ozcare
15 Charlotte St, West Mackay
★★★
A site assessment in June found the facility’s post falls procedures were not followed and neurological observations not charted in a timely manner.
The home was found to have breached Standard 3: “Personal care and clinical care”.
A performance report found the home breached one of the eight standards.
It found that a resident was not reviewed by a physiotherapist within 24 hours of falling, care documentation was not reviewed after the fall and a visual monitoring chart was not active.
Management met with staff to discuss the assessment findings and to implement a document to monitor the emerging needs of residents from shift to shift.
The nursing home met with relevant staff and identified that some had now resigned. The facility also bought non-slip mats for chairs, which has helped to reduce the number of falls from chairs.
The site assessment also found the service was unable to demonstrate effective medication management for two people.
The facility is conducting a review of the medication management system.
Ozcare Palm Lodge
Ozcare
424 Bowen Tce, New Farm
★★★★
A site assessment in August and a September performance report found the nursing home did not provide safe and effective care to a resident with suicidal intentions and was in breach of one of the eight standards.
Not all residents subjected to chemical restraints had been identified and some cases did not have appropriate consent or authorisation.
The home was found to have breached Standard 3: “Personal care and clinical care”.
Behaviour support plans did not consistently contain individualised strategies to guide staff in managing residents.
Management refuted some of the information contained in the site assessment report but acknowledged there were gaps in the management of restrictive practices.
It has taken steps to address the deficits.
The nursing home had no monitoring processes to determine the location of a resident who displayed suicidal intentions on three occasions between April and July, the report said.
Referral to a dementia advisory service, older persons mental health service or psychologist had not occurred despite recommendations after the person attempted suicide in April, the report said.
Peninsula Aged Care Service
Beaumont Care (Holdings) Pty Ltd
111 George Street, Kippa-Ring
★★★★
An assessment in September and a performance report in October found the nursing home did not comply with one of the eight federal government standards and did not demonstrate safe and effective clinical care that was best practice and tailored to residents’ needs.
The home was found to have breached Standard 3: “Personal care and clinical care”.
The report said there were some residents who were subjected to chemical, mechanical, and environmental restraints without the appropriate assessments, authorisation, consent, and support plans in place.
The report said an internal audit in July identified some of the issues which had not been addressed by September.
The service was also found not to be documenting behavioural incidents and alternative pain management strategies had not been used for residents who experienced significant and ongoing pain.
Management undertook an immediate review and assessed the performance of a recently recruited clinical nurse experiencing challenges in the new role.
Informal clinical coaching was provided, and weekly meetings conducted to review care documentation and use of assessment and reporting tools.
The management also said it would establish monthly reporting to the Group Service Manager.
Pinaroo Roma Inc
50-56 Bowen St, Roma
★★★★
The nursing home was found to have not complied with one of the eight federal standards in a performance report published in August.
The home was found to have breached Standard 3: “Personal care and clinical care”.
The report said the home was unable to demonstrate informed consent for all residents who were subjected to restrictive practices. The report also found that a piece of furniture had been used to block a door to stop a resident from wandering at night.
The furniture was removed and a bed sensor mat placed on the resident’s bed to alert staff, the report said.
The resident’s behaviour support plan was updated to include strategies to assist when the person wandered, the report said.
The assessment report also found that incidents of aggression had not been consistently recorded or documented.
Regis Sandgate – Lucinda
Regis Group Pty Ltd
60 Wakefield St, Sandgate
★★★★
The Sandgate home was found not to comply with one of the federal standards.
The home was found to have breached Standard 3: “Personal care and clinical care”.
Registered staff told an assessment team in July that they believed care was safe and effective because they monitored residents’ conditions, referred sick people to other health providers when required, received feedback from residents, reviewed care documentation and analysed incidents.
However, the assessment report found that the service did not have a shared understanding of restrictive practices, resulting in a number of residents being subjected to chemical restraint without assessment, consent or review.
The assessment team found 10 residents were subjected to chemical restraint without prior assessment, planning or consent and subsequent review.
But after a review, management said there were nine residents who did not have authorisation documentation in place.
Management instigated a full review of all residents prescribed psychotropic medications and consulted with residents and their families about the use of chemical restraints.
Sunnymeade Park Aged Care Community
Jomal Pty Ltd
362-376 King St, Caboolture
★★★
A performance report in October found the nursing home was not ensuring consistent and effective clinical monitoring and management of high-impact and high-prevalence risks, specifically in relation to post-falls management and medication management.
The home was found to have breached Standard 3: “Personal care and clinical care: and Standard 8: “Organisational governance”.
The report found the service was not ensuring clinical deterioration and unplanned weight loss were being responded to in a timely manner and it did not comply with one of the federal standards.
The assessment team found a resident, who fractured her neck in a fall, was not taken for an X-ray or to hospital for 13 days.
“The service did not identify the injury and ensure referral to appropriate health professionals occurred in a timely manner,” the performance report said.
“There was no evidence to show a head-to-toe post fall assessment was conducted.
“Despite the consumer complaining of pain at the back of her head and neck, and staff escalating this to registered nursing staff, actions were not taken to immediately organise an X-ray or transfer the resident to hospital until 13 days after the fall.”
Residents were also not monitored for changes in their health when medication was missed, or when medication was administered at double the prescribed dosage, the report said.
Management have since set up an automated alert and referral system to ensure appropriate post-falls management processes and developed new flowcharts and training for staff.
TriCare Annerley Aged Care Residence
TriCare Annerley Aged Care Pty Ltd
421 Annerley Rd, Annerley
★★★
The Brisbane nursing home was found to not meet two national standards with a report documenting magpies seen inside and interrupting meals.
The home was found to have breached Standard 3: “Personal care and clinical care” and Standard 5: “Organisation’s service environment”.
Bird droppings were found inside and in outdoor recreational areas and a stench was noted throughout the facility, according to a performance report published in August.
Management took immediate action to mitigate the presence of the malodour.
A balcony door was identified as being locked, however, one resident was reported being able to access the area freely, the report said.
Outdoor paved areas were identified as uneven and potential trip hazards in the report.
“The service took immediate action to secure these areas during the assessment contact and initiated works on these areas to improve safety for consumers,” an August performance report said.
“The approved provider, in their response, outlined actions taken and committed to an updated plan of continuous improvement.
“I am satisfied that adequate measures have been taken to address and provide safe consumer freedom of movement.
“However, it is my decision that this requirement is non-compliant due to the ongoing presence of wild birds and malodour within the service.”
TriCare Bundaberg Aged Care Residence
TriCare Bundaberg Aged Care Pty Ltd
Walker St, Bundaberg
★★★
An assessment in May found the nursing home had breached four federal standards with ongoing deficiencies in pain management.
Pain management was not tailored to residents’ needs and did not optimise their wellbeing, according to a performance report published in June.
The home was found to have breached Standard 2: “Ongoing assessment and planning with consumers”, Standard 3: “Personal care and clinical care”, Standard 4: “Services and supports for daily living”, and Standard 7: “Human resources”.
Family of one resident with a cognitive impairment and a degenerative disease that causes pain, raised concerns.
The resident’s care documentation showed the person was prescribed regular pain medication but a non-verbal pain assessment had not been completed.
Another resident with a history of pain was reviewed by the physiotherapist and prescribed daily massage and heat packs, which were not administered, the report said.
The report also found that changes to a person’s weight had not been adequately assessed and monitored.
A large number of residents and family members said there was a lack of activities for inside the outside the nursing home.
Feedback included in the report said residents were bored, had little to do and that no regular activities were provided.
The service no longer allowed residents to go shopping, the report said.
Management said there was a reduction in lifestyle staff hours as key lifestyle staff were on leave and no plan to continue the activities had been implemented.
Management also said those who did not have Covid could leave the service and interact with others.
There were board games, craft sessions, movies and outside activities on offer.
The management also produced photographs of board games and documented evidence of visits from the Community Visitors Scheme.
Management said in June there were exercise classes, bingo, craft, mens’ groups and music concerts. Monthly pet therapy was also available along with church services.
Management said shopping trips were suspended during Covid but staff took orders and made purchases.
The assessment team found residents were dissatisfied with staffing levels and staff also reported feeling rushed impacting care delivery.
STAR RATINGS GUIDE
■ Ratings are subject to change.
1 star – significant improvement needed.
2 stars – improvement needed.
3 stars – an acceptable quality of care.
4 stars – a good quality of care.
5 stars – an excellent quality of care.
Ratings can change throughout the year, see how:
Compliance: Based on noncompliance decisions made by the Aged Care Quality and Safety Commission reported daily.
Residents’ Experience: At least 10 per cent of older Australians living in residential aged care homes are interviewed face-to-face about their overall experience at their residential aged care home by a third-party vendor once a year.
Staffing minutes: From quarterly reports.
Quality Measures: Based on data from five existing quality indicators (pressure injuries, physical restraint, unplanned weight loss, falls and major injury, and medication management) reported quarterly
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