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CARE, QUALITY AND CHOICE

Cornish Street, Castlemaine Vic 3450, PO Box 50www.castlemainehealth.org.au

ANNUAL REPORT 2015

Our Vision Exceptional care of every person, every time

Key Achievements 1

Overview of Services 2 Provided

Report to the Community – President 3 – Chief Executive Officer 4

Organisational Chart 6

Corporate Governance 7

Statement of Priorities 8

Nursing Care and Education 12

Community Programs 14

Corporate Services 17

Statutory Compliance 23

Acknowledgments and 24 Maps

Disclosure Index 25 Exceptional Care of Every Person, Every TimeLast year we developed a new vision, mission and set of values to underpin all the work we do

here at Castlemaine Health. It is both a framework that guides our actions, and a firm

commitment that we make to our community.

Our vision is ‘exceptional care of every person, every time’. Whether we are caring for our

residents, assisting a person to get well or rehabilitate, helping people in their own homes, or

consulting with the community on a wide range of health issues, we are committed to providing

exceptional care of every person, every time.

Our mission is to deliver ‘a well run and trusted organisation that engages with the community

to provide high quality health services’. This is something that our community expects and we

constantly strive to deliver. Community consultation is key to ensuring our success in this

regard – the unique perspective that consumers provide is vital in helping us enhance the

customer experience.

Finally, everything that we do is conducted according to our key values – ‘integrity, care, unity

and excellence’. We believe that if we as an organisation epitomise these attributes, we can

function effectively and better achieve our goals.

Thank you for being part of the Castlemaine Health community. We hope that you see these

goals and values reflected in the work that we do. If you have any feedback, please contact the

Community Engagement Coordinator on 5471 1505.

Castlemaine Health acknowledges the support of the Victorian Government

VisionExceptional care of every person, every time.

ValuesIntegrity, Care, Unity and Excellence.

MissionA well run and trusted organisation that engages with the community to provide high quality health services.

CONTENTS

LEGISLATION REQUIREMENT PAGE REFERENCEMINISTERIAL DIRECTIONSREPORT OF OPERATIONSCHARTER AND PURPOSEFRD 22F Manner of establishment and the relevant Ministers 1FRD 22F Purpose, functions, powers and duties 7FRD 22F Initiatives and key achievements 1FRD 22F Nature and range of services provided 2MANAGEMENT AND STRUCTUREFRD 22F Organisational structure 6FINANCIAL AND OTHER INFORMATIONFRD 10 Disclosure index IBCFRD 11A Disclosure of ex-gratia expenses 23FRD 12A Disclosure of major contracts 23FRD 21B Responsible person and executive officer disclosures AFSFRD 22F Application and operation of Protected Disclosure Act 2012 23FRD 22F Application and operation of Carers Recognition Act 2012 23FRD 22F Application and operation of Freedom of Information Act 1982 23FRD 22F Compliance with building and maintenance provisions of Building Act 1993 23FRD 22F Details of consultancies over $10,000 23FRD 22F Details of consultancies under $10,000 23FRD 22F Employment and conduct principles 19FRD 22F Major changes or factors affecting performance AFSFRD 22F Occupational health and safety 20FRD 22F Operational and budgetary objectives and performance against objectives AFSFRD 22F Significant changes in financial position during the year AFSFRD 22F Statement of availability of other information 23FRD 22F Statement on National Competition Policy 23FRD 22F Subsequent events AFSFRD 22F Summary of the financial results for the year AFSFRD 22F Workforce Data Disclosures including a statement on the application of employment and conduct principles 19FRD 24C Reporting of office-based environmental impacts 18FRD 25B Victorian Industry Participation Policy disclosures 23FRD 29A Workforce Data disclosures 19SD 4.2(g) Specific information requirements 23SD 4.2(j) Sign off requirements 23SD 3.4.13 Attestation on data integrity 23SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 23SD 4.5.5 Risk management compliance attestation 23FINANCIAL STATEMENTS REQUIRED UNDER PART 7 OF THE FINANCIAL MANAGEMENT ACT

Letter of comfort AFSSD 4.2(a) Statement of changes in equity AFSSD 4.2(b) Comprehensive Operating Statement AFSSD 4.2(b) Balance Sheet AFSSD 4.2(b) Cash Flow Statement AFSOTHER REQUIREMENTS UNDER STANDING DIRECTIONS 4.2SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements AFSSD 4.2(c) Accountable officers declaration AFSSD 4.2(c) Compliance with Ministerial Directions AFSSD 4.2(d) Rounding of amounts AFSLEGISLATIONFreedom of Information Act 1982 Protected Disclosure Act 2012Carers Recognition Act 2012Victorian Industry Participation Policy Act 2003Building Act 1993 Financial Management Act 1994

The annual report of Castlemaine Health is prepared in accordance with all relevant Victorian legislation. This index has been

prepared to facilitate identification of the Department’s compliance with statutory disclosure requirements.

AFS – Attached Financial Statement; IF – Inside Front

Financial statements attached. If the statement is not attached please contact Personal Assistant to the Chief Executive Officer on (03) 5471 1401

DISCLOSURE INDEX

1

ANNUAL REPORT 2015 Our Vision Exceptional care of every person, every time

• Developedandimplementedanewstrategicplan,vision,missionandvaluestounderpinthewayweoperateandcareforourcommunity.

• Receivedpositiveresultsfromexternalauditors,withallservicesremainingfullyaccredited.

• Increasedthenumberofsurgicalproceduresto65sessionspermonthandapproximately1000majorand1400minorsurgeriesperyear,duetotheexpansionoftheOperatingSuiteinMarch2014.

• ReviewedandimplementedanewmodelofnursingworkforcewithintheResidentialAgedCareUnits,creatingefficienciesandimprovedlevelsofcare.

• Continuedourpatternofimprovedinfection control, increasing our organisationalcompliancebyalmostthreepercentinthelast12months,achieving97.7%compliance.

• Implementedanewsystemforprovisionandrecordingofstafforientationandmandatoryeducation.

• DevelopedacollaborativeprojectbetweenCastlemaineCommunityHealthCentre,MountAlexanderShireandMaldonHospitalprovidingtrainingandeducationforover100

staffinDementiaEssentials.

• Implementedanantimicrobialstewardshipprogramwithtrafficlightprescribingindicationsforantibiotics.

• Furtherimprovedourinfectionpreventionmeasures,withalcoholhandrubmadeavailableinallagedcareareas,andauditingofhandhygieneintheseareasoccurringforthefirsttime.

Key Achievements

• EstablishedapartnershipwithCharlesSturtUniversity,withcommitmentstosuperviseandtrainthirdandfourthyeardieteticsstudentsonaregularbasis.

• IntroducedtheActiveTuesdayprogramwhich,undertheprinciplesofActiveServiceModel,promotesconnectingpeopletothewidercommunity.

• EstablishedanagreementwithBendigoHealthonthepurchaseofmedicalandsurgicalsupplies,enablinggreateraccesstoexpertadvice,abroaderproductevaluationforumandimprovedpricing.

• ExtendedourContinenceServicetotheCentralGoldfieldsShire,whichhasbeenpromotedandreceivedwellinthiscommunity.

• RestructuredourSupportServicesdepartment,creatingefficienciesandenablingimprovementsincustomerservice.

• ImprovedourInformationTechnologycapabilities,withnumerousupgradestonetworkinfrastructureandapplications.

• ImplementedtheCommonwealth’sLiving Longer, Living Better reform, givingolderpeopleeasieraccessandbettercareinouragedcare

facilities.

• Strengthenedourcommitmenttopreventinginjuriesintheworkplace,includingengagingaManutentionexperttotrainclinicalandnon-clinicalstaffmemberstobecomeInjuryPreventionFacilitators.

• DevelopedaSecurityFrameworktoensurebetterprotectionofconsumers,residents,visitorsandstaffintheeventofasecurityincident orcrisis.

Manner of Establishment and Relevant MinistersCastlemaine Health is a public hospital incorporated under the Health Services Act 1998 and has a variety of programs and services funded by the State Government.

TheHonJillHennessyMLA,MinisterforHealth,MinisterforAmbulanceServices 4Dec2014to30Jun2015

TheHonMartinFoleyMLA,MinisterforMentalHealth,MinisterforHousing,DisabilityandAgeing 4Dec2014to30Jun2015

TheHonJennyMikakosMLC,MinisterforFamiliesandChildren 4Dec2014to30Jun2015

TheHonDavidDavisMLC,MinisterforHealth,MinisterforAgeing 1Jul2014to3Dec2014

TheHonMaryWooldridgeMLC,MinisterforMentalHealth,MinisterforCommunityServices,MinisterforDisabilityServicesandReform 1Jul2014to3Dec2014

TheHonWendyLovellMLC,MinisterforChildrenandEarlyChildhoodDevelopment 1Jul2014to3Dec2014

CARE, QUALITY AND CHOICE2

Acute/sub acute (50 staffed beds)• Medical

• Obstetric

• Paediatric

• Rehabilitation

• GeriatricEvaluationandManagement

• Respite

• Surgical

• UrgentCare

Residential Aged CareHigh care (90 beds)• ElleryHouse

• ThompsonHouse

Low care (63 beds)• Spencely

• Penhall

• ThompsonHouse

Transition Care (6 beds/places)• ThompsonHouse(4beds)

• Community(2places)

Community• DistrictNursingServices/Palliative

Care

• AdultDayServices

• CommunityRehabilitationCentre/AlliedHealthdepartmentsandContinenceService

• HealthIndependencePrograms:SubacuteCareServices-non-admitted(SACS),ComplexCare(formerlyknownasHospitalAdmissionRiskProgram-HARP),PostAcuteCare(PAC)

• VolunteersProgram

• CastlemaineandDistrictAccommodationandResourceGroup(CADARG)

• EarlyChildhoodInterventionProgram

• CaseManagementService(HomeCarePackages)

Client Services• Medical

• NursingandPersonalCare

• Socialwork

• Podiatry

• OccupationalTherapy

• Physiotherapy

• SpeechPathology

• Dietetics

• Continenceservice

• VolunteersProgram

• Pharmacy

• Psychiatry

• Pastoralcare

• Infectioncontrol

• Recreationalactivities

• Pathology(providedonsitebyStJohnofGodPathology)

• Radiologyandultrasonography(providedonsitebyBendigoRadiology)

Corporate Services• Engineering

• Supply

• Transport

• HumanResources

• HealthInformationServices

• PublicRelations/Fundraising

• Finance

• OccupationalHealthandSafety

• QualityandRisk

• FoodServices

• Payroll

• Laundry

• EnvironmentalServices

• InformationTechnology

OVERVIEWOFSERVICESPROVIDED

Training and Development• Traininganddevelopment

ApprenticeshipsandTraineeships

• GraduateNurseProgram

• InitialRegistrationofOverseasNurses Program

• ReturntoPracticeNursesProgram

• PublicHealthPrograms/HealthPromotions

• StaffEducation/ProfessionalDevelopment

• UndergraduateProgram

• WorkExperienceProgram

3


REPORTTOTHECOMMUNITYItisapleasuretoreflectonwhatwehave

achievedinthepastyearandtoalso

considerwhatisinstoreforusnextat

CastlemaineHealth.Inourlastannual

reportIindicatedwewereaboutto

commencestrategicplanning.Wenow

haveafiveyearstrategicplanthat

outlinesfivecleardirectionsfor

CastlemaineHealthtofocuson.Theplan

isbasedonasoundreflectionand

analysisofhealthdata,considerationof

thefactorsthatinfluencesourservice

deliveryenvironment,andtakesaccount

oftheviewsandcapacityofotherhealth

andcommunityorganisationsinour

region.

Our vision for ‘exceptional care of every

personeverytime’encapsulatesour

focusongenuinecareforeachperson

whoattendsCastlemaineHealthaswell

asafocusonhighqualityservicesand

continuousserviceimprovement.Our

missionisfor‘awellrunandtrusted

organisationthatengageswiththe

communitytoprovidehighqualityhealth

services’.

Thenotionofcommunityengagement

andindeedengagementwithother

healthandcommunityservice

stakeholdershasbecomeanincreasing

priorityfortheboard.Werecognisethat

goodhealthisdeterminedbyarangeof

factors,manyofwhicharewellbeyond

thereachofCastlemaineHealth.Wealso

recognisethatweneedtomoreactively

seekarangeofviewsandperspectives

onhowwedeliveranddevelopour

services.

Wehavestrongrelationshipswithlocal

andregionalhealthandcommunity

servicesaswellaslocalgovernment.Our

strategicplanwasinfluencedbytheir

inputandnowaswedeliveritweneedto

continuetobuildinwaysofhearingand

respondingtocommunityexpectations

andideas.

TheAnnualReporthighlightsmanyofour

directachievementsoverthepasttwelve

monthsandIencourageyoutoreadthe

entirereporttogetabetterunderstanding

ofallthatCastlemaineHealthdelivers.

Iwouldlikeacknowledgetheskills,

dedicationandcarethatthestaff

membersbringtotheirworktomakea

positiveimpactonthepeoplewhoutilise

ourservice.Ialsoagainacknowledgethe

contributionofourvolunteersandour

Boardmembersandthankallfortheir

greatinput.Therearemanywayswecan

worktogethertoimprovethehealthand

wellbeingofourcommunity.

InaccordancewiththeFinancial

ManagementAct1994Iampleasedto

presenttheReportofOperationsfor

CastlemaineHealthfortheyearending

30June2015.

Carolyn Wallace

President

Our vision for ‘exceptional care of every person every time’ encapsulates our focus on genuine care for each person who attends Castlemaine Health as well as a focus on high quality services and continuous service improvement.

Carolyn Wallace, President


REPORTTOTHECOMMUNITYOnmanyfronts2014-15hasbeena

successfulyearforCastlemaineHealth.

Our financial position is improving, all

servicesarefullyaccredited,ournewand

refurbishedfacilitiesareworkingwell,our

patientsandresidentsratedourservices

highly,ourconsumersandcommunity

aremoreengagedandwecompleteda

newStrategicPlanthatwillguideustoa

brightfuture.

Wehavecompletedourfirstfullyearof

functioninginourrefurbishedtheatre

suiteandupgradedreception,urgent

care,medicalimagingandpartsofthe

acuteward.Ourstaff,clientsandvisiting

medicalofficershaveallappreciatedthe

facilitieswhichhaveenhancedour

capacitytodeliverhighqualityand

safecare.

Ouroperatingtheatresinparticularhave

workedverywellwhichhasbeenshown

byanincreaseinsurgicalpatients,a

widerrangeofsurgicalprocedures

performed,andenabledustomeetour

acutetargetsforthefirsttimeinmany

years.Ourcapacitytotakeonfurther

casesanddelivercaresuccessfullyhas

beenacknowledgedthroughtheTravis

Reviewwhichapprovedfundingfor

additionalpatientthroughputfor

CastlemaineHealthinthe2015-16

financialyear.

Duringtheyearwecompletedanewfive

yearstrategicplan,2014-2019.Forthe

firsttimeinmanyyearstheorganisation

hasdevelopedasetofvaluesthatreflect

themannerinwhichtheBoard,

ManagementandStaffwillconductour

business.Integrity,Care,Unityand

Excellencewerethevaluesidentifiedby

staffaskeyforCastlemaineHealthto

functioneffectively.

Ournewstrategicfocusisabout

ensuringthatCastlemaineHealth

effectivelyandefficientlyprovidesa

broadrangeofhealthservicesthat

enablesourcommunitytohaveaccess

toserviceslocally.Asstatedinourvision,

our goal is also to maintain your safety,

delivercareaccordingtoyourdesire,

andensuretheexpectedoutcomeis

achieved.

Thisyearhasbeenunusualinthatall

inpatient,residentialandmostof

communityserviceswentthroughan

accreditationprocess.Eachareawas

surveyedbyexternalsurveyorsagainst

therelevantstandards,includingthenew

NationalStandardsforouracuteand

subacuteservices.Whileensuringand

maintainingstandardsisanongoing

process,participatinginanaccreditation

involvesasignificantworkloadtobe

surveyready.Wepassedallofthe

accreditationsurveyswellwhichwasa

greatresultforstaffandourQualityTeam.

CastlemaineHealthacknowledgesthe

importanceandexpertiseofother

agenciesbothwithinandexternaltothe

Shirenecessaryforourcommunityto

deliverabroadrangeofhealthand

communityservices.Thereisagood

spiritbetweentheagenciesanda

commondesiretoworktogetherto

improvethehealthandwellbeingofour

communities.Forexamplewithmajor

capitalworkstobecompletedat

BendigoHealthwithin18monthsitwill

provideourcommunityaccesstoa

significantrangeofhighleveltertiary

services,andprovideCastlemaine

Healthwithopportunitiestoprovide

servicesthatcomplimentandsupport

thehealthneedsoftheregion.

Our financial position is continuing to

improveduetosupportoftheState

Government,implementationof

numerous financial improvement

strategiesandgreaterconsistencyand

accuracyinourfinancialreporting.Our

DepartmentHeadsnowparticipateinthe

annualbudgetingprocessandhave

monthlyaccesstoreliableperformance

monitoringreports.Delegatingand

accountabilityformeetingactivitytargets,

qualityandfinancialmanagementiskey

toourimprovedresults.

5


IwouldliketothankourBoardof

Managementfortheirtimeand

commitmenttofulfilltheirBoardroles

andresponsibilities.TheBoardhasover

thelasttwoyearsfocusedournew

strategicdirectionstopositionthe

organisation to meet future care

standardsandcommunityneeds.The

BoardofManagement’smembership

hasbeenconstantlyreviewedtoensure

thedesiredskillsetisachieved,ongoing

Boardeducationanddevelopment

occursandoursub-committeesoperate

effectivelyandkeeptheBoardinformed.

TheExecutiveandstaffacknowledgethe

contributionoftheBoardandthe

leadershipofBoardPresident,Carolyn

Wallace,BoardVicePresident,Sharon

Fraser,andTreasurer,AdamSevdalis.

Whenthereisconstantchangeoccurring

withintheorganisationandanecessity

forimprovedperformancethepressureis

oftenontheExecutivestoidentifyand

implementstrategieswhileensuringcare

isnotcompromisedandthesupportof

staffisretained.Iacknowledgethehard

workoftheExecutiveteam–Executive

DirectorofNursingServices,Amanda

Edwards,ExecutiveDirectorof

CommunityPrograms,RhondaWilliams,

ExecutiveDirectorofCorporateServices,

KerrynHealy,andExecutiveDirectorof

MedicalServices,DrPeterSloanfortheir

achievementsthisyear.

Therearenumerousformsofreceiving

feedbackfrompeoplewhohave

experiencedourcare.Theoverwhelming

themefromfeedbackwereceiveisthat

thestaffmemberswerewonderfuland

verycaring.Thankyoutoeverystaff

memberforyourgreatworkandthe

positiverelationshipsthatyouhavebuilt

withourconsumers.

Ourlocalmedicalstaffmembershave

againmadeasignificantcontributionto

CastlemaineHealth.Weareextremely

luckyasacommunitytohavesucha

dedicatedgroupofmedicalpractitioners

whomaintainaveryhighlevelof

professionalcompetenceandprovide

coveragenecessaryforCastlemaine

Healthtoofferaccesstosuchabroad

rangeofservices.Wealsoappreciatethe

visitingspecialistmedicalstafffortheir

contribution.

Theinvolvementofvolunteersisagood

barometertomeasuretheengagement

ofthecommunityintheHealthService.

Weareextremelyproudtohavesuch

largenumbersandparticipationinmany

aspectsofourservice.Wethankallof

ourvolunteersandlookforwardtoyour

continuedworkwithourstaff,patients

andresidents.

Nextyearwillagainraisemany

challengesbutthereisagrowing

confidencethatwehavethewilland

capacity to maintain our positive

direction.Weareenteringanexcitingera

forCastlemaineHealthandIlookforward

toworkingwithallstakeholdersto

achieveourcommongoals.

Ian Fisher

Chief Executive Officer

Ian Fisher, CEO

‘Our operating theatres in particular have worked very well, demonstrated by an increase in surgical patients, a wider range of surgical procedures, and an achievement of our acute targets.’


ORGANISATIONALCHART

THE COMMUNITY

BOARD OF MANAGEMENT

CHIEF EXECUTIVE OFFICER - Ian Fisher

EXECUTIVE DIRECTOR OF COMMUNITY PROGRAMSRhonda Williams

Community Rehabilitation Centre:

• OccupationalTherapy

• Physiotherapy

• SpeechTherapy

• Dietetics

• Podiatry

DistrictNursing/PalliativeCare/PostAcuteCare

AdultDayService

HomeCarePackages

EarlyInterventionProgram

ContinenceAdvisoryService

HARPComplexCare(HospitalAdmissionRiskProgram)

CADARG (Castlemaine & DistrictAccommodation&ResourceGroup)

Volunteer/SocialSupport

HealthInformationServices

EXECUTIVE DIRECTOR OF CORPORATE SERVICES Kerryn Healy

EXECUTIVE DIRECTOR OF NURSING Amanda Edwards

AfterHoursManagers

StaffDevelopment

ClinicalResourceUnit

AcuteMedical/Surgical

Services

Midwifery

UrgentCareCentre

RehabilitationServices

OperatingSuite/DayProcedureUnit

ResidentialServices:

• ElleryHouse

• ThompsonHouse

• Penhall

• Spencely

Transitional Care

Recreation

Radiology/Pathology

Pharmacy

InfectionControl

DIRECTOR OF MEDICAL SERVICES

Dr Peter Sloan

VisitingMedicalOfficers

SpecialistMedicalOfficers

Engineering

Finance

HumanResources

• Payroll

• OH&S

InformationTechnology

ContractManagement

SupportServices

• Fleet

• Laundry

• EnvironmentalServices

• FoodServices

• Supply

• Security

QUALITY & RISK DEPARTMENT

7


CORPORATEGOVERNANCE

Board of ManagementPRESIDENT

Ms Carolyn WallaceRegionalDirectorGraduateDiplomaofEducation,BachelorofArts,GAICD MasterofPublicPolicyandManagementAppointmentexpires30June2016

VICE PRESIDENTMs Sharon FraserGeneralManagerMasterofBusiness(Management)BachelorofAppliedScience(SpeechPathology),GAICDAppointmentexpires30June2016

TREASURER (from Nov 2014)Mr Adam SevdalisManagingDirectorBachelorofEconomics,MBAAppointmentExpires30June2015

TREASURER (to Nov 2014)Mr Ian McKenziePharmacist/WineMakerBachelorofPharmacyAppointmentexpires30June2016

BOARD MEMBERSDr Les Fitzgerald (Retired)SeniorLecturerinHealthSciencesRN,RM,Dip(TeachNurs),BAEd,MN(NursStudies),PhDAppointmentexpired31October2014

Ms Elizabeth GraingerTeacherTrainedInfantTeachersCertGradDip,EducationAppointmentexpires30June2015

Mr Glenn SutherlandRetailerandExporterBA,DiEd,GradDipEd,Administration,GradDipManagementFAIMGAICD,AdvancedDiplomaofBusiness,Cert.1VProjectManagementAppointmentexpires30June2016

Ms Janet CropleySmall Business Mentor BA(SocialSciences)DipinBusinessStudies,GradCertifIndustryandTrainingAppointmentexpires30June2017

Mr Garry FehringDirectorofClinical&SiteServicesRN BNCertOncologyNursing,CertRehabilitationNursingGradDipNursingManagementAppointmentexpires30June2017

Mr Rony CaspiPsychotherapistBACounsellingAdvCert(GestaltPsychotherapy)Appointmentexpires30June2015Ms Kate HamondPrimary Regulator DiplomaofTeachingAppointmentexpires30June2017

Board of Management Structure & FunctionThefunctionoftheBoardofManagementistooverseethegovernanceoftheHealthServiceandtoensurethattheservicesprovidedbytheHealthServicecomplywiththerequirementsoftheHealthAct1988andtheBy-LawsoftheHealthService.

MembersarerequiredbytheActtoactwithintegrityandobjectivityatalltimes.Theyarerequiredtodeclareapecuniaryinterest,whenapplicable,duringBoarddebateandwithdrawfromproceedings.Therewerenooccasionsthatrequireddeclarationthisyear.ConflictofinterestisdeclaredduringBoardproceedings,inaccordancewiththeBy-LawsofCastlemaineHealth.

Boardmembersserveinavoluntarycapacityanddonotreceivepayments.Anumberofsub-committeesconsistingofBoard,Staff,VisitingMedicalOfficersandmembersofthecommunityhavebeenformedtoadviseandrecommendonrelevantmatters.

TheBoardofManagementmeetsonthefourthMondayeveningofeachmonthtodealwithaformalagendaandreportsontheHealthServices’performanceasreportedbytheChiefExecutiveOfficer.Meetingscommenceat6.30pmintheBoardRoom,CastlemaineHealthandareopentothePublic.

Board of Management membership of Sub-committeesCredentials and Medical Appointments Advisory CommitteeMsElizabethGraingerChief Executive Officer Evaluation CommitteeMsCarolynWallaceMsSharonFraserMrGarryFehring

Finance CommitteeMrAdamSevdalisMrIanMcKenzieMrGlennSutherlandMsJanetCropley

Community Consultation CommitteeMrRonyCaspiMsJanetCropley

Audit and Risk Management CommitteeMrAdamSevdalisMrIanMcKenzieMsKateHamondMsCarolynWallace

Clinical Governance and Quality CommitteeMsSharonFraserMsElizabethGraingerMrGarryFehring

Executive ManagementTheExecutiveDirectorsmeetwiththeChiefExecutiveOfficerweeklytodiscussstrategicandoperationalissuesrelatingtothemanagementoftheorganisation.

CHIEF EXECUTIVE OFFICERMrIanFisherMBus,GradDipAcc,PGradDipHealthAdministration

EXECUTIVE DIRECTOR OF COMMUNITY PROGRAMSMrsRhondaWilliamsRN,BPubHealth,GradDipHealthServices Management

EXECUTIVE DIRECTOR OF NURSING SERVICES MsAmandaEdwardsMHSM,PGDAN(Emergency),PGDAN(Mid),RN

DIRECTOR OF MEDICAL SERVICES DrPeterSloanMBBS,MBA,FRACMA

EXECUTIVE DIRECTOR OF CORPORATE SERVICES MrsKerrynHealy(AppointedOctober2014)BBus(Accounting)CPA,GAICD


REPORTINGAGAINSTTHESTATEMENTOFPRIORITIES

State and CH Priorities

Action Deliverable Status

Developing a system that is responsive to people’s needs

• Developanorganisationalpolicyfortheprovisionofsafe,highqualityendoflifecareinacuteandsubacutesettings,withclearguidanceabouttheroleof,andaccessto,specialistpalliativecare.

• Policyfortheprovisionofsafe,highqualityendoflifeendorsedbyBoardofManagementandimplemented.

• Anorganisationpolicyfortheprovisionofsafe,highquality,endoflifecareinacuteandsubacutesettingswasdevelopedandapproved.

• Workhasbeenundertakentoimproveaccesstopalliativecareservicesformoreofourpatientsbothinthecommunitysettingandwithintheclinicalcareareas.

• CastlemaineGeneralPractitionersandstaffintheclinicalareasprovidehighqualityendoflifecareandundertakeongoingprofessionaldevelopmentinthisarea.

• CastlemaineHealthaccessesspecialistpalliativecaresupportandadvicethroughtheBendigoRegionalPalliativeConsultancyServices.CastlemaineHealthalsoprovidescommunitypalliativecareservicestopeoplewithintheMountAlexanderarea.

• Implementanorganisation-widepolicyforrespondingtoclinicalandnon-clinicalviolenceandaggression(includingCodeGrey)thatalignswithDepartment’sGuidelines.

• SecurityPolicy(includingCodeGrey)endorsedbytheBoardofManagementandimplemented.

• SecurityProcedure(includingCodeGrey)hasbeenadopted.

• TrainthetrainerforCodeGreyhasbeenarranged.

• Implementformaladvancecareplanningstructuresandprocesses,includingputtingintoplaceasystemforpreparingand/orreceiving,anddocumentingadvancecareplansinpartnershipwithpatients,carersandsubstitutedecisionmakers.

• AdvanceCarePlanningstructureandprocessesfullyimplemented.

• TheAdvancedCarePlanning(ACP)WorkingGroupcommencedinJanuary,2015.AnActionPlanwasdevelopedandiscurrentlybeingimplementedacrosstheorganisation,andtheAdvancedCarePolicyandProcedurehasbeenwrittenandapproved.Asuiteofformshasbeenalsobeenapprovedforuseintheorganisation,ashasasystemforensuringallclinicianshaveeasyaccesstotheACPinthepatientrecord.

• Educationisbeingrolledoutacrosstheorganisationtoensureallstaffmembersunderstandthepoliciesandprocedures.

• MostresidentshaveanACPinplaceandGPsarehavingtheconversationwithmorepatientspriortotheiradmission.

Improving every Victorian’s health status and experiences

• Useconsumerfeedbacktoimprovepersonandfamilycentredcare,healthservicepracticeandpatientexperience.

• Consistentwithaccreditationstandardsprovideevidencethatconsumerfeedbackhasledtoimprovedservices.

• CastlemaineHealthhasparticipatedinaccreditationsurveysofacute,agedresidentialandcommunityserviceswherestandardsofconsumerparticipationandpersoncenteredcareweredemonstrated.Patient,residentandclientsurveysalldemonstratedveryhighsatisfactionlevels.

• SupportlocalimplementationoftheVictorianHealthandWellbeingPlan2011-2015throughcollaborationwithkeypartnerssuchasLocalGovernment,MedicareLocals,communityhealthservicesandotheragencies(forexampleWomen’sHealthVictoriaandVACCHO).

• ParticipatinginlocalforumssupportingtheimplementationoftheVictorianHealthandWellbeingPlan.

• JointprojectswereestablishedwithMountAlexanderShire,MacedonRangesCommunityHealthandKynetonDistrictHealthService.

• CastlemaineHealthisamemberoftheCentralVictorianPrimaryCarePartnership,withtheCastlemaineHealthCEOasChair.

• TheHealthyAgeingProjectwasimplementedasacollaborativebetweenCastlemaineHealth,MaldonHospital,CastlemaineDistrictCommunityHealthandMountAlexanderShireCouncil.

• CastlemaineHealth,MountAlexanderShire,CastlemaineandDistrictCommunityHealth,MaldonHospitalandWindarringhaveagreedtojointlydevelopaserviceplanfortheShire.

• Optimisealternativestohospitaladmission.

• Optionstofurtherreducehospitaladmissionsidentifiedandimplemented.

• StrategieswereimplementedtostrengthenandbettertargetclientsthatmeettheHospitalAdmissionRiskProgramprofile.ChangesweremadetothePostAcuteCareProgramtoprovidedconsistencyofservicedelivery.

Part A: Strategic Priorities

9


State and CH Priorities

Action Deliverable Status

Expanding service, workforce and system capacity

• Developandimplementaworkforceimmunisationplan(WIP)thatincludespre-employmentscreeningandimmunisation assessment for existing staffthatworkinhighriskareasinordertoalignwithAustralianinfectioncontrolandimmunisationguidelines.

• WorkforceImplementationPlandevelopedandimplemented.

• Theworkforceimmunizationplanwasdevelopedwithallnewstaffundertakingpre-employmentscreeningandimmunizationassessment.

• Allclinicalstaffmembersarebeingprogressivelyreviewedforimmunisationstatus.

• Buildworkforcecapabilityandsustainabilitybysupportingformalandinformalclinicaleducationandtrainingforstaffandhealthstudents,inparticularinter-professionallearning.

• WholeofSystemClinicalPlacement program reviewedandimprovements recommendedforclinicaleducationandtrainingdeveloped.

• Reviewundertakenandchangestotheclinicalplacementprogramcommenced.

• BestPracticeClinicalLearningEnvironment(BPCLE)frameworkcompletedandimplemented.

• Optimiseworkforceproductivitythroughidentificationandimplementationofworkforcemodelsthatenhanceindividualandteamcapacityandsupportflexibility.

• NewnursingworkforcemodelimplementedacrossResidentialAgedCarebyJanuary2015.

• ChangesimplementedinSpencelyandPenhallwhileElleryandThompsonHousesworkforcemodelsarecurrentlybeingevaluated.

Increasing the system’s financial sustainability and productivity

• Identifyandimplementpracticechangetoenhanceassetmanagement.

• Newassetmanagementsystemimplemented.

• ReviewofassetmanagementoccurredundertheoversightoftheAuditandRiskManagementCommitteeandnewarrangementswereimplementedtoenhancesecurity,valuationandmanagementofassets.

• Reducehealthserviceadministrativecosts.

• Reviewofadministrativerolescompletedandactionstoachievesavingsimplemented.

• Administrativepositionswerereviewedandreductionsmadewherepossible.

Implementing continuous improvements and innovation

• Developafocuson‘systemsthinking’todriveimprovedintegrationandnetworkingacrosshealthcaresettings.

• ParticipateinStrengtheningHealthservicesprojectsincludingsharedservices.

• ActiveparticipantintheStrengtheningHealthServicesproject.CastlemaineHealth’sCEOsatonGovernanceCommittee.

• Driveimprovedhealthoutcomesthroughastrongfocusonpatient-centredcareintheplanning,deliveryandevaluationofservices,andthedevelopmentofnewmodelsforputtingclientsfirst.

• Structuresandsystemsimplementedandevaluatedthatdemonstratea strong focus on patient centredcare.

• ConsumerParticipationFrameworkadopted.CommunityrepresentativesonBoardsubcommitteeandoperationalcommitteeandfocusgroups.

Increasing accountability and transparency

• Undertakeanannualboardassessmenttoidentifyanddevelopboardcapabilitytoensureallboardmembersarewellequippedtoeffectivelydischargetheirresponsibilities.

• DemonstrateastrategicfocusandcommitmenttoResidentialAgedCarebyrespondingtocommunityneedaswellastheCommonwealthLivingLongerLivingBetterreforms.

• AnnualAustralianCentreforHealthcareGovernance(ACHG)assessmentcompleted.

• Strategiestoimprovethesustainabilityofagedcareresidentialservicesimplemented.

• AnnualassessmentcompletedandactionplantoaddressgapsidentifiedadoptedbytheBoardofManagement.

• Financialmodelingofagedresidentialcareservicescompleted.

• Residentcareplansandfundingalignedresultinginrevenueincrease.

• InternalcommitteeestablishedtoreviewCastlemaineHealthserviceprofileincludingServicePlanrecommendations.

Improving utilisation of e-health and communications technology.

• Utilisetelehealthtobetterconnectserviceprovidersandconsumerstoappropriateandtimelyservices.

• Newtelehealthprogramimplemented.

• CastlemaineHealthinconjunctionwithLoddonMalleeHealthAlliancehasdevelopedstrategiestofurtherutilizetelehealth.

• EnsurelocalICTstrategicplansareinplace.

• ICTStrategicPlancompleted.

• CastlemaineHealthincollaborationwithLoddonMalleeHealthAlliancehasidentifiedstrategicdirections.

• FundinghasbeenreceivedtoimplementWi/FiintoResidentialAgedCareUnits.

Part A: Strategic Priorities Continued


Safety and quality performance

SOP Measure Target 2014-15 actual

Patient experience and outcomes

Percentageofwomenwithprearrangedpostnatalhomecare 100 Fullcompliance

Governance, leadership and culture

PatientSafetyCulture 80 Achieved

Safety and quality

Healthserviceaccreditation Fullcompliance Fullcompliance

Residentialagedcareaccreditation Fullcompliance Fullcompliance

Cleaningstandards(Overall) Fullcompliance Achieved

Cleaningstandards(AQL-A) 90 Achieved

Cleaningstandards(AQL-B) 85 Achieved

Cleaningstandards(AQL-C) 85 Achieved

SubmissionofdatatoVICNISS Fullcompliance Fullcompliance

Handhygiene(rate)–quarter2 75 89.1



Healthcareworkerimmunisation–influenza 75 72

Financial sustainability performance

SOP Measure Target 2014-15 actual

Finance

AnnualOperatingResult($m) 0

Notavailable.RefertoAFSCreditors <60days

Debtors <60days

PercentageofWIES(publicandprivate)performancetotarget 100 107.3

Asset management

Basic Asset Management Plan Fullcompliance Fullcompliance

Part B: Performance Priorities

REPORTINGAGAINSTTHESTATEMENTOFPRIORITIEScontinued

11


Funding type Target 2014-15 Activity Achievement

Acute admitted

WIESpublic 1,711 1,789

WIESprivate 438 518

TOTALWIES(publicandprivate) 2,149 2,307

WIESDVA 54 95

WIESTAC 4 19

WIES TOTAL 2,207 2,421

Subacute and Non Acute Admitted

GEMDVA 141 40

GEMPrivate 662 137

GEMPublic 967 426

RehabDVA 681 629

RehabPrivate 1,456 1,830

RehabPublic 5,356 5,601

Subacute Non-Admitted

HealthIndependenceProgram 16,130 15,687

Aged Care

ResidentialAgedCare 55,324 53,936

HACC 23,868 23,623

Part C: Activity*

*Activityachievementissubjecttoconfirmation.


NURSINGCAREANDEDUCATION

Achievements• Duetotheexpansionofour

OperatingSuiteinMarch2014from

oneoperatingtheatretotwo,wehave

increasedthenumberofsurgical

proceduresundertaken.Wenow

conduct65sessionspermonthand

approximately1000majorand1400

minorsurgeriesperyear.Wealso

addedabroaderrangeofurology

procedureswiththecommencement

ofanewurologysurgeon.

• AspartoftheAgedWorkforce

Review,wehavechangedourstaffing

skillsmixandworkpracticestobetter

matchthechangingneedsofour

residents.Thishasimproved

medicationmanagementandwork

flowwithintheunits.

• Wehavekeptcurrentwithbest

practiceandthelatestevidenced-

basedresearchviaourstaff

educationdepartment.Thisyearwe

havereviewedthewaythatwe

orientatenewstafftotheorganisation

andhowweensurethateverystaff

membercompletestherequired

updatesfortheirareaattherequired

time.Morestaffmembersarenow

abletoaccesslearningandattend

educationsessionsthaninprevious

years.

• Lastyearwereceivedfundingto

undertakeacollaborativeprojectwith

CastlemaineCommunityHealth

Centre,MountAlexanderShireand

MaldonHospitaltoimproveand

streamlinethecareforelderlypeople

inresidentialcareandthoseoutin

thecommunitythatneedsupportto

maintainsocialcontactwiththe

community.Thecollaborativehas

seentheestablishmentofa

combinedvolunteergroupand

providedtrainingforover100staffin

Dementia Essentials.Wearealso

planningtoimplementaspecialised

programcalledMontessorifor

Dementiatoeducatecarers,nurses

andvolunteerstodelivercareina

waythatoptimizespeople’sabilities,

improvesbrainandmotorfunction

andincludesthemincommunityand

socialactivities.

Medical ServicesMedicalServicesatCastlemaineHealth

hashadanothersuccessfulyear.The

local general practitioners continue to

workcooperativelywiththehospital

caringforinpatientsandemergency

presentationsattheUrgentCareCentre.

Followingtherenovationoftheoperating

suite,ourelectivesurgeryservicehas

returnedfromKynetonDistrictHealth

Services.Withtheadditionofasecond

theatre,thishasallowedustoexpand

oursurgicalservices.Urology,general

surgeryandgynaecologynowhave

additionallists.

Thenewfacilitieshavebeenwarmly

welcomedbythesurgeons,anaesthetists

andnurses.

TheConnollyrehabilitationservice

continuestoacceptrehabilitationand

geriatricreferralsfromacrossthestate.

Inearly2015,ProfessorMichaelMurray

fromAustinHealthundertookareviewof

theservice.Thefeedbacktothehealth

servicewaslargelypositive,praisingthe

highstandardofcarebeingprovidedina

teamenvironment.Asaresultofthe

reviewweplantoexpandoursubacute

servicesbothwithinthehospitalandfor

patientsathome.

Aspartofqualityassuranceprocesses,

wecheckkeyindicatorstoensureour

qualityofcare.Ourhandhygieneand

infectionauditsshowthattheriskof

hospitalacquiredinfectionat

CastlemaineHealthisextremelylow.All

inpatientdeathsatthehospitalare

reviewed.Nearlyalldeathsareexpected

andarepalliativeinnature.Transfersare

alsoreviewed,indicatingthatwhen

patientsneedmoreadvancedcarethat

cannotbeprovidedlocallytheyare

transferredinatimelyandappropriate

manner.

The Nursing and Education Directorate continue to work hard to provide the high standard of clinical and residential care that the community has come to expect. A broad range of services are provided within the Directorate including Residential Aged Care, Rehabilitation, Acute Medical and Surgical, Midwifery and Accident and Urgent Care services and Clinical Education.

13


PharmacyCastlemaineHealthhasanonsite

pharmacyservicethatoversees

dispensingofmedicationtoacuteand

subacuteservices.

Infection controlTheInfectionControlDepartment

managestheriskofinfection

transmissionforstaff,patients,residents

andvisitorstoCastlemaineHealth.In

terms of infection control, our pattern of

improvedcomplianceoverthelastfew

yearshascontinuedinrecentmonths.In

particularwe:

• improvedorganisationalcompliance

from77%in2012-13,to95%in

2013-14and97.7%in2014-15;and

• improvedclinicalcompliancefrom

79%in2012-13,to93.5%in2013-14

and93.8%in2014-15.

Handhygieneandcleaningstandards

remainhighatCastlemaineHealthand

HospitalAcquiredInfectionratesare

verylow.

Significantimprovementsand

innovationshavebeenimplementedto

ensureaccreditationstandardsaremet

inresidential,communityandacutecare

areas.Anantimicrobialstewardship

programwithtrafficlightprescribing

indicationsforantibioticshasbeen

successfullyimplemented.Further

improvements in infection prevention

occurred,withalcoholhandrubmade

availableinallagedcareareasand

auditingofhandhygieneintheseareas

occurringforthefirsttime.

Theintroductionofsinglepatientuse

tourniquetsandsafetyneedleshave

beenotherriskreductionstrategies

implemented.Furtherdevelopmentofthe

InfectionControlLiaisonTeamtoassistin

auditsandeducationofstaffhas

assistedinstaffknowledgedevelopment

andtheabilitytorespondandcope

effectivelyinchallengingsituationssuch

asoutbreaks.

As part of quality assurance processes, we check key indicators to ensure our quality of care. Our hand hygiene and infection audits show that the risk of hospital acquired infection at Castlemaine Health is extremely low.

Operating Suite


COMMUNITYPROGRAMSCastlemaineHealthCommunity

Programsprovidearangeof

multidisciplinaryservicesincluding

outpatientrehabilitation,functional

assessment,therapeuticintervention,

carecoordination,casemanagement

andsocialsupporttoclientsofallages

fromtheCentralGoldfields,Macedon

RangesandMountAlexanderShires.

DepartmentsCommunityProgramdepartments

include:EarlyChildhoodIntervention

Service,Physiotherapy,Occupational

Therapy,Podiatry,Dietetics,Speech

Pathology,HARP/ComplexCare

(HospitalAdmissionRiskProgram–

ComplexCare),PAC(PostAcuteCare),

ContinenceService,DistrictNursing,

PalliativeCare,AdultDayService,

VolunteersProgram,CADARGandCase

ManagementService.

Health Independence ProgramsTheHealthIndependencePrograms

(HIP)areasuiteofservicesthatoffer

time-limitedcoordinatedinterventionfor

peopletosupporttheirtransitionfrom

hospitaltohome,recoveryfromillness,

andmanagementofcomplexorchronic

conditions.TheHIPservicesavailableto

eligibleclientsacrossourregioninclude:

PostAcuteCare(PAC),outpatient

SubacuteCare(SACS)andHARP-

ComplexCare(HospitalAdmissionRisk

Program-HARP).HIPservicesinvolve

specialiststafffromPhysiotherapy,

OccupationalTherapy,Podiatry,Speech

Pathology,Dietetics,ContinenceNurse

AdvisorsandRegisteredNurses.AllHIP

servicesarebasedintheCommunity

RehabilitationCentre(CRC).

Achievements

• Asignificantre-organisationofCRC

SACS-fundedprogramshastaken

placethisyeartoimprovealignment

withHealthIndependenceProgram

(HIP)guidelines.Thishasledtothe

introductionofadditional

multidisciplinaryclinicsdesignedto

enhancethecoordinationofclients

withcomplexneedsandtomaintain

arehabilitationfocus.New

multidisciplinaryoutpatientstreams

include:Neuro/AcquiredBrainInjury,

OrthopaedicRehabilitation,Lower

LimbClinic,HandandForearmclinic,

andCognitiveDisordersprogram.

Theseclinicsareinadditionto

existingCRCmultidisciplinary

programssuchasBetterBalance,

PainManagement,Cardiac

RehabilitationandPulmonary

Rehabilitation.

• Thereviewandreorganisationof

programsintheCRCalsoaimsto

improveHIPserviceaccessacross

theMacedonRangesoverthe

coming12months.

• ACRCCommunityFeedbackForum

washeldon14October,withpositive

feedbackfromparticipants.Anaction

planhasbeendevelopedtoaddress

thesuggestionsforimprovement.

Thesuccessoftheforumhasledto

planstoholdthisconsumerfocus

groupannually.

• InJuly2014,CastlemaineHealthtook

overasthefundholderforPostAcute

Care(PAC)servicesfromBendigo

Health,aspartoftheDepartmentof

Health’sdisaggregationofPAC

servicesregionally.ThePACservice

isco-locatedalongsideotherHealth

IndependencePrograms(HIP)

servicesintheCommunityRehab

Centre.TheoutcomeforCastlemaine

Healthisastrengthenedabilityto

offeranincreasedrangeofHIP

fundedservicesacrossMount

Alexander,MacedonRangesand

CentralGoldfieldsShires.

• TheAlliedHealthGraduateProgram

wasrunagainthisyear,withAllied

Healthgraduatesattendingfrom

CastlemaineHealthandthesub-

regionalcluster.Anoccupational

therapygraduatefromCobaw

CommunityHealthparticipatedinthe

program,alongwith6alliedhealth

graduatesfromtheCommunity

RehabilitationCentre(CRC).

• Ongoinginvolvementwithsupervision

andtrainingofAlliedHealth

undergraduatestudentsacrossall

alliedhealthdisciplines.Dieteticshas

commencedanewpartnershipwith

CharlesSturtUniversity,with

commitmentstotakethirdandfourth

yearstudentsregularly.

Future directions

• Improveregionalaccesstothe

HealthIndependencePrograms

providedbyCastlemaineHealth.

• Continuetoreviewanddevelop

SACSprograms.

• Increasethefocusonstaffeducation

andinitiativesintheareasof

consumerparticipation,health

literacyanddiversity.

15


• Ongoingconsumerinputinto

developmentofourservicesand

programs.

• Continuetoexploreoptionsfor

partnershipsandjointinitiativesto

improveservicecoordinationand

accesswithlocalhealth

organizations.

Home and Community Care (HACC) programs ArangeofHACC-fundedprogramsare

offeredatCastlemaineHealth,including:

AlliedHealth(PodiatryandOccupational

Therapy),DistrictNursingService,Adult

DayServiceandContinenceservice.

Achievements

• Successfulreviewagainstthe

CommunityCareCommon

Standards.Thisisthefirsttimethat

alloftheHACCfundedservicesat

CastlemaineHealthhavegone

throughthissystemofreview.

• Redesignofthedistrictnursingand

palliativecareservices.Thishas

allowedforstafftofocustheirskillsin

specificclinicalareas.

• BendigooncologistDrBecky

Chapmanisworkingwiththe

palliativecareteamtoprovideclinical

supportincludingfortnightlycase

conferencingofpalliativeclients.

• IntroductionofActiveTuesday

programwhichundertheprinciples

ofActiveServiceModelpromotes

connectingpeopletothewider

community.

• Recruited11newvolunteersto

undertakeimportantworkat

CastlemaineHealth.

• Volunteersandstaffattended

dementiaawarenesstraining.

• CastlemaineHealthVolunteerswere

celebratedwithanafternoonteaat

Skydancersandthoseinvolvedin

AgedCareServicesinMount

AlexanderShireenjoyedacommunity

celebration.

• OccupationalTherapy’sco-location

programhasresultedinacloseand

strongworkingrelationshipwith

MountAlexanderShirestaff.The

programisguidedbytheactive

servicemodelprinciplesandaimsto

assistclientstodoasmuchfor

themselvesaspossible,inorderto

remainindependentintheirown

homewithagreatersenseofwell

being.

• Podiatryinhomefootcareprogram

continuestoexpand.Thisservice

supportspersonalcarestaffbeing

involvedinfootcareinasafe

environmentwithclosesupportfrom

thepodiatryteam.

• Theprogramhasseenthe

developmentofaShirewidediversity

planensuringconsultationand

considerationwhenaddressing

diversity.Italsosupportsusin

buildingstrongpartnershipswith

otherlocalHACCproviders.

• TheContinenceservicehasreceived

extrafundingtoprovideservicesto

CentralGoldfieldsShire.Thishas

beenpromotedthroughtheCentral

GoldfieldsShirewithgreatsuccess.

• PromotionoftheContinenceservice

hasseenstaffpresentoncommunity

radio.

• StaffattendedGay,Lesbian,Bisexual,

TransgenderandIntersex(GLBTI)

traininganddiscussionshavebegun

aroundprovidingfurtheropportunities

fortrainingstaffandimprovements.

National Respite for Carers Program (NRCP)

• AllstandardsweremetintheHome

CareStandardsQualityreviewinMay

2015.

• 100%carersatisfactionwithrespite

houseprogram.

Case Management Services (CMS Home Care Packages)

• InvolvementwithAlzheimersAustralia

andMINDAustraliatobringthe

MINDdogtrainingprogramto

regionalVictoria,asapilotforclients

withearlyonsetdementia.

• TheBendigoBranchreceivedfunding

to implement a volunteer visitor

programtorecipientsofHomeCare

PackagesacrosstheBendigo,

CentralGoldfieldsandMacedon

RangesShireregions.

• CMShasbeenworkingoverthelast

twoyearstoprovideclientswith

informationandeducationonthe

consumerdirectedmodelofcare,

whichcameintofulleffectfrom1July

2015.Thisgradualintroductionof

howthenewmodelwillaffectthe

futuredeliveryoftheirservicehas

allowedclientstoabsorbinformation

insmalldosesandprovidevaluable

feedbacktotheCMS.

• Allstandardsweremetsuccessfully

intheHomeCareStandardsQuality

reviewinMay2015.


COMMUNITYPROGRAMScontinued

Children’s ServicesEarly Childhood Intervention Program

• Ongoingserviceprovisiontofamilies

ofchildren0-6yearswithcomplex

needs.

• Servicescontinuetoextendacross

theMountAlexanderandCentral

GoldfieldsShires.

• ReceivedProfessionalDevelopment

grantfromtheDepartmentof

EducationandTrainingwhich

enabledstafftoattendtrainingon

BridgesoutofPoverty,Managing

EmotionsinChildrenandthe

VictorianAutismConference.

• Currentlyinvestigatingfutureoptions

forcontinuingtodeliverhighquality

servicestofamiliesandchildren

undertheNationalDisability

InsuranceScheme(NDIS).

Allied Health

• Ongoingserviceprovisiontochildren

ofMountAlexanderShire.

• ServicesofferedincludeSpeech

Pathology,Physiotherapy,

OccupationalTherapy,Dietetics,

PodiatryandContinenceService.

• Regularcaseconferencingand

coordinationofcaremeetingsare

heldwiththeAlliedHealthteamand

Paediatrician.

Paediatrician

• DrAnneDawsonwasappointedJuly

2014.Servicesareprovidedona

monthlybasisattheCastlemaine

HealthChildren’sCentre.

Castlemaine & District Accommodation Resource Group (CADARG)Achievements

• Expansionofoutreachservicesto

communitylunches,eventsand

invitedfunctions.

• PartnershipwithCantwellsRealtyto

extendaccesstoouremergency

accommodationandhousing

establishmentservice.

• Partnershipwithlocalschoolstoraise

awarenessofhomelessnessandits

effects.

Future Directions

• Furtherpartnershipdevelopmentto

addressrecurringhomelessnessand

riskofhomelessness.

• WorkwithDepartmentofHealthand

HumanServicestocombinewith

state-wideServicesConnectInitiative

foramorecomprehensiveservice.

17


CORPORATESERVICES

Support ServicesTheSupportServicesteamcomprisesof

approximately100staffandis

responsibleforHotelServices:Catering,

LinenandEnvironmentalServices.

SupportServicesalsoincludesSupply,

SecurityServices,PatientTransportand

FleetManagement.

HotelServices,SupplyandFleet

Managementarealsoprovidedto

MaldonHospitalonacontractualbasis.

Therewasarestructureoftheseservices

undertakenoverthepastyear.Wewould

liketoacknowledgethestafffortheir

assistanceduringthistimeofsignificant

change.

Food Services

OurFoodServicesteamofapproximately

60staffprovidesmorethan305,000

mealseachyeartopatients,residents,

visitorsandstaffatCastlemaineHealth

andMaldonHospital,andinexcessof

15,000mealsfortheCouncil’sMealson

Wheelsprogram.

The$400,000kitchenupgradewas

completedresultinginamodern,

state-of-the-artkitchen.Anewmenu

systemiscurrentlybeenimplemented

whichwillensurepatientmealsare

monitoredcloselyregardingdietsand

mealtexturerequirements.

Thedeliverymethodformealstoourlow

careResidentialAgedCarefacilities,

PenhallandSpencley,haschangedwith

themealsnowbeenplatedandservedto

residentsinthefacilitiesprovidingamore

home-likefeeltotheirdiningexperience.

TheFoodServicesCoordinatorhasbeen

meetingwithresidentsandworkingwith

theDieticianstodevelopanewmenu

takingintoaccountresidentpreferences

whilstensuringnutritionalrequirements

areaddressed.Thenewmenuis

currentlybeingfinalisedandwillbe

implementedinthenearfuture.

Environmental Services

TheEnvironmentalServicesstaffof

approximately30continuestheirquality

workdeliveringexcellentresultsacross

thefacilityandensuringthevery

demandingnationalcleaningstandards

weremetandoftenexceeded.The

followingresultswereachieved,

indicatinganexcellentperformance:

• Veryhighriskareas

Achieved98.8%Target90%

• Highriskareas


• Moderateriskareas


Laundry Services

Thelaundryservicesstaffof10continues

toworkeffectivelyaftertheprevious

year’srestructure.Throughthisreview

thestaffworkedasaunitedteamthat

nowdeliversaservicewithquality

outcomestoCastlemaineHealthand

contractedservicestoexternalclients.

Wecontinuetoendeavortoensurethat

personallinenismanagedwiththe

requiredcareforourresidentsin

ResidentialServices.

Transport & Fleet Management

Thetransportandfleetmanagement

serviceswererestructuredduringthe

year.CastlemaineHealthisworkingwith

ourfleetmanagementsystemproviderto

addressthereplacementofouraging

fleetandtoprovideinformationonthe

environmentalperformanceofthe

CastlemaineHealthvehiclefleet.

Supply

Inlinewiththeidealsofthe

StrengtheningHealthServicesproject,

whichencouragesHealthServicesto

worktogetherwhereverpossible,

CastlemaineHealthhasenteredintoan

arrangementwithBendigoHealthto

providematerialsmanagementservices

forthepurchaseofmedicalandsurgical

suppliesanddomesticservices

products.Thisarrangementwillenable

CastlemaineHealthtoaccessexpert

advice,abroaderproductevaluation

forumandimprovedpricing.

OurtwomemberSupplyteamcontinues

toworktirelesslytocollaterequisitions

fromstaff,placeorders,receiveand

dispatchmaterialstoallareasacrossthe

CastlemaineHealthsite,aswellasto

MaldonHospital.

Information TechnologyTheITDepartmenthasbeenverybusyoverthelasttwelvemonthswithnumerousupgradestonetworkinfrastructure,applicationsandotherprojects.

Theseprojectsincluded:

• Significantworkbehindthescenestoreducecosts,mainlyintheareaofmobilephones,aswellasreplacingkeypartsofthenetworkinfrastructuretoimprovespeed,reliabilityandperformance.

• Anewbackupsystemhasalsobeenintroducedtoallowgreatercontroloverthebackupprocess,aswellasfasterrecoveryandrestoretimes.


• iPadshavealsobeenintroducedtotheCommunityRehabilitationCentre,whichprovidesstaffwithfargreaterflexibilitywithhowtheyworkandwheretheywork.

Alargeprojectisalsocurrentlyunderwaythatwillseesomemajorimprovementstothewaynetworkservicesareprovidedinthefuture.

FinanceTheFinanceteamenjoyedayearofstabilityfromapersonnelperspective.Thishasenabledfurtherstrengtheningofskillsandknowledge,withakeyfocusalsooncross-trainingstaff.

FinancialreportinghasbeenstrengthenedatalllevelsfromindividualDepartments/UnitsthroughtoBoardreporting.Theturnaroundofmonthlyfinancialreportinghasalsobeenimprovedwhichprovidesfurtheropportunityforanalysisandoperationaldiscussion.

TheCommonwealth’sLivingLonger,LivingBetterreformwasimplementedon1July2014.ThesereformsrepresentedasignificantchangewithfinancialimplicationsforresidentsenteringResidentialAgedCare.Educationandknowledge-buildingaroundthesereformsrequiredmajoreffortfromtherelevantfinancestaff.

TheappointmentofanewInternalAuditorinJanuary2015hasfurtherstrengthenedtheorganisation’sfinancialgovernanceandcapability,withapositivecollaborativeworkingrelationshipestablished.

TheFinancestaffwillfurtherdevelopknowledgeandskillstosupportcontinuingimprovementin2015/16.AkeyfocuswillbefurtherdevelopmentofourITsystemstoimproveefficiencies,whichwillenableastrengthenedmanagementaccountingfunction.

EngineeringEngineeringcompleted6,344programmed/requestedworkordersforthe2014/15year.Ourstaffgardenerretiredinlate2014andwehaveengagedacontractortoprovidethisserviceintothefuture.TheEngineeringDepartmentcontinuestomaintainahighsafetystandardwithnotimelosttoaccidents.

Theaveragemonthlynumberofworkordersonthesystemawaitingattendancehasdecreasedby6.1%to434fromlastyear’saverageof462/month.Powerconsumptionhasincreasedby3.9%,naturalgasby0.6%andwaterconsumptionissteadyincomparisontothe13/14year.Wecontinuetomonitorenergyusageandstrivetoimproveefficiencywherepossible.

Wehavehadimprovementsinboiler,heatingandair-conditioningcontrolsthroughtheresidentialbuildingsthatareincreasingourabilitytomaintainacomfortabletemperaturerangeforourresidents.Overall,aconsistentresultforthe14/15yearwasachieved.

Utilities consumption charts

Natural Gas MJ

0200000002200000024000000260000002800000030000000

20010/11 20011/12 2012/13 2013/14 2014/15

20010/11 20011/12 2012/13 2013/14 2014/15

20010/11 20011/12 2012/13 2013/14 2014/15

20010/11 20011/12 2012/13 2013/14 2014/15

Electricity kWh

01900000

1950000

2000000

2050000

2100000

2150000

Water kL

0210002150022000225002300023500240002450025000

kWh/m2

090.0091.0092.0093.0094.0095.0096.0097.0098.0099.00

100.00

Electricity kWh

Natural Gas MJ

WaterKL

kWh/m2

CORPORATESERVICEScontinued

19


Aboriginal Employment Plan

IncollaborationwithCastlemaineHealthandEchucaRegionalHealth,BendigoHealthwassuccessfulinsecuringadditionalfundingtosupportimplementationofourAboriginalEmploymentplan.Activitiesassociatedwithimplementationoftheplantodatehaveincludeddeliveryofculturalawarenessandmentoringprograms,adaptionofrecruitmentpoliciestoincludeKarreetaYirrimboiandexaminationofseveraltraineeshipmodels.BendigoandCastlemainewereunsuccessfulinobtainingcontinuingfundingforthisprogram.

Graduate Nurse Program 2015

CastlemaineHealthoffersacomprehensiveGraduateNurseProgramcombiningrotationsthroughouracuteunit,rehabilitationandagedcareunits.TheprogramalsoincludesshortsupernumeraryplacementsinDistrictNursing.FourfulltimepositionsareofferedannuallyfornewlygraduatedRegisteredNursesandoffersaremadethroughtheregion’scomputermatchservice.

Human ResourcesTheHumanResourcesDepartmentismadeupofprofessionalanddedicatedstaffmembersthathavecontinuedtoprovideavalueaddedservicetostaffatCastlemaineHealth.TheHumanResourcesTeamisleadbyVickyMellingtonwhocommencedinthisroleinMay2015,replacingBruceDuncanwhowasintherolefromJanuary2011.TheHumanResourcesDepartmentincludesthefunctionsofrecruitmentandretention,employeesupport,payrollandoccupationalhealthandsafety(includingWorkCover).

Future Directions

• ImplementtheEmployeeSelfServicemoduleoftheKronostimeandattendancesystem,toallowemployees to log into Kronos from workorhometoviewtheirowntimesheets(pastandpresent),applyforleaveandenteravailability.

• DeveloptheSelfServicecomponentofSAPPayrollsystem,toenableemployeestoupdatetheirpersonalinformation.

• Consultwithmanagersonrequiredareasoftraining–forexampleKronos,SAP,PowerBudget,PerformanceManagement,ConflictResolutionandInductions.

• Developsuccessionplanningstrategiesincludingstaffretentionandemployeeengagement.

• Implementhealthandwellbeingstrategiesforstaff.

• Introduceexitinterviewstogatherfeedback.

• Maintainregularcommunicationwithstaffviainternalstaffnewsletter.

• ReviewstaffPerformanceManagementSystem.

• Improvetheinductionprocessformanagersandstaffbydevelopingchecklistsandtrainingsessions.

Industrial Relations

TheWorkplaceConsultativeCommitteecontinuestomeetmonthlyandprovidesaforumforopencommunicationbetweenmanagement,staffrepresentativeandunions.Thiscommitteefocusesonprovidingtheopportunitytotableproposedchangesandassistswithplanningforthefuture.

Staff Support Services

ProfessionalpastoralcareandbereavementsupportisprovidedtoallCastlemaineHealthstaff,aswellasclientsandtheirfamilies,asindividualneedsareidentified.Confidentialityisstrictlymaintainedandstaffappointmentswiththepastoralcarecoordinatorareavailableonrequest.MemorialservicesandservicessuchastheTimeofPeacePlaceofReflectionserviceareheld,providingopportunitiesforstafftoreflectandprocessgriefandlossissuesintheworkplace.ThePastoralCareCoordinatoralsotrainsnursinggraduatesinidentifyingthepastoralandemotionalneedsofclients.

EmployeesarealsoprovidedwithaccesstoPreventionofBullyingandHarassmentContactOfficers,EmployeeAssistantProgramservicesprovidedbyCounsellingBendigo,astaffgymnasiumandshorttermaccommodation.Occupational

Health&Safety

Statement of Merit and EquityCastlemaineHealthensuresafairandtransparentprocessforrecruitment,selection,transferandpromotionofstaff.Itbasesitsemploymentselectiononmerit,andcomplieswiththerelevantlegislation.PoliciesandProceduresareinplacetoensurestaffaretreatedfairly,respectedandprovidedwithavenuesforgrievanceandcomplaintprocesses.

Labour categoryJune current month FTE* June YT FTE*

2014 2015 2014 2015

Nursing 161.00 162.30 162.30 166.10

AdministrationandClerical 61.00 57.90 60.00 59.40

MedicalSupport 12.40 14.70 12.85 14.30

HotelandAlliedServices 115.63 111.05 111.60 107.78

MedicalOfficers(inclusiveofhospitalmedicalofficers) 1.35 1.80 0.50 2.10

SessionalClinicians 0 0 0 0

AncillaryStaff(alliedhealth) 33.30 38.60 33.70 36.00

TOTAL 384.68 386.35 380.95 385.68

Staff profile as at 30 June 2015


Occupational Health & SafetyCastlemaineHealthcontinuestobuilda

cultureofaccountabilityandimproved

andsustainedperformanceintheareaof

OccupationalHealthandSafety(OH&S).

Withamarkeddecreaseinthenumberof

averagedayslostperworkrelatedinjury

andeffectiverehabilitationithasmeant

thatinjuredstaffmembershavebeen

abletohaveanearlierreturnbackto

work.

Managersareembeddingaproactive

reportingculturewiththeirstaffforallof

ourOH&Sincidentsandhazards.We

havenowimplementedapaper-based

reportingformwhichstaffcanutilisein

somedepartmentstoaddressthelackof

access to computers to input an

electronicreportingincident.

Therehasbeenanincreaseinthe

numberandqualityofcompleted

investigationsasaresultofanOH&S

incidentorhazardasmanagersare

takingownershipforOH&Sintheirarea

ofcontrol.

Ouraimistocontinuetohavehealthy

andresilientemployeesbysupporting

themthroughEarlyInterventioninitiatives

whichhaveahighfocuson

musculoskeletalandpsychological

healthconcerns/issues.

Overthepast12monthsRisk

Managementfundsobtainedthroughour

insurerhaveassistedCastlemaineHealth

inbeingabletoconsultwithexpert

externalconsultantstovisitand

undertakeappropriatereviewsacrossa

rangeofareasandissues.

TheOH&SDepartmentsecured

additionalRiskManagementfunding

throughCGUtoreviewCastlemaine

Health’scurrentpoliciesandprocedures

formanagingsafetyagainstthe

requirementsofaformalmanagement

systemstandard(inthisinstanceAS

4801:2001).Thisreviewassessed

conformitywithsystemrequirementsas

wellasregulatorycomplianceand

contemporarysafetyissuessuchas

contractormanagementandbullying.

Thepurposeoftheriskmanagement

fundingwasto:

• Identifyareasforimprovementinthe

areasofsafety/workplacerisksand

suggest a performance improvement

planforthenext12months.

• Identifyopportunitiesforimproved

safety/workplaceriskforthepurpose

ofreducingtheclient’sinsurance

premiumin2014/15.

• Identifythreatsagainstmaintaining

currentsafety/workplacerisks.

• Makerecommendationsfor

performanceimprovement.

CastlemaineHealthwasgivena

substantialreportwhichincludesarange

ofrecommendationswhichtheOH&S

Departmentareworkingthroughacross

multipledepartmentsinthehospital.

Thesehaveincludedaworkflowanalysis

ofthekitchenoperationsatCastlemaine

Health,specificallyto:

• Identifypotentialgapsinsystemsand

processeswithinthekitchen

operation.

• Ensurecompliancewithlegislative

obligations.

• Reviewmanualhandlingprocesses

withinthekitchen.

• ReviewSafeWorkProcedures

(SWPs).

• Prepareaninitialroadmaptowards

sustainedperformanceimprovement.

Thisassessmentwasconductedthrough

thecollectionandanalysisofrelevant

datafromareviewofdocumentation

pertainingtothemanagementofOH&S

andFoodSafetyatCastlemaineHospital

alongwithanextensiveonsitereviewof

thekitchen.Allmealtimesand

productiontimeswereassessedovera

twodayperiod.

Recommendationswereidentifiedoutof

thisreport.Ofnoteisthatallmanual

handlingtaskswhichwereobserved

duringthetwodaysofthekitchen

assessmentwerecarriedoutinasafe

waybythekitchenstaff.Itwasidentified

thattheyareverygoodatusingtrolleys,

engagingotherstaffmemberstoassist

withliftingheavyitemsandstoringheavy

productsorcommonlyuseditemsonthe

correctshelves.


21


Workers Compensation Baseline Risk Assessment*

InsuranceYear

Remuneration or Wages 1

Premium Paid

inc GST 2

Claims Costs Paid

Average Premium

Rate 3

Weighted AverageIndustryRate 4

Days CompPaid 5

Time LostClaims 6

Total StandardClaims 7

2010/2011 $23,983,099 $525,389 $550,389 2.19% 1.36% *2,438 16 18

2011/2012 $23,233,490 $643,373 $390,026 2.77% 1.35% *2,377 11 16

2012/2013 $25,615,414 $922,181 $242,636 3.60% 1.28% *1,393 16 17

2013/2014 $26,269,785 $751,623 $93,205 2.86% 1.22% *354 8 11

2014/2015 $27,146,362 $862,132 $60,304 3.18% 1.77% *228 10 11

* DatasuppliedbyCGUandcorrectasat27June20151. 2014/2015premiummaybesubjecttoadjustmentinOctober2015whenremunerationhasbeenconfirmed2. ActualPremiumpaidbyCastlemaineHealthisexclusiveofGST3. AveragePremiumRateisthepremiumamountpaidasapercentageofremuneration4. WeightedAverageIndustryRateiscalculatedbyWICCodeandremunerationdistributionacrossworkplacesbyVWA5. DaysCompPaidistheVWADaysonly,andexcludesemployerunderexcessdays(1st10dayslost)

* Numbersfluctuateduetoclaimsineachyearremainingopen/activeandcontinuingtoaccumulatelosttimedays6. TimeLostClaimsreflectclaimswitheitherfullorpartiallosthours7. TotalStandardClaimsareclaimsthathaveeitherexceeded10dayslosttimeand/orhavemedicalexpensesincurredaboveemployer

excess amount

Injury Prevention Week – November 2014 and May 2015

Overthepastthreeyearsmorethan300

injuriesaffectingstaffhaveoccurredat

CastlemaineHealth.Alargeproportionof

theseinjurieswereasadirectresultof

manualhandlingincidents.Someof

theseinjuredstaffmemberscouldnot

returntotheirpre-injuryroleandcould

notcontinueintheirchosencareers.

Inresponse,in2014CastlemaineHealth

engagedtheservicesofamanutention

experttotrainarangeofbothclinicaland

non-clinicalstaffmemberstobecome

InjuryPreventionFacilitators(IPF’s).

Manutentionisapracticethatteachesus

–whenundertakingmanualhandling

tasks–tomoveourbodiesinwaysthat

protectusbothatworkandhome.The

roleofIPF’sistoensurethatstaffknow

howtoapproachmanualhandlingtasks

inawaythatkeepsthemsafeand

reducestheriskofinjuries.Castlemaine

Healthnowhasabroadrangeof

motivated,enthusiasticandpositiveIPF’s

whoareleadingthehospitalinmakinga

positivedifferenceintheirrespective

workareasandathome.

Particularlyimpressiveduringthetraining

sessionswashowstaffmemberscould

adaptthetheoriestheyhadlearnttotheir

individualworkingareas/tasks.Manyof

theIPF’shavesincecontactedtheOH&S

Departmenttodiscusssafety

improvementsandchangestheyare

makingintheirworkareassincethe

training.

ItisapparentthatmanyCastlemaine

Healthstaffmembersarepassionate

aboutimprovingworkplacesafety,and

opentobetterordifferentwaysofdoing

things.ItisclearthatamongsttheIPF’s

wehavesomeexcellentpresenterswho

areengaging,funnyandenthusiastic.All

theIPF’scouldidentifyareasoutside

theirnormalareaofexpertisethatthey

couldtrainothersin–asmanutention

techniquesareeasilyadaptabletoa

rangeofareas/tasks.

OurIPF’shavebeenpresentedwiththeir

certificatesofcompletionby

representativesoftheExecutiveOffice

andSeniorManagement,andrecently

tookpartinapracticaldemonstrationat

aDepartmentHeadsMeeting,

emphasisingthatsafebending,lifting

andreachingtechniquesapplytoallof

usintheworkplace.

OurfirstInjuryPreventionWeek(IPW)

occurredinNovember2014andour

secondinMay2015whereourIPF’s

continuedtoassesstheircolleagues

againstthemanualhandling

competenciesforbothclinicaland

non-clinicalworkareas.


Risk ManagementEmergency Response and Recovery Plan

TheEmergencyResponseandRecoveryPlandocumentsthearrangementsforthepreventionof,responseto,andrecoveryfromanincident,emergencyorcrisisthatmayimpactuponCastlemaineHealth,itsstaff,thecommunity,stakeholdersorphysicalassets.Itisexpectedthatknowledgeof;andadherencetotheseprocedureswillensurethatallclients,visitorsandStaffareguaranteedthehighestpossiblestandardsofhealthandsafetywhilstinCastlemaineHealth.

TheEmergencyResponseandRecoveryPlanistestedthroughouttheyearthroughfiredrillsanddesktopexercises.

Emergency Response and Recovery Planning Committee

TheEmergencyResponseandRecoveryPlanningCommittee(ERRPC)hasjointmembershipwithMaldonHospital.Thecommittee’sroleistoevaluate,adviseandmakerecommendationswith

respecttopoliciesandstrategicmattersrelatedtotheEmergencyResponseandRecoveryPlan(ERRP)consistentwiththeEmergencyResponseandRecoverypoliciesofbothCastlemaineandMaldonHospitals.

TheEmergencyResponseandRecoveryPlanningCommitteemeetsonamonthlybasistoplanfromOctobertoMarcheachyearandthenonanasneedsbasis.

Security Framework

2014sawthedevelopmentofaSecurityFrameworktoensureaproactiveapproachintheprotectionofpatients,residents,visitors,staffandhealthsystemassetsandanappropriateresponseto,andrecoveryfrom,anincident,emergencyorcrisisthatistheresultofasecurityincident.TheframeworkiscollaborationofCastlemaineHealthandMaldonHospital.

Security Liaison Committee

TheSecurityLiaisonCommitteeisaconsultativecommitteethatprovidesadvicetotheBoardandExecutiveof

CastlemaineHealthandMaldonHospitalonissuesrelatingtoexisting,newandemergingissueswithinthecommunitythatmayimpactonthehealthandsafetyofhospitalstaffandcarerecipients.

ThecommitteehasmembershipfrombothhospitalsaswellasBendigoHealth,VictoriaPolice,MountAlexanderShire,LoddonPrisonService,CastlemaineCommunityHealthCentreandcontractedSecurityCompany(WorkforceEX).

Risk Management Framework

CastlemaineHealthhasastrongcommitmenttomanagingriskandhasactivelyworkedtoincreasesoundriskmanagementpracticethroughouttheorganisation.TheRiskManagementFrameworkalignsbusinessopportunitiesandsupportsmanagersandstaffintheidentificationandtreatmentofrisksastheyarise.RiskManagementisoverseenanoperationallevelbytheClinicalServicesandQualityandRiskCommitteesandataGovernancelevelbytheAuditandRiskandtheClinicalGovernanceandQualityCommittees.

Clinical Risksrelatedtothedeliveryclinicalcareofallpatients,residentandclients.

Corporate Riskrelatedtothesoundandeffectivecorporategovernance.

Emergency Preparedness

and Business Continuity

Risksassociatedwithreadinesstosustainminimumbusinessfunctionalityandanorganised

responsetoacrisisorunexpectedevent.

Financial Risksassociatedwiththefinancialmanagement,reporting,accountingandadministrationoffunds.

Governance and Legislation Risksassociatedwithnoncompliancetolegislation,regulationsandmaintainingstandards.

Human Resources Risksassociatedwithensuringpolicies,proceduresandprocessesareinplacefortherecruitment,

retention,managementofstaff.

Infrastructure and Equipment Risksrelatedtoensuringinfrastructureandequipmentaremaintainedinanappropriatemannertobe

safelyandeffectivelyused.

Knowledge and Systems RisksassociatedwithITsystems,managementandprotectionofinformationandcorporate

knowledge.

Public Relations/Reputation Risksassociatedwithengagingcustomersandthecommunity.

Safety, Health, Environment

and Security

Risksassociatedwithensuringasecureandsafeworkingenvironmentforallstaff,contractors,

visitorsandcompliancewiththeOccupational Health and Safety Act 2004.

Allidentifiedrisksarealignedwithtenhighlevelcorporaterisks:


23

ANNUAL REPORT 2015

STATUTORYCOMPLIANCE



ACKNOWLEDGEMENTS/MAPSWewishtothankeveryonewho

contributedtothewritingandproduction

ofthisannualreport.Thisincludesstaff,

membersofthecommunity,volunteers

andclients.

Printing:BendigoModernPress

Cover design and page layout

template:BillingtonPrideauxPartnership

Editors:ChrisMitchelland

KateO’Connor

Bank:BendigoBank

External Auditor:Auditor-General,

Victoria

External Auditor’s agents:Richmond

SinnottandDelahunty

Internal auditor:AccountingandAudit

Solutions,Bendigo/AFSandAssociates

PtyLtd,Bendigo

Feedback:CastlemaineHealth

welcomesyourvaluablecommentsand

feedbackregardingourannualreport.

Contact details:

CastlemaineHealth

P O Box 50

CastlemaineVIC3450

Email:[email protected]

Website:www.castlemainehealth.org.au

Main entrance viaOdgers Road

Key Achievements 1

Overview of Services 2 Provided

Report to the Community – President 3 – Chief Executive Officer 4

Organisational Chart 6

Corporate Governance 7

Statement of Priorities 8

Nursing Care and Education 12

Community Programs 14

Corporate Services 17

Statutory Compliance 23

Acknowledgments and 24 Maps

Disclosure Index 25 Exceptional Care of Every Person, Every TimeLast year we developed a new vision, mission and set of values to underpin all the work we do

here at Castlemaine Health. It is both a framework that guides our actions, and a firm

commitment that we make to our community.

Our vision is ‘exceptional care of every person, every time’. Whether we are caring for our

residents, assisting a person to get well or rehabilitate, helping people in their own homes, or

consulting with the community on a wide range of health issues, we are committed to providing

exceptional care of every person, every time.

Our mission is to deliver ‘a well run and trusted organisation that engages with the community

to provide high quality health services’. This is something that our community expects and we

constantly strive to deliver. Community consultation is key to ensuring our success in this

regard – the unique perspective that consumers provide is vital in helping us enhance the

customer experience.

Finally, everything that we do is conducted according to our key values – ‘integrity, care, unity

and excellence’. We believe that if we as an organisation epitomise these attributes, we can

function effectively and better achieve our goals.

Thank you for being part of the Castlemaine Health community. We hope that you see these

goals and values reflected in the work that we do. If you have any feedback, please contact the

Community Engagement Coordinator on 5471 1505.

Castlemaine Health acknowledges the support of the Victorian Government

VisionExceptional care of every person, every time.

ValuesIntegrity, Care, Unity and Excellence.

MissionA well run and trusted organisation that engages with the community to provide high quality health services.

CONTENTS

LEGISLATION REQUIREMENT PAGE REFERENCEMINISTERIAL DIRECTIONSREPORT OF OPERATIONSCHARTER AND PURPOSEFRD 22F Manner of establishment and the relevant Ministers 1FRD 22F Purpose, functions, powers and duties 7FRD 22F Initiatives and key achievements 1FRD 22F Nature and range of services provided 2MANAGEMENT AND STRUCTUREFRD 22F Organisational structure 6FINANCIAL AND OTHER INFORMATIONFRD 10 Disclosure index IBCFRD 11A Disclosure of ex-gratia expenses 23FRD 12A Disclosure of major contracts 23FRD 21B Responsible person and executive officer disclosures AFSFRD 22F Application and operation of Protected Disclosure Act 2012 23FRD 22F Application and operation of Carers Recognition Act 2012 23FRD 22F Application and operation of Freedom of Information Act 1982 23FRD 22F Compliance with building and maintenance provisions of Building Act 1993 23FRD 22F Details of consultancies over $10,000 23FRD 22F Details of consultancies under $10,000 23FRD 22F Employment and conduct principles 19FRD 22F Major changes or factors affecting performance AFSFRD 22F Occupational health and safety 20FRD 22F Operational and budgetary objectives and performance against objectives AFSFRD 22F Significant changes in financial position during the year AFSFRD 22F Statement of availability of other information 23FRD 22F Statement on National Competition Policy 23FRD 22F Subsequent events AFSFRD 22F Summary of the financial results for the year AFSFRD 22F Workforce Data Disclosures including a statement on the application of employment and conduct principles 19FRD 24C Reporting of office-based environmental impacts 18FRD 25B Victorian Industry Participation Policy disclosures 23FRD 29A Workforce Data disclosures 19SD 4.2(g) Specific information requirements 23SD 4.2(j) Sign off requirements 23SD 3.4.13 Attestation on data integrity 23SD 4.5.5.1 Ministerial Standing Direction 4.5.5.1 compliance attestation 23SD 4.5.5 Risk management compliance attestation 23FINANCIAL STATEMENTS REQUIRED UNDER PART 7 OF THE FINANCIAL MANAGEMENT ACT

Letter of comfort AFSSD 4.2(a) Statement of changes in equity AFSSD 4.2(b) Comprehensive Operating Statement AFSSD 4.2(b) Balance Sheet AFSSD 4.2(b) Cash Flow Statement AFSOTHER REQUIREMENTS UNDER STANDING DIRECTIONS 4.2SD 4.2(a) Compliance with Australian accounting standards and other authoritative pronouncements AFSSD 4.2(c) Accountable officers declaration AFSSD 4.2(c) Compliance with Ministerial Directions AFSSD 4.2(d) Rounding of amounts AFSLEGISLATIONFreedom of Information Act 1982 Protected Disclosure Act 2012Carers Recognition Act 2012Victorian Industry Participation Policy Act 2003Building Act 1993 Financial Management Act 1994

The annual report of Castlemaine Health is prepared in accordance with all relevant Victorian legislation. This index has been

prepared to facilitate identification of the Department’s compliance with statutory disclosure requirements.

AFS – Attached Financial Statement; IF – Inside Front

Financial statements attached. If the statement is not attached please contact Personal Assistant to the Chief Executive Officer on (03) 5471 1401

DISCLOSURE INDEX

CARE, QUALITY AND CHOICE

Cornish Street, Castlemaine Vic 3450, PO Box 50www.castlemainehealth.org.au

ANNUAL REPORT 2015


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