casterton memorial hospital · casterton memorial hospital strategic plan 2017 – 2020 to support...

Casterton Memorial Hospital

Serving the Casterton & District Community Since 1908

victorian quality

account2018-2019

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Casterton Memorial Hospital Victorian Quality Account 2018-2019 |

Victorian Quality Account | 1

ContentsStrategic Plan Inside front coverOur Model of Care 1Governing Board, Responsible Officers & Senior Employees 2Demographics & Service Profile 3President & Executive's Report 4-5Our Supportive Community 6Services to our Community 7Accessing CMH Community Services 8Case Study: Planning Your Care 9Consumer, Carer and Community Participation – Patient Experience 10Interpreter Services 11Disability Action Plan 11Maternity Care 12Building Capacity of Rural Consumers 12Accreditation Status 13Staphylococcus aureus 14Feedback 15Adverse Events 16People Matter Survey Results – Patient Safety 17Protecting the Casterton Community from Influenza 18Escalation of Care 19Improving the Service Experience 20Health Literacy in Practice 20Glenelg House: Residential Aged Care Services 21-24Finance & Activity Overview 25Workforce Information 26Photos 27Employee List 28Organisational Chart Inside back cover

Our Model of CareCasterton Memorial Hospital is classified as a Small Rural Health Service (SRHS) by the Department of Health & Human Services Policy and Guidelines. This classification allows Casterton Memorial Hospital, a Small Rural Health Service, to direct service delivery within budget which will best meet the needs of the community.

This service and planning decentralisation of the Hospital is important for flexibility from year to year or as circumstances may alter, but also allows at the local level to identify and target community needs.

It is the role of the Board of Directors in consultation with the community to utilise information available in the local area to maximise the health gains for the community.

Casterton Memorial Hospital fulfils its mission through provision of Acute, Residential Care and Community Health / Primary Care Services from its modern facility, as well as services into the home.

2 | Victorian Quality Account

| Casterton Memorial Hospital Victorian Quality Account 2018-2019

The Casterton Memorial Hospital is a public health facility established under the Health Services Act 1988. The responsible Ministers are detailed below:

Responsible MinistersCommonwealth Government AustraliaThe Hon Greg Hunt MP, Minister for Health The Hon Ken Wyatt AM MP, Minister for Aged Care and Senior Australians (01/07/2018 – 29/05/2019) Senator the Hon Richard Colbeck, Minister for Aged Care and Senior Australians (29/05/2019 – 30/06/2019)

State Government VictoriaThe Hon Jill Hennessy, MP, Minister for Health, Minister for Ambulance Services (01/07/2018 – 29/11/2018)Jenny Mikakos, MP, Minister for Health, Minister for Ambulance Services (29/11/2018 – 30/06/2019) Martin Foley, MP, Minister for Housing, Disability and Ageing (01/07/2018 – 29/11/2018) Minster for Mental HealthThe Hon Luke Donellan, MP, Minister Child Protection, Minister Disability, Ageing and Carers (29/11/2018 – 30/06/2019)

Casterton Memorial HospitalABN 62 051 291 134

Hospital Board of DirectorsPresidentM. Rowe

Vice PresidentG. Smith

MembersP. GreenJ. KensenB. RobertsJ. CrowleH. Moore

Audit CommitteeP. Green – ChairB. Roberts – Independent MemberH. Moore – Independent MemberL. Hulm – Independent MemberO. Stephens – Chief Executive OfficerM. Betinsky – Finance Officer

Visiting Medical OfficersDr. B. S. Coulson: M.B.B.S., D.R.O.G., F.A.C.R.R.M.Dr. Y. Yu: M.B.B.SDr. K. Moussa: M.B.B.S.Dr. T. N. Halloran: B.D., B.Sc. (Hons)Mr. P. H. Tung: M.B., B.S., F.R.A.C.S.Mr. S. Clifforth: M.B., B.S., F.R.A.C.S.Mr. R. H. Moore: M.A.(Camb.), MB., BCHIR., S.R.C.S.Mr. U. K. Naidoo: M.B.C.H.B., F.R.A.C.S., F.C.S.S.A.Dr. C. de Kievit: M.B., B.S., D.R.A.N.Z.C.O.G., F.A.C.R.R.M.Dr. K. Fielke: M.B., B.S., D.R.A.N.Z.C.O.G., F.A.C.R.R.M.

Emeritus Dr. A. F. Floyd: M.B., B.S., D.Obst., R.C.O.G.

Principal OfficersChief Executive OfficerO. P. Stephens: B.Bus., A.C.H.S.E.

Manager Nursing ServicesM.A. Betson: N.P.,R.N., R.M., Cert. Critical Care, Nurse Immuniser, Cert IV Training & Assessment, MNsg, MNP, FACN

Infection Control/ AHSH. Gill: R.N, Cert Infection Control & Sterilisation, Nurse Immuniser, MACN

Nurse Unit Manager Acute Ward/AHSS. Gill: R.N., Cert Aged CareP. Gunning: R.N.

Nurse Unit Manager Residential CareK. Sealey: R.N., Cert IV in Frontline Management, MACN

Nurse Unit Manager Community Health / Education Officer P. Layley-Doyle: R.N., R.M., Cert IV Training & Assessment, MACN

Nurse Unit Manager Community NursingC. Mahanda-Makore: R.N., Grad Cert Ad Nsg (Emergency Nursing)

Night Nurse in Charge / Quality ImprovementH. Dillon: R.N.,R.M., Grad Cert Ad Nsg Practice (Rural Remote)

After Hours SupervisorsS. Dehnert: R.N., R.M., Nurse Immuniser, Grad Dip Child Maternal Health A. Jenkins: R.N., Grad Dip Palliative Care, Grad Cert Ad Nsg Practice (Rural Remote), Grad Cert Gerentology S. Bryan: R.N., B.N., Grad Cert Ad Nsg (Emergency Nursing) C. Jose*: R.N., B.N.

Social Support Group Co-ordinatorB. Bryan: E.N., Cert IV in Leisure & Lifestyle

Corporate Services Officer / HRL. Hulm

Finance OfficerM. Betinsky: Cert IV Accounting

Health Information / Quality ImprovementH. Rees: Clinical Coder

Hotel Services SupervisorJ. East

Maintenance Coordinator / SafetyS. Zippel: Trade Carpenter/Builder

Meals on Wheels CoordinatorV. Ross

* Resigned during the year



Casterton Memorial Hospital - Small Rural Health Service (SRHS)

Demographics and Service ProfileCasterton Memorial Hospital was established in 1908 and is situated in the northern sector of the Glenelg Shire within the township of Casterton. Nestled amongst rolling hills and river red gums of the Glenelg River valley, it is located on the Glenelg Highway, 359 kilometres west of Melbourne and 42 kilometres east of the South Australian border.

The shire has a total population base of 19,520 and Casterton rural north has a catchment population of 3,500. Our catchment area includes the townships of Digby, Merino and Sandford and the surrounding rural localities. Casterton Memorial Hospital provides services to all within its population base as well as neighbouring shires.

As a Small Rural Health Service, the hospital is provided flexibility in its funding base to ensure that the services provided directly to our community are within budget and will best meet the needs of the community. The Board utilises local area information and community input to plan for and provide the most appropriate care and intervention options for our local catchment area to maximise health gains and status for the community.

The Hospital provides a range of acute health, aged residential care and primary healthcare services incorporating 15 medical/surgical inpatient beds, operating theatre, 2 bay urgent care centre, 2 dialysis chairs and 30 bed residential care facility ‘Glenelg House’. The Hospital also provides an extensive range of allied and primary healthcare personnel and programs along with visiting consultant services. All of these services are provided from the facility ensuring effective triaging and access of best care in the best possible time for consumers.

The Board of Directors and employees at the Casterton Memorial Hospital are committed to providing strong and efficient health and community services to meet the needs and expectations of the community it serves to providing strong and efficient health and community services to meet the needs and expectations of the community it serves.

Strategic Planning Casterton Memorial Hospital strategic plan 2017-2020 can be found inside the front cover of this publication, or visit our website www.castertonmemorialhospital.com.au

Dergholm

Balmoral

Cavendish

Ararat

Ballarat

Glenthompson

Hamilton

Dunkeld

ColeraineCasterton

Merino

Penshurst

Heywood

Dartmoor

Nelson

PortlandWarrnambool

Geelong

MelbourneMt. Gambier SA

Hamilton



President & Executive’s ReportIt is with great pleasure, on behalf of the Casterton Memorial Hospital Board of Directors, employees, volunteers and consumers that I present to you our 2018-19 Victorian Quality Account.

2018-2019 continued on from previous years in striving to meet the Casterton community’s needs with

a diverse range of services from community health, urgent care, inpatients and aged residential care.

Financial SustainabilityCasterton Memorial Hospital maintains systems and processes that ensure financial sustainability, accountability and responsibility for the delivery of safe, responsive patient centred care services.

This year we have produced an operating surplus prior to capital and specific items of $102,221.57 whilst meeting service demands and our Model of Care for the Casterton community. This sound financial performance is a result of appropriate Government funding, good private patient revenue and ostensibly achieving Department of Veterans’ Affairs inpatient activity and other set targets for the year. Expenditure levels have been well controlled once again for the year and this together with sound revenue achievement has produced an operating surplus.

Glenelg House Residential Care’s occupancy rate of 99.25% has been a positive contribution once again and this recognises the need for quality high care service for the community. Casterton Memorial Hospital has continued to maintain a very solid balance sheet with a current asset ratio of 1.42 indicating sufficient funds to meet current liabilities.

Community Service ProvisionCasterton Memorial Hospital’s home and community services continue strongly with community home nursing, health promotion, provision of home maintenance, meals on wheels and a community transport program to support access to essential medical and health services.

Additional staffing resources across the Community Health program has proven successful in meeting the required needs of our community.

Our specialist visiting services and allied health personnel, from physiotherapists to dental clinicians and surgeons to podiatrists, continue to provide a strong level of service and commitment to our Community.

GovernanceCasterton Memorial Hospital has met its obligations within the Statement of Priorities 2018/19 with the Department of Health and Human Services. This contract is negotiated annually between the Casterton Memorial Hospital Board of Directors and the Department which results in funding for service delivery and establishment of certain targets for us to achieve from infection control to consumer satisfaction surveys.

Casterton Memorial Hospital now has in place a three year Strategic Plan 2017-2020, this can be viewed on our website. Key Performance Indicators are being steadily achieved with details of the current Strategic Plan to be found on the inside cover of this report.

The Board has also processed and governed the implementation of many changes and improvements during the 2018-2019 year including, but not limited to;

• Strengthened partnerships with Clinical Governance Collaborative within the Region

• Regional Health Infrastructure funding $105,000 gained for Acute Ward fire sprinkler system.

• 99KW Solar Power system installed and operational

• Dr Floyd Community Room & Medical Precinct upgrade planning on-going

• Flu Vaccinations second in the state take-up rate 97%

• Fun Run / Colour Walk with 300 participants of all ages

• Kelpie Weekend dinner & auction for mental health support, sold out again

• National Standards Accreditation achieved July 2018

• South West Health Services increased collaboration from clinical to corporate programs

• Bendigo Bank account establishment• Victorian Central Banking Model changes• Aged Care Royal Commission submission• Board and employees continuing high levels of

education resources

Ms Merridy RoweBoard Chair



The Casterton Memorial Hospital TeamCasterton Memorial Hospital has a diverse team of employees and volunteers who ensure safe, consistent and efficient care across the three domains of community, acute and aged care. These employees and volunteers work in teams of catering, environmental services, maintenance, administration and clinical services. Each area is committed to the person centred care approach both to the consumer and to the Casterton Memorial Hospital team. The Board of Directors would like to acknowledge the continued excellence in service provided by employees and volunteers.

The continued successful outcomes for consumers are maintained through the support of contracts especially the Casterton Coleraine (CC) Medical Clinic principal partner Dr Brian Coulson, and Drs Moussa and Yu. We thank the CC Medical Practice team for their 24 hours coverage for all of the Casterton community. It is a wonderful service and the support shown to Casterton Memorial Hospital through their attendance and active clinical governance role is well evidenced. Casterton Memorial Hospital is supportive of their continued ongoing recruitment and succession planning.

Casterton Memorial Hospital is proud of the continuing clinical care provided by the nursing team. As a Small Rural Health Service, the nurses are skilled to provide care to a wide range of presentations and conditions from Urgent Care, to Aged, Acute and Community. Maintaining clinical excellence in care, clinical competence, continuing professional development, ensuring clinical supervision of students and graduates and work experience students are all part of the broad role that nurses undertake at Casterton Memorial Hospital.

Casterton Memorial Hospital nursing team maintain a continued close working relationship with external education providers to facilitate student placement, support the Post Graduate Nurse Entry to Practice program and to ensure that this clinical supervision meets best practice standards. Casterton Memorial Hospital is proudly supported by Barwon Health with both clinical and education support through the use of real time video conferencing and clinical practicums and regular “in person” visits both to Barwon and to Casterton.

The service divisions of Catering and Environmental Services have worked through a major change this year with the two services being merged forming

the Hotel Services Division. Headed up by Jenelle East the team is working more efficiently and purposely toward consumer support and care.

Maintenance under Stephen Zippel and administrative employees under Corporate Services Officer Loren Hulm are continuing on with strong output in management and maintenance of CMH’s assets and sustainability. Casterton Memorial Hospital has continued to have outstanding results in external cleaning audits, maintenance of the facility and a cohesive and organised administration system.

Consumers also praise the meals and the quality of their product and this is of particular importance to consumers who are unwell and who genuinely appreciate nutritious and appealing meals cooked and served quickly.

Casterton Memorial Hospital continues to have an amazing relationship and strong support from the community who provide additional funding and a wonderful sense of wellbeing by participating in voluntary groups to fundraise for CMH needs.

These groups are the Murray to Moyne Cycle Relay Team, Casterton Memorial Hospital Ladies Auxiliary, Hospital Social Club, Friends of Glenelg House, employees, as well as the now annual events of the ‘Colour Fun Run’ and ‘Dog and Dinner Auction’ just before the June Kelpie weekend.

Volunteering for the hospital has many benefits, not only for the consumers who reap the reward of the additional equipment from funds raised but also the sense of wellbeing and participation that improves small communities to become strong communities. Well done for another great year.

Finally, to my fellow Board Directors and the Executive Management team of Owen Stephens and Mary-Anne Betson; your input, vision and support of Casterton Memorial Hospital for and on behalf of our community is to be commended. The future for Casterton Memorial Hospital will continue to be progressive while we all team together as a cohesive unit and work in collaboration with our partners across the Barwon Southwest Region.

Ms Merridy RoweBoard Chair22nd August, 2019



Our Supportive CommunityCasterton Memorial Hospital is well supported by its employees and the community. We offer our sincere thanks to employees, the Hospital Ladies Auxiliary, Hospital Social Club, Murray to Moyne Cycle Relay team, Friends of Glenelg House and the Wando Vale Ladies Auxiliary for their support and fundraising contributions. We also acknowledge the various businesses, community groups, estates, families and individuals who continue to support us financially and by way of in-kind donations.

During the 2018/2019 financial year, fundraising contributions and donations totalled $48,729.47. These valuable funds assist with the upgrading of equipment and the maintenance and furnishing of our modern hospital, aged care facility and community health development.

Our many volunteers provide purposeful activities and roles, and as such are greatly appreciated by employees and the community we serve. We extend our sincere appreciation to the community volunteers who assist with the delivery of meals on wheels, bus driving, visiting, outings, entertainment, diversional and lifestyle activities. Our volunteers assist us to meet the needs of our community and foster community connections for our residents and their families.

The Hospital also appreciates the input and contributions from the businesses and the broader community through our community surveys, questionnaires and Hospital Card Program. This community spirit contributes to Casterton Memorial Hospital being a proud facility and also supports our continual effort to provide the best quality services to meet the changing needs of our community.

The Board of Directors sincerely thanks all Casterton Memorial Hospital supporters for their generous, tireless and invaluable support during 2018/2019 year.

Acknowledging 2018/19 donations Fundraising CommitteeCasterton Memorial Hospital Staff 1548.00Casterton Memorial Hospital Ladies Auxiliary 823.00Casterton Memorial Hospital Social Club 1000.00CMH Murray 2 Moyne Cycle Relay 13278.54Hospital Card Program 3800.00Community Member SupportAnonymous 66.00Casterton Kelpie Association 500.00Knit & Natter Group 1384.75Memory of Marjory Cathels 285.00Memory of Ernest Dexter 65.00Memory of Patrick McGuinness 70.00Memory of Cliff Tischler 230.00Memory of Len Baker 200.00Memory of James Condon 30.00Memory of John Egerton 20.00Memory of Maisie Humphries 200.00Dog & Dinner Fundraiser 5245.00Malcolm Ginn 2995.00Friends of Glenelg House 1690.00John & Maria Shanks 50.00Casterton Sandford Football Netball Club 100.00Phyllis Arnall 100.00Jean McCallum 70.00Sally Henty-Anderson 10.00Joyce Edwards 310.00Leon Jordan 57.65Casterton CWA 8000.00Pamela McIntyre 10.00Lenox Spears 50.00Liela Dohle 100.00Velda Cookson 10.00Benjamin Mair 500.00Expressoworx 1000.00EstatesEstate Louisa Henty 745.28Equity Trustees - Estate Stanley William Heath 400.00Equity Trustees - Estate John Russell MacPherson 625.00Estate Norma Gilbert 3000.00Estate Gwen Cameron 161.25Total Donations $48,729.47

Acknowledging our Life GovernorsRecognised for Service and Dedication to Casterton Memorial Hospital

Mr. T. Baker OAM Mrs. B. Collins

Mr. R. Cowland Mr. E. Edge

Mrs. E. Flanders Dr. A. F. Floyd

Dr. T. Halloran Mrs. C. McKinnon

Mrs. M. Moffatt Mr. R. Nicol

Mrs. J. Ross Mr. P. L. Sandow

Mr. G. Sheppard Mr. C. R. Simson

Mrs. K. L. Simson

Mr G Sheppard receiving his Life Governorship



HOSPITAL 2017/18 2018/19Total Multistay Inpatient Separations* 264 235Total Same Day Separations* 235 255Bed Days* 2512 2346Total WIES 382.77 369.29% Occupancy Rate 46% 43%Average Length of Stay** 4.15 4.32% Public Bed Days 94% 81%% Private Bed Days 6% 19%Obstetrics / Gynaecology 14 8Operations / Procedures 100 82Urgent Care Presentations 1192 1141Glenelg House Residential CareResidents Accommodated 38 46Bed Days 10909 10868Average Daily Occupancy 29.89 29.78% Occupancy Rate Full Year 99.63% 99.25%Planned Activity GroupAttendances 1164 1416Community Home NursingHome Visits 4955 5237Kilometres Travelled 19981 22753Community HealthAttendance (contacts) 244 281Allied HealthPhysiotherapy Attendance *** 1145 841Dietetics *** 61 75Meals ProducedHospital / Residential Care / Other 64876 65597Meals on Wheels 6681 5039Home Maintenance Program (HACC Service)Number of Clients 101 112Number of Visits 1216 1209Number of Hours 1242 1212* Does not include Newborn transfers ** Excludes Nursing Home Type *** Includes inpatients

Services to our Community Other Services facilitated from Casterton Memorial Hospital through private practitioners include:• Audiology• Visiting Medical Specialists• Radiology Services• Podiatry Services• Occupational Therapy• Drug & Alcohol• Physiotherapy• Speech Therapy• Dental• Mental Health

Michael Naylor on the mower as part of CMH’s home maintenance program



Accessing CMH Community ServicesCasterton is a small community which makes it easy for consumers to find the location and the services offered at CMH. The Community Victorian Health Experience Survey (VHES) results for 2018 showed that 92% of consumers found it easy to locate the health service.

When consumers were asked how they typically travel to CMH, 67% used private cars, 21% walked, 13% used community transport provided through the hospital and 4% were visited at home by Community Home Nurses. Transport facilities scored 100% - CMH has very good parking areas, foot paths, drop off and access to public transport. Consumers for Seasons usually drive themselves or use the hospital bus service.

The data shows that CMH reception employees are rated 100% for politeness and helpfulness. This welcoming reception makes the process easier for consumers to book appointments and pay accounts.

After admission to the community health service, 95% of consumers agree that health care workers considered all their needs such as health, culture, living and family situations.

92% responded yes to being provided with a written copy of a plan for their health and wellbeing.

50% of consumers responded ‘yes’ to being involved in the discussion and review of their care plans and that the care plan was helpful. Due to these results, the care plan form was updated and reviewed to be more person-centred in how goals and actions are planned. The new care plan indicates if a copy of the care plan is offered to consumers after each review. Consumers are now able to rate the outcome of their planned goals and actions.

CMH continues to work with the multi-disciplinary health team to provide care to the Casterton community. This includes access to services such as dietetics, physiotherapy, podiatry, palliative care and a wound specialist, as well as frequently communicating with the consumers’ GP.

The VHES data shows that 92% of consumers say that their health workers take their concerns seriously and 82% responding positively that the health care services work together as a team to help improve their health and wellbeing.

52% of consumers feel they had to repeat some information that should have been in their health records. To improve these results, community health has worked to gain consent from consumers to access information for / from their GP, hospital records or other service providers to complete the continuity of care.

Cathy Crowle and Moana Shone at reception



Case Study: Planning Your CareA very independent consumer went for surgery and experienced complications resulting in them not being able to function or socialise as they had previously. The consumer and their family were suffering emotionally due to chronic extensive wound complications. CMH Community Home Nurses (CHN) accepted a referral for this consumer to provide care which then allowed the consumer to return home to Casterton. A goal directed care plan was developed on admission with the consumer, their partner and nurses which involved current situation, goals and actions. The goals were person-centred and the consumer, partner and the nurses all had separate actions to work towards achieving these. Goals were broken down into short term achievable steps which when combined, worked together to maintain and improve health and provide emotional support.

Community Home Nurses used motivating factors and measured little gains to assist the consumer to live the best life they could during this very distressing time, which ensured that the family

were supported to return to some normality in their lives.

A multi-disciplinary team were involved in this consumer’s care ranging from the major city Hospital (who performed the initial surgery), the consultant surgeon, rural hospital services, post-acute care, regional consultant services, local dietician, Community Home Nurses and the consumer’s GP.

Family members were exceptional and attended to the transport and appointment needs of the consumer, however it took more than 12 months to regain their health and lifestyle after this traumatic experience.

Following ongoing professional consultation and quality nursing practices, this consumer had a positive improvement both in their mental/emotional state and health status.

Consumer: “perfect,” I was able to be around my family

and be in my own home.

Consumer was able to drive again and has regained

mental health with improved interaction with friends and

the community again.

Consumer’s partner: Was able to go back

to work with the carer support provided by CHN which worked to alleviate

strain and stress.

GP: Did not think the consumer would fully regain health. “CHN

provided persistent and diligent well planned care, focussing not only on the

clinical care but emotional wellbeing as well.”



Consumer, Carer and Community Participation – Patient ExperienceThe Victorian Healthcare Experience Survey or VHES, is how we learn about consumer experience at CMH. This survey is conducted on behalf of the Department of Health & Human Services for a range of healthcare services such as inpatient, community and midwifery services. You may have received a survey following discharge from hospital. The questions relate to a range of experiences during a healthcare service. We use results to identify areas where we can improve and compare our performance to other like sized health services. We continue to monitor results in order to learn from the experiences of consumers who use our healthcare services.

We now liaise closely with the local pharmacy to create a medication discharge list which informs consumers about their medications, including time to take, what the medication looks like, warnings about the medications and any further instructions. These reports are shared (with consent) with GP’s, pharmacy and community services to support the continuity of care.

The pharmacy reports that consumers are bringing in lists for review and consumer feedback shows that 98% agree that the discharge lists are helping them to understand their medications better.

KEY PERFORMANCE INDICATOR TARGET 2018/19 RESULT

Victorian Healthcare Experience Survey – percentage of overall positive patient experience responses

95% 100%

Victorian Healthcare Experience Survey – percentage of very positive responses to questions on discharge care

75% 100%

Victorian Healthcare Experience Survey – patients perception of cleanliness 70% 100%

What were the best things about your stay in hospital?

• Being looked after by doctors & nurses

• Care & consideration of all the staff

• Hospitality from staff... Excellent!!

• Nice, friendly environment

• Not treated as a number, but a person

What were the worst things about your stay in hospital?

• All the staff were great could not fault the hospital maybe more doctors thank you

• Cold food that was supposed to be hot. It was usually, at best, barely warm. The food itself was quite okay

• I could not fault the care I received

Casterton staff are lovely people and the hospital is well

kept. I cannot think of anything that would

enhance what it is currently provided.



Interpreter ServicesThe need for interpreter use for consumers in aged, acute and community care is very rare at CMH. However, should the occasion occur, CMH is supported through a language service line funded through the Department of Human Services. This program provides telephone link service with an interpreter who can assist in ensuring the consumer is understood and able

to be active in their care. Due to the low usage of this scheme, nurses are provided with regular updates and guidelines are often checked to ensure they remain current.

Disability Action PlanCMH has drafted its first Disability Plan which was ratified in June 2019 at the Board of Directors meeting. The plan aims to provide “safe, inclusive and accessible care” for everyone in our community.

CMH will, over the coming year, commence work on meeting the goals of the plan which align with the organisation’s strategic plan and also the larger Glenelg Shire Access and Inclusion Action Plan which CMH contributed to. This plan will support the principles of the Disability Act 2006 and the Disability Discrimination Act 1992 in supporting access to health services and health services employment equally for people with a disability, as those without a disability.

The four key areas CMH will focus on are:

1. Reducing barriers to persons with a disability accessing goods, services and facilities by

continuing to improve accessibility of CMH to persons with physical, language or hearing impairments.

2. Reducing barriers to persons with a disability obtaining and maintaining employment. This will be achieved through provision of accessible application and employment conditions.

3. Promote inclusion and participation in the community for persons with a disability by engaging and encouraging consumers to be involved in our community participation groups and forums.

4. Achieving tangible changes in attitudes and practices which discriminate against persons with a disability, through education of employees, clinicians and public education initiatives.

Bernie Bryan and Keith Edwards show how consumers of all abilities can access the services at CMH.



Maternity CareCMH does not provide birthing services, but does provide postnatal care and domiciliary visits for new mothers. Over the last 12 months CMH has worked collaboratively within the Barwon South West Region to develop a capability and sustainability framework for all 9 maternity services in the region. CMH is rated a Level 1 facility with no onsite birthing. Birthing facilities in the region then rank to Level 5 which includes high risk birthing and newborn care at Barwon Health.

At CMH midwives, medical officers, birthing facilities and Child Maternal Health Nurses all communicate to support new families during this very busy and exciting time of their lives. Women who wish to return closer to their community can have inpatient postnatal care, or home care provided by the midwives from CMH. Ongoing support is then provided until the Child Maternal Health Nurse visits.

Midwives Paula Layley-Doyle and Mary-Anne Betson review the cover made by volunteer Kathy Parfrey for the neo-natal resuscitation unit

Building Capacity of Rural ConsumersSupporting rural communities to participate effectively in their healthcare can be a challenge when dealing with small numbers, diverse communities and of course distance and transport access. CMH has, for more than a decade, worked collaboratively with our partners in mental health, emergency, aged care and numerous specialists to support access through telehealth and have specialist support groups visit the area.

Currently telehealth, through the Barwon Telehealth Project, allows older consumers’ access to a Geriatrician. This allows GPs, carers and the consumer to be together in one place to discuss some of the health issues and treatment required for their care. This makes an enormous amount of difference to empowering consumers and their families in accessing specialist care without leaving town.

Supporting after-hours access for mental health consumers in the area has also been a collaborative effort, with the implementation of the South West Healthcare mental health services telehealth service. The service allows telehealth consultations for consumers from the urgent care centre to the on-call mental health worker. Consumer feedback on this service has been very positive. Whilst numbers on consultations to date are few, the availability of the service is a great back up, not only for the consumer but also for their carers and health professionals.

Feedback from a telehealth consumer:

The telehealth service at CMH has allowed us to access a specialist Geriatrician in

Geelong. This personal communication with the specialist has allowed Dad to talk

honestly about his feelings and worries. From this service, the Geriatrician has been

able to offer advice and the appropriate medication to help him.



Accreditation StatusCMH is required to meet a number of healthcare accreditation programs that measure quality and safety systems. Accreditation is ‘a formal process to assist in the delivery of safe, high quality health care based on standards and processes….’ Accreditation surveys are undertaken by independent external accreditation agencies such as the Australian Council on Healthcare Standards (ACHS) and the Aged Care Quality and Safety Commission (formerly the Aged Care Accreditation Agency).

Aged Care:Glenelg House Residential Aged Care underwent a re-accreditation visit in September 2018. This visit assessed Glenelg House against the 44 expected outcomes of the Aged Care Accreditation Standards.

Glenelg House were very happy to be able to demonstrate achievements against all 44 outcomes and were awarded full accreditation.

From July 2019 the Aged Care Standards have changed to the Aged Care Quality and Safety Standards and Glenelg House looks forward to again demonstrating their commitment to safe and quality care through these new measures.

Acute:In July 2018 CMH underwent a periodic survey with the ACHS against the National Safety & Quality Healthcare Standards (NSQHS). These standards focus on consumers, leadership, culture and best practice. Following recommendations from the previous survey, we improved our education program to ensure that all clinicians undertake training for aseptic techniques and employees (not just clinicians) have training in basic life support. Again we were very happy to demonstrate achievement against all required standards and re-affirm ongoing facility accreditation.

ACCREDITATIONS Status

National Safety and Quality Healthcare Standards Periodic Survey 2018

Achieved

Aged Care Accreditation 2018 Achieved

Food Safety Certification 2018 Achieved

CHSP/HACC Community Care Common Standards 2017

Current



Staphylococcus aureusCMH is happy to report that over the 2018/19 year there have been no Staphylococcus aureus bacteraemia (SAB) infections. This can be attributed to the employees and volunteers’ dedication to ensuring that infection prevention and control is part of everyday practice, including the 5 moments of hand hygiene.

Infection rates and antimicrobial (antibiotics etc.) usage in both acute and residential care is monitored on a monthly basis as part of the infection control role. These reports are reviewed at the Clinical and Board of Directors meetings and a copy is sent to each Medical Officer so they can review their practice against best practice.

YEAR Healthcare Associated (public hospital)

Healthcare Associated (non- public hospital) Community Associated

No. of SAB No. of MRSA No. of SAB No. of MRSA No. of SAB No. of MRSA

2018/19 0 0 0 0 0 0

VICNISS 5 year Aggregate (n=101)

1968 344 174 24 4627 684

Wendy Zippel discussing the role of hand sanitiser in effective hand hygiene with Jarrod Davidson

Jessie Acton demonstrating aseptic technique to NUM Shane Gill

CMH Hand Hygiene Audit

performance 87%

State Target 80%



FeedbackAt CMH we believe that actively seeking and listening to consumers’ feedback is essential to providing care and services that meet the goals and needs of our community.

We have a number of ways for consumers to provide us with feedback, either positive or negative.

We received feedback from a resident of Glenelg House, who noted that his visitors did not always know how to get the attention of carers when entering the facility.

We trialled some different signage at the entrance with success and now permanent signage has been put onto the window and an alert button installed at the entrance.

Feedback from visitors was very positive with the majority noting they had observed the new instructions and they were easy to follow. Two people noted that when they used the alert button the response from nurses was timely, polite and helpful.

Inpatient Feedback: “I feel the staff were

wonderful. Gave me over and above attention and were

all so efficient.”

Inpatient Feedback: “Excellent care was provided by all. The

surroundings are beautiful and restful.”

• We provide further information on how to escalate your feedback if you are not satisfied with our actions.

• Consumers provide feedback

• We will acknowledge your feedback.

• We will inform you of the outcome of your feedback and how it will be managed.

• We treat all types of feedback as a potential opportunity to improve our care and services.



Adverse EventsLike all health care facilities, CMH strives to reduce the risk of adverse outcomes for all consumers. CMH monitors every incident or near miss through a system called the Victorian Health Incident Management System (VHIMS). Information is put into this system which then can identify the level of risk or negative outcome. Employees are aware of the requirement to report any near miss or incident. A grading system is used to identify the level of harm or danger ranging from ISR4 (least harm or near miss) to ISR1 (most harm).

Sentinel events are adverse safety events that result in serious harm or death of a consumer whilst in the care of a health service. If a sentinel event occurs then a formal review of the incident is undertaken and is reported to Safer Care Victoria within a certain time frame. CMH did not have any sentinel events for the 2018/19 year.

The value of undertaking reviews of all incidents (including near misses) is that sometimes there

is a theme that can be identified and a change in practice can be made which will reduce the risk of it occurring again.

An excellent example of this is where CMH reported that a needle became disengaged from a syringe during an injection resulting in the consumer only receiving half the dose. This resulted in two injections being required to get the full dose.

An internal investigation was made and it was noted that the sealing of the syringe to the needle was not tight and therefore became loose during the injection of fluid. It was reported to the manufacturer of the syringes (pre filled with a drug) and apparently CMH was not the only facility in which this occurred. The outcome was a state wide notification to all health care facilities that a certain brand of needles were not compatible with this particular syringe. Whilst this incident did not result in harm to the consumer, it was one that many clinicians were reporting and as such, practice was changed.

100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%

ISR 4 ISR 3 ISR 2 ISR 1

July18

Oct18

Aug18

Nov18

Sep18

Dec18

Jan19

Feb19

Mar19

Apr19

May19

Jun19

9

6

7

12

7

11

5

13

11

11

13 13

1515

7

77

14

14

10 10

14

20

1 2

7

Number of incidents reported 2018/19 according to severity



People Matter Survey Results – Patient Safety CMH employees annually participate in the Victorian Public Sector Commission ‘People Matter Survey’. The survey results tell CMH how employees see their workplaces, including views on:

• equal employment opportunity,• discrimination,• fair and reasonable treatment; and• diversity and inclusion.

The results help CMH understand employee engagement and job satisfaction and are used to improve the working environment for employees.

CMH’s overall score for positive responses to safety and culture questions has increased from 82% in 2017/18 to 93% in 2018/19.

The Employee Assistance Program available to employees at CMH offers a wide range of services including education, mental health assistance / counselling, immunisation and medical / allied health appointments. This program is accessed regularly by employees who require assistance in the workplace.

CMH periodically conducts a number of reviews / audits of the work areas and procedures to ensure that it is providing a safe and functional workplace for employees. Any issues identified through these reviews are addressed by management. Employees are also regularly given the opportunity to suggest improvements in the workplace. One of these being the introduction of stick vacuum cleaners and spray mops for the Environmental Services department.

Employees had noted at their meetings that the use of the heavier vacuum cleaners and a mop and bucket to clean up a small spill was both labour and time intensive. By introducing the stick vacuums and spray mops this allows for employees to be able to quickly and effectively clean up small spills without the need to get out the heavier equipment.

Num

ber o

f inf

ectio

ns

KEY PERFORMANCE INDICATOR TARGET 2018/19 RESULT

People Matter Survey – percentage of employees with an overall positive response to safety and culture questions.

80% 93%

People Matter Survey – percentage of employees with a positive response to the question, “I am encouraged by my colleagues to report any patient safety concerns I may have”.

80% 94%

People Matter Survey – percentage of employees with a positive response to the question, “Patient care errors are handled appropriately in my work area”

80% 91%

People Matter Survey – percentage of employees with a positive response to the question, “My suggestions about patient safety would be acted upon if I expressed them to my manager”.

80% 89%

People Matter Survey – percentage of employees with a positive response to the question, “The culture in my work area makes it easy to learn from the errors of others”.

80% 96%

People Matter Survey – percentage of employees with a positive response to the question, “Management is driving us to be a safety-centred organisation”.

80% 96%

People Matter Survey – percentage of employees with a positive response to the question, “This health service does a good job of training new and existing employees”.

80% 93%

People Matter Survey – percentage of employees with a positive response to the question, “Trainees in my discipline are adequately supervised”.

80% 91%

People Matter Survey – percentage of employees with a positive response to the question, “I would recommend a friend or relative to be treated as a patient here”.

80% 98%

Julianne McCalman and Louise Kerr with the new stick vacuums



Protecting the Casterton Community from InfluenzaIn 2018-19 CMH continued to work towards reducing the risk of influenza not only in the workplace but also in the wider Casterton community. As a public sector health care facility promoting and supporting health (especially in preventable diseases) is a key role of all clinicians and employees.

This year we continued our usual high uptake of vaccination in the employee group and residential care facility consumers. We promoted this to the

wider community with our award-winning float in the Kelpie Festival parade.

Due to this, we have seen increasing community support for vaccination, and as a small rural cohort the impact of “herd immunity” is extremely important. The more of the community vaccinated, the less chance of influenza spreading. This high uptake has certainly seen less cases of influenza and hospitalisations. Well done Casterton!

100%

80%

60%

40%

20%

0%

Nur

sing

Adm

inis

trat

ion

Alli

ed H

ealth

Cate

ring

Mai

nten

ance

Am

bula

nce

Serv

ice

Envi

ronm

enta

l Ser

vice

s

Volu

ntee

rs

Boar

d of

Dire

ctor

s

Gle

nelg

Hou

se

CMH Flu Vaccine Rates 2018/19

Percentage Vaccinated DHS Required Rate

CMH's float at the 2019 Kelpie Festival



Escalation of CareEscalation of care is the action taken during the early stages of deterioration which can prevent further consumer harm. It can also prevent progression of deterioration, and results in improved outcomes for consumers.

CMH has systems in place to support clinicians and consumers to gather as much information and use tools to identify early changes in condition which may result in clinical deterioration.

It starts with a good training system for clinicians and employees to understand how to respond to the changing conditions of consumers. Employees (not just clinicians) undertake basic life support training (updated annually) on how to respond to an emergency. Clinicians undertake professional development on and off-site and utilise Barwon University Hospital Emergency department education providers for onsite and tele-education and support in managing clinical deterioration. CMH clinicians undertake routine advanced life support education and practicum and uses best practice clinical pathways to support clinical deterioration identification and early care.

The consumer (or their carer) on admission is supported to understand that they know themselves best and to ensure they inform the clinicians of any concerns they may have and to call for assistance. Each room clearly identifies the process to call for assistance. Call bells and emergency responses are practiced by clinicians regularly and include advanced life support and emergency transfers if necessary.

A good history and understanding of the individual is taken and reported using the

electronic patient management system which clinicians use to identify specific potential

risks. The “VICTOR” observation chart for children and the “TRAK” observation chart for adults provides a safe range of observations which guide the clinician whether to escalate care further, i.e.: to a more senior

nurse or medical officer.

“Treated with the utmost

professionalism and

friendliness.”

Paula Gunning and Dr Khaled Moussa reviewing consumer documentation

Debbie Gartlan and Heather Gill practicing advanced life support

‘Call for Help’ ward advice



Improving the Service ExperienceThe regular Strength & Balance group numbers were becoming larger and abilities of the consumers more varied. Outgrowing the space and meeting each consumers needs was becoming a challenge, particularly as some consumers needed more individualised support and attention to ensure their safety and maximise results. Whilst some consumers could participate in the chair based exercises they found other exercises too difficult or strenuous.

All consumers still wanted to continue attending the class as they were benefiting from the exercise, and enjoyed the social interaction.

We needed a solution…

With our person-centred approach in mind we discussed how best to meet the consumers’ various needs. After collaboration, various ideas were put forward and it was decided by the group that rather than anyone miss out we needed to start a second group! Everyone could choose which group they would prefer to attend (or both!) to meet their needs allowing scope to adjust the exercises. Naming and marketing this new group was also led by the consumers. The second group was named Going Strong (“we want something that shows we’re not giving up to this ageing thing” one consumer laughed).

Health Literacy in PracticeLike the expansion of one exercise group to two, when given a blank canvas on how to market the various exercise programs at CMH, including the new “Going Strong” Group, there was no “one size fits all”.

Instead two resources were developed, one which focused on less words and mostly pictures showing the content of the classes, the other a Monday-Friday

version with some extra explanations. The group was then happy to take whichever they preferred, invite friends and people they knew along to join in.

Participant numbers for both groups has continued to grow with attendees reporting increased satisfaction in meeting their personal goals. They are pleased that CMH could change what they provided to meet everyone’s different needs.

Exercise groups in action

Exercise Group information brochures



Glenelg House: Residential Aged Care ServicesQuality Indicators in Victorian Public Sector Aged Care Services (PSRACS) commenced in 2006. Public sector aged care facilities like Glenelg House collect and report data on performance against a number of indicators, and these are reported to the Department of Health & Human Services. This program has received high recognition in supporting aged care services to improve quality of care as well as being able to compare performance against other like sized facilities.

Glenelg House has voluntarily participated in the PSRACS program since its inception, collecting and reporting data on all indicators. Data is compared against a number of other aged care facilities in the state. Glenelg House, as a care facility that provides more complex care, reviews results against other similar facilities (high care rate).

In 2016 the PSRACS went national with the commencement of the National Aged Care Quality Indicator Program.

Since July 2019 it is now a mandatory requirement for all Commonwealth funded aged care services to participate and report indicators for pressure injuries, use of physical restraint and unplanned weight loss. CMH will continue our practice of reporting against all indicators to support our commitment to quality and safety in Glenelg House.

Victorian services publish performance information through their Quality Account and consolidated indicator information is published on the Australian Institute of Health & Welfare website.

Glenelg House shows their support to fight MND (Daniher’s Drive)

Q12017/18

4.30

4.306.005.004.003.002.001.000.00

4.65

4.00

4.81

2.96 3.32

5.004.41

4.37 4.36

2.993.71

4.734.48 4.65

Q22017/18

Q32017/18

Q42017/18

Q12018/19

Q22018/19

Q32018/19

Q42018/19

Glenelg House Rate High Care Rate

Nine or more medications

Use of Nine or more MedicationsThe use of increased numbers of medications can increase health risks to older Australians, however in some situations, polypharmacy may be necessary to ensure a quality health outcome for individuals. Polypharmacy can increase the risk of hospitalisation due to the increased incidence and susceptibility to adverse drug reactions. People aged 65 years

and over are the highest consumers of multiple medicines in Australia.

Glenelg House monitors medication use and undertakes regular reviews of the consumer’s medication in conjunction with the consumer’s GP and the pharmacist.



Glenelg House: Residential Aged Care Services cont.

Q12017/18

1.60

1.20

0.80

0.40

0.00

1.090.82 0.85 0.92 0.94 0.99 1.06

0.770.85 0.73 0.74 0.74 0.73

0.36 0.00 0.37

Q22017/18

Q32017/18

Q42017/18

Q12018/19

Q22018/19

Q32018/19

Q42018/19


Unplanned Weight Loss

Q12017/18

1.60

1.20

0.80

0.40

0.00Q2

2017/18Q3

2017/18Q4

2017/18Q1

2018/19Q2

2018/19Q3

2018/19Q4

2018/19


Significant Weight Loss > 3kg

1.45

0.860.74

0.92 0.92 0.85

1.20

0.85

0.000.74 0.73

0.36 0.37 0.37

0.730.96

Unplanned Weight LossWeight management is important especially for older people suffering with dementia who are at high risk of significant and sustained unplanned weight loss. Adverse events due to weight loss / malnutrition include: pressure injury

development, poor wound healing, increased risk of falls and fractures and even death. Glenelg House monitors consumers’ weights monthly, and provides healthy, nutritious, dietician-approved freshly cooked meals and snacks.

Use of Physical RestraintRestraint is an aversive practice or action that restricts the consumers’ movement. Evidence shows that the prevalence of physical restraint in residential aged care is between 12-49%. Evidence shows that the use of physical

restraint does not prevent falls or fall-related injuries and can even exacerbate behaviours in consumers with dementia. Glenelg House does not utilise any physical restraint devices or employ restrictive practices.

Q12017/18

1.60

1.20

0.80

0.40

0.00Q2

2017/18Q3

2017/18Q4

2017/18Q1

2018/19Q2

2018/19Q3

2018/19Q4

2018/19


Intent to Restrain

0.410.57 0.54

0.34 0.31 0.33 0.46 0.41

0.000.00 0.36 0.00 0.00 0.00 0.00 0.00




Pressure InjuriesPressure injuries are defined as a localised injury to the skin or underlying tissue, mostly over a bony prominence which is usually a result of pressure, shear/ friction or a combination of both. These injuries are then categorised according to the criteria and allocated a stage from 1-4 or unstageable.

Ageing consumers are more prone to pressure injuries, especially those who reside in Aged Care facilities. This risk increases with age due to changes in consumers who have one or more co-morbidities and factors such as changes to skin integrity, decreasing mobility, incontinence, reduced fluid and nutritional intake, declining cognition and insight, and increased fragility.

CMH has a proactive approach to pressure injury prevention and management with pressure relieving mattresses on all beds with regular mattress audits. We have taken our prevention one step further with the acquisition of several air mattresses and pumps for use in consumers who are deemed a severe risk according to the Norton Scale (which measures the risk of a pressure injury according to several evidence-based risk criteria).

Consumers requiring an air mattress are reviewed by a Registered Nurse weekly using the Norton Scale and the appropriate documentation is performed and recorded on the pressure injury prevention and management chart.

These strategies are used in conjunction with other pressure relieving actions such as the use of pillows and wedges, frequent repositioning, correct lifting and transferring techniques, adequate hydration and nutrition, moisturising skin at a minimum of twice daily, daily skin inspections as well as ensuring that the consumer’s pain is managed effectively and according to their goals and preferences.

CMH pressure injury occurrences in Glenelg House have been sustained at low rates comprising of newly acquired stage 1 and stage 2 pressure injuries (lower risk category) during 2018/19.

Q12017/18

0.00

0.230.36

0.25 0.19 0.19 0.25 0.28 0.23

0.25 0.27

0.55 0.46 0.37

0.19

1.60

1.20

0.80

0.40

0.00

Q22017/18

Q32017/18

Q42017/18

Q12018/19

Q22018/19

Q32018/19

Q42018/19


Overall Pressure Injury rates

Sue Wombwell inspecting and testing a pressure relieving mattress




Falls and Fall-Related FracturesA fall is defined as an event that results in a person coming to rest inadvertently on the ground / floor or other lower level (World Health Organisation and Safety and Quality Council Guidelines for preventing falls and harm from falls in older persons).

Consumers in Aged Care facilities are five times more likely to fall than those living in the wider community. Consumers over the age of 80 have the highest risk of falls. The adverse outcomes associated with a fall may include: skin tears / lacerations, fractures (hip being the most common), head injuries, decreased independence, increased functional decline, increased anxiety and fear of falling or death.

In order to advise consumers (and their representatives) on things they can do to help prevent falls, CMH have regular visits from the Falls Fairies, ‘Scruffy Scruff’ and ‘Lace-Up Lynnie’. These wonderful fairies provide education on the

right type of footwear and other practical ways to prevent falls with consumers in both Glenelg House and Primary Care services. Falls Fairies are always fun and colourful and help consumers understand how to help themselves to prevent falls.

CMH continues a proactive approach to falls prevention and management with the introduction of a safety check program implemented into Glenelg House. The aim of this program is to ensure that all consumers have their ongoing needs met through a proactive approach to safety, care and risk assessment through a systematic, regular and routine safety check, which aims to decrease anxiety, falls and pressure injuries and meet the consumers’ needs.

The safety checks are performed according to the consumers’ assessed risk category. Consumers who have been assessed as high risk will have checks every 20 minutes throughout the day and night. This assessment is done in collaboration with the consumer and or representative and some consumers may request not to be involved in this process.

Since the introduction of the safety check program, early results are already showing a downward trend in falls overall.

Scruffy Scruff and Lace-Up Lynnie

Q12017/18

20.0016.0012.00

8.004.000.00

Q22017/18

Q32017/18

Q42017/18

Q12018/19

Q22018/19

Q32018/19

Q42018/19


Falls

10.917.84 7.40 8.71 7.76 7.90 8.97

8.12 7.644.81 4.43 5.10 3.63

8.333.34

8.46

Q12017/18

1.601.200.800.400.00

0.00 0.00 0.00 0.00 0.00 0.16

0.74

0.13

0.15 0.14

0.15 0.13 0.09 0.140.36

0.74

Q22017/18

Q32017/18

Q42017/18

Q12018/19

Q22018/19

Q32018/19

Q42018/19


Fall-related fractures



Finance & Activity OverviewTotal income from transactions of $9,362,237 represents a 3.43% increase on previous year and can be attributed to increases in both government grants and resident fees. Total expenses from transactions represents an increase of 2.81% on previous year and main factors include increased salary and wages costs of EBA’s and higher depreciation. A positive note was the decrease of other operating expenses by 24.84% underlying the responsible maintenance of operating expenditure.

The accepted performance indicator from the Department of Health and Human Service’s is the net operating result as outlined in the Statement of Priorities. Casterton Memorial Hospital’s net operating result reports a surplus of $102,221. This result is reconciled to the net result from transactions in the table below and excludes capital purpose income, depreciation and finance costs.

Comprehensive ResultEntity Comprehensive Result of ($1,916,697) is a decrease of $3,017,471 on the prior year result and is largely due to revaluation of land and buildings from the Victoria Valuer General.

LiquidityCasterton Memorial Hospital's financial position is stable with current assets exceeding current liabilities by $1,567,234 as at 30 June 2019.

Casterton Memorial Hospital's current asset ratio stands at 1.44. This remains considerably higher than the DHHS benchmark of 0.7 and has been the case over the past 5 years.

Cash FlowCasterton Memorial Hospital has generated a positive net cashflow from operating activities of $60,265 for the financial year. Casterton Memorial Hospital remains in a secure position with cash and cash equivalents totalling $4,288,731 as at 30 June 2019. This amount includes $2,041,572 in accommodation bonds.

Five Year Financial Comparative Statement2019$000

2018$000

2017$000

2016$000

2015$000

OPERATING RESULT 102 (41) 281 76 161

- Total Revenue 9,362 9,052 9,637 9,135 8,927

- Total Expenses 10,229 9,949 10,062 9,867 9,428

- Net result from transactions (867) (897) (426) (732) (528)

- Total other economic flows (65) (4) 15 (30) 0

- Net result (932) (901) (410) (762) (528)

- Total Assets 26,693 29,434 28,621 28,658 28,465

- Total liabilities 3,993 4,816 5,110 4,736 3,782

- Net assets/Total equity 22,700 24,618 23,511 23,922 24,683

Summary of Significant Changes2019 2018 % Variance

Cash & Cash Equivalents 4288731 5156908 -16.8

Assets 26693191 29433598 -9.3

Liabilities 3993110 4815705 -17.1



Workforce InformationCasterton Memorial Hospital is committed to the provision of a safe and healthy work environment for all employees, contractors and visitors.

Workforce dataDuring the 2018/19 year Casterton Memorial Hospital employed a total of 124 employees, 33 full-time and 91 part time / casual across the labour categories as detailed in the following table. Statistics provided are consistent with information provided in the entity’s MDS/F1

datasets which are reported on a monthly basis to the DHHS. Condition of employment is that Casterton Memorial Hospital employees will adhere to the values as outline in the Code of Conduct for Victorian Public Sector Employees 2015 and CMH Code of Conduct Policy.

Labour CategoryJUNE Current Month FTE Average Monthly FTE

2018 2019 2018 2019

Nursing 40.74 36.62 41.79 37.78

Administration & Clerical 9.42 8.72 9.95 8.86

Hotel & Allied Services 23.19 30.25 23.75 30.73

EMPLOYEE RECOGNITION YEARS OF SERVICE 2018-2019

Name Years of Service Name Years of Service

Sally Goodwin 5 Valinda Ross 10

Chiedza Mahanda-Makore 5 Loren Hulm 15

Michelle McPeake 5 Mary-Anne Betson 25

Jane Richardson 5 Shane Gill 30

Stephen Zippel 5 Heather Rees 30

Olivia Makwati 10 Kathy McArlein 35

David Richardson 10

Employee of the Year Helen Dillon: Senior Night Nurse in Charge / Quality Improvement

Helen has been a longstanding member of the CMH team working

as Senior Night Nurse in Charge / Quality Improvement for the majority of her current 31-year

tenure at CMH.

Helen’s dedication to education and the demanding senior night nurse role has earned her rightful recognition with this year’s award.

Well done Helen!



Employee ListADMINISTRATIONBetinsky, M. J. Crowle, C. E.Harvey, V. E.Hulm, L. S.MacFarlane, J. L.Rees, H. Rees, K.Richardson, J. F.Shone, C. M.Stephens, O. P.Toma, B. G.*Whitchurch, L.

CATERINGCraig, E. A.DeBomford, S.Goodwin, S. M.Gould, D. A.Green, J. R.Kensen, M. D.McPeake, M. L.*Murrell, J. A.*Naylor, J. H.Niewand, S. J.Nolte, M. R.Northcott, C. J.Ross, V. L.Sealey, D. J.Smith, J.Southern, D. L. Stanislawski, H.

COMMUNITY HEALTHLayley-Doyle, P. L.Jenkins, L. J.

MAINTENANCEHill, M. C.Naylor, M. L. Richardson, D. J.Zippel, S. J.

SOCIAL SUPPORT GROUPBryan, B. H.

REGISTERED NURSESActon, J.Betson, M.A.Bryan, S.Clutterbuck, M. P.*Davidson, J.Dehnert, S. D.Dillon, H. V.Duerden, S.*Freeland, J.*Gartlan, D. A.George, A. A. *Gill, H. L.Gill, S. M. D.Gunning, P. S.Henderson, S.*Jenkins, A. J.Jose, C.*Koenig, T.*Lear, K. J.Mahanda-Makore, C.Makwati, O.Marureth-Achenkunju. B.Matthews, J. A.McKinnon, D. R.Sealey, K.Shaw, A.*Sheahan, V. J.Sheriff, F.Siemon, R.*Stephens, R.Taylor, A. C.Thomas, J.Thomas, J. M.Young, J. L.Zhang, X.Zippel, W. J.

PERSONAL CARE ATTENDANTSBalzan, A.Naylor, S.Reilley, R. F.Sealey, T. B.Tucker, R.

ENROLLED NURSESBeever, A. Benson A. M.*Condon, C. A.Hamill, J. K.Irving, A. P.Jackson, A. M.Jacobs, A. M.*James, C.Jepchirchir, D.Jones, S. M.Kaur, S.*Killey, R.McArlein, K. M.McCabe, J. A.Meena*Nesbitt, D. A.Parsons, K. L.*Pratt, D. J.Russell, M. R.Tait, P. M.Tibbles, W. K.Wombwell, S. M.

DIVERSIONAL THERAPYPerry, K. M.Roberts, C.

ENVIRONMENTAL SERVICESBellinger, C.Bunnik, I.Carr, K. East, J. A.Jamieson, R.Jones, P. A.Kerr, L. M.McCalman, J.McDonald, L.*O’Connell, S. J.Smith, C. L

HEALTHCARE ATTENDANTKent, B. M.

* Resigned during the year

Acute CareOperating Room

Planned Activity GroupCommunity Health /

Health PromotionInfection Control

Home NursingUrgent CareEducation

Visiting Medical ServicesDirector Medical Services

PharmacistAllied Health

Principal Committees• Executive• Audit• Quality Committee• Visiting Medical Officers• Credentials• Medical Appointments• Facility, Fabric & Assets• Environmental

Management

Residential Aged Care Finance ReportingIT/Information Systems

Health InformationReception

Human ResourcesPayroll

Supply ServicesRisk Management

ContractsAged Care Entry

CateringLinen

Waste DisposalLaundry

HousekeepingMeals on Wheels

Plant & Equipment Building & Maintenance

Garden & GroundsEssential Services

Home MaintenanceFleet Management

Committee Composition

Functional Organisational ChartCasterton Memorial Hospital

Casterton Memorial Hospital

BOARD OF DIRECTORS

DEPARTMENT OF HEALTH & HUMAN SERVICES

BOARD OF DIRECTORS

CHIEF EXECUTIVE OFFICERMANAGER NURSING SERVICES

SAFETY / CONTINUOUS QUALITY IMPROVEMENT / OH&S / RISK

EXECUTIVE

BOARD SUB-COMMITTEES

ExecutiveAudit

QualityFacility / Fabric and Assets

CredentialsMedical Appointments

Environmental Management

CLINICAL SERVICES

Clinical Services CommitteeAcute Nursing Staff

Residential Care StaffSenior Nursing Staff

Primary Care StaffMedication Advisory Committee

Minimal HandlingVisiting Medical Officers

Midwifery Staff

CLINICAL & COMMUNITY

SERVICES

RESIDENTIAL CARE

ADMINISTRATIVE SERVICES

HOTEL SERVICES

MAINTENANCE SERVICES

CORPORATE SERVICES

Department HeadsOccupational Health & Safety

Legislative ComplianceInformation, Communication &

TechnologyAdministration

Environmental ServicesCatering

Procurement

OTHER

Consumer ForumsResident’s Committee

Planned Activity GroupPerson Centered Care

Working Groups

Casterton Memorial Hospital63 - 69 Russell Street, Casterton, Victoria 3311

Phone: (03) 5554 2555 Fax: (03) 5581 1 051 Email: [email protected]

Our values:

Welcoming

Excellence

Accountable

Respect

Empathy & Compassion

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