blue care tweed heads amaroo aged care facility · blue care tweed heads amaroo aged care facility...

Blue Care Tweed Heads Amaroo Aged Care Facility

RACS ID 2791 68-78 Keith Compton Drive TWEED HEADS NSW 2485

Approved provider: The Uniting Church in Australia Property Trust (Q)

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for three years until 21 July 2018.

We made our decision on 17 June 2015.

The audit was conducted on 12 May 2015 to 14 May 2015. The assessment team’s report is attached.

We will continue to monitor the performance of the home including through unannounced visits.

Home name: Blue Care Tweed Heads Amaroo Aged Care Facility RACS ID: 2791 2 Dates of audit: 12 May 2015 to 14 May 2015

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

Within the philosophy and level of care offered in the residential care service, management systems are responsive to the needs of residents, their representatives, staff and stakeholders, and the changing environment in which the service operates.

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

Residents' physical and mental health will be promoted and achieved at the optimum level in partnership between each resident (or his or her representative) and the health care team.





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

Residents retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care service and in the community.





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

Residents live in a safe and comfortable environment that ensures the quality of life and welfare of residents, staff and visitors.





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Blue Care Tweed Heads Amaroo Aged Care Facility 2791


Introduction

This is the report of a re-accreditation audit from 12 May 2015 to 14 May 2015 submitted to the Quality Agency.

Accredited residential aged care homes receive Australian Government subsidies to provide quality care and services to care recipients in accordance with the Accreditation Standards.

To remain accredited and continue to receive the subsidy, each home must demonstrate that it meets the Standards.

There are four Standards covering management systems, health and personal care, care recipient lifestyle, and the physical environment and there are 44 expected outcomes such as human resource management, clinical care, medication management, privacy and dignity, leisure interests, cultural and spiritual life, choice and decision-making and the living environment.

Each home applies for re-accreditation before its accreditation period expires and an assessment team visits the home to conduct an audit. The team assesses the quality of care and services at the home and reports its findings about whether the home meets or does not meet the Standards. The Quality Agency then decides whether the home has met the Standards and whether to re-accredit or not to re-accredit the home.

Assessment team’s findings regarding performance against the Accreditation Standards

The information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 12 May 2015 to 14 May 2015.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of two registered aged care quality assessors.

The audit was against the Accreditation Standards as set out in the Quality of Care Principles 2014.

Assessment team

Team leader: Lynne Hill

Team member/s: Sharon Dart

Approved provider details


Details of home

Name of home: Blue Care Tweed Heads Amaroo Aged Care Facility

RACS ID: 2791

Total number of allocated places:

101

Number of care recipients during audit:

52

Number of care recipients receiving high care during audit:

51

Special needs catered for: Dementia Specific

Street/PO Box: 68-78 Keith Compton Drive

City/Town: TWEED HEADS

State: NSW

Postcode: 2485

Phone number: 07 5536 1388

Facsimile: 07 5599 1649

E-mail address: [email protected]

http://www.comlaw.gov.au/Details/F2011L00821

mailto:[email protected]


Audit trail

The assessment team spent three days on site and gathered information from the following:

Interviews

Category Number

Cluster Management team 8

Assistant Integrated Services Manager 1

Registered staff 5

Care staff 7

Administration Assistant 1

Care recipients/representatives 14

Lifestyle staff 2

Hotel services staff 6

Occupational health and safety representatives 2

Maintenance staff 2

Sampled documents

Category Number

Care recipients’ files 7

Personnel files 6

Medication charts 6

Other documents reviewed

The team also reviewed:

Advanced health directives, Enduring Power of Attorney documents and end of life care pathway

Adverse event register

Agency and permanent staff orientation records

Allied health and specialist referrals and reports

Approved suppliers list and service contracts

Audit tools, survey schedule and results

Case conference records


Chemical register, safety data sheets and risk assessments

Clinical assessment records

Comments and complaints documents

Communications including diaries, emails, memoranda and faxes

Continuous improvement log and feedback forms

Criminal history and Qualification records

Dietary preferences, profiles, forms and supplements list

Education resources and attendance records

Emergency and incident management plans and related documents

Emergency response documents and fire drill records

Fire detection equipment and fire panel inspection records

Fire evacuation lists

Food authority licence, safety plan, Food safety supervisor certificates and associated records

General and kitchen cleaning schedules

Hazard reporting documents, risk register and safety records

Incident forms, reports and data

Infection control documentation

Legislative update summary documents

Lifestyle records

Maintenance records – internal and external

Mandatory reporting register and associated records

Medication records, controlled drugs registers, alerts and directives

Meeting minutes

Menus and associated records

Newsletters

Organisational quality statement

Orientation resources, checklists and associated competencies


Performance development and review plans

Pest control documents

Policies and procedures

Position descriptions and duties lists

Probity check register for staff and volunteers and related documents

Quality action plan

Reaccreditation self- assessment

Recruitment and selection documents

‘Resident list’ and handover worksheets

‘Resident’, visitor and contractor sign in/out books

‘Residents’ Handbook’ Charter of rights and responsibilities, agreements and information package

Restraint records

Roster, staff replacement processes and staff daily attendance sheets

Staff signature registers

Temperature monitoring records

Test and tag records and safety switch inspection logs

Texture modified diet guidelines

Training matrix, education calendar and medication competencies

Work books, work instructions and reports

Observations

The team observed the following:

Activities in progress and activity calendar on display

Archive storage area

Catering, cleaning and laundry operations in progress

Chemical, equipment and supply storage areas

Communication boards

Complaint and advocacy brochures and posters displayed


Daily menu on display

Emergency lighting and fire/smoke doors in operation and exits free of clutter

Equipment to support infection control practices

Fire equipment, inspection tags and emergency evacuation diagrams

Handover processes

Interactions between staff and care recipients and representatives

Internal and external living environment

Meal and beverage delivery and service

Medication administration and storage

Notice boards and notices on display

Reaccreditation information displayed

Secure suggestion boxes, records and confidential information

Short group observation

Storage areas for food, medical supplies and cleaning equipment

Staff work practices


Assessment information

This section covers information about the home’s performance against each of the expected outcomes of the Accreditation Standards.

Standard 1 – Management systems, staffing and organisational development

Principle: Within the philosophy and level of care offered in the care residential care service, management systems are responsive to the needs of care recipients, their representatives, staff and stakeholders, and the changing environment in which the service operates.

1.1 Continuous improvement

This expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findings

The home meets this expected outcome

Blue Care Tweed Heads Amaroo Aged Care Facility (the home) actively pursues continuous improvement activities through monitoring processes including audits conducted across the four Accreditation Standards and risk management processes. The home conducts, collates and analyses information from audits, hazard/incident reporting processes and feedback processes including surveys, forms and individual or group meetings. Information resulting from these processes is discussed in a consultative manner between management, staff and care recipients/representatives and other interested parties, to identify, action, evaluate and resolve improvement activities. Management records document action steps, monitors progress and evaluates outcomes as appropriate. Care recipients/representatives and staff are satisfied with improvements implemented.

Examples of improvements in relation to this Standard include:

As a strategy to improve quality systems across the organisation, a Quality Council at the organisation’s Central Support office has been established. This council monitors quality activities for the organisation and identifies areas for improvement at the strategic level, including at the home. This has resulted in an enhanced continuous improvement system with positive outcomes for care recipients and staff.

The home has now been integrated with two sister facilities. This integration facilitates collaboration between care recipients and staff at these related services. Staff are able to work between the services and this has resulted in an enhanced continuity of care, up skilling of staff and sharing of knowledge and skills.

The home has recently employed a clinical nurse to oversee the clinical care of care recipients, including complex clinical needs, and supervision of nurses and care staff. The clinical nurse also monitors the home’s care governance processes and data collection to ensure trends are identified and actioned as appropriate. This has resulted in improved clinical care and analysis of data.


1.2 Regulatory compliance

This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines”.

Team’s findings


The home has organisational systems and processes to identify and ensure compliance with legislation, regulatory requirements, professional standards and industry guidelines. The home provides information to relevant personnel via electronic alerts, policy updates, memoranda, newsletters, meetings and education; this information is available to staff electronically and in hardcopy. Compliance with legislation, organisational procedures/policies and the Accreditation Standards is monitored through the audit system, performance appraisals and observation of staff work practices. Care recipients/representatives are notified of reaccreditation audits and the organisation has systems and processes to monitor currency of criminal history certificates and designated personnel receive alerts for staff, volunteers and relevant service providers.

1.3 Education and staff development:

This expected outcome requires that “management and staff have appropriate knowledge and skills to perform their roles effectively”.

Team’s findings


Management and staff have appropriate knowledge and skills to perform their roles effectively. Recruitment processes ensure staff have the skills, ability and relevant qualifications to perform the role. Organisational orientation processes include mandatory and other training programs specific to their roles provided by qualified personnel and the completion of identified competencies and assessments. Education is planned, scheduled, advertised and monitored for attendance by organisational personnel and staff at the home. The need for further education is identified through monitoring processes including incident and hazard reporting, risk assessments, feedback from staff and care recipients/representatives, receipt of new goods/equipment, implementation of new processes, observation of staff practice and the environment and changes in care recipients’ needs. Staff and management are encouraged and supported to undertake further education and formal qualifications utilising internal and external training processes.

In relation to this Standard relevant education includes customer service, code of conduct, orientation, recruitment and selection, complaints management, mental health training for managers, preparation for accreditation, performance development and review, computer skills and literacy and Registered Nurse (RN) Leadership Training.


1.4 Comments and complaints

This expected outcome requires that "each care recipient (or his or her representative) and other interested parties have access to internal and external complaints mechanisms".

Team’s findings


The home has an organisational system to manage comments and complaints. Care recipients/representatives have access to internal and external complaints and advocacy processes and are advised in the ‘care recipient handbook’, the care recipient residential agreement and brochures. Feedback forms are available to care recipients and a secure suggestion box is available for anonymous submission of complaints. The complaints process is discussed at care recipients and staff meetings and complaints are incorporated into the continuous improvement system. The comments and complaints register is logged, monitored and reviewed by designated personnel to ensure complaints are actioned, evaluated and closed out. Feedback is provided through individual or group meetings, noticeboards, electronic communication, memoranda, letters and newsletters. Care recipients/representatives are aware of the complaint process and are satisfied with staff response to their concerns.

1.5 Planning and leadership

This expected outcome requires that "the organisation has documented the care residential care service’s vision, values, philosophy, objectives and commitment to quality throughout the service".

Team’s findings


The organisation has consistent documentation of their vision, mission, values, philosophy and objectives which are published in handbooks and relevant documents and discussed at orientation and other forums. This information is available to care recipients, staff and other interested parties.

1.6 Human resource management

This expected outcome requires that "there are appropriately skilled and qualified staff sufficient to ensure that services are delivered in accordance with these standards and the care residential care service’s philosophy and objectives".

Team’s findings


Organisational systems and processes are in place to ensure that appropriately skilled and qualified staff are sufficient to provide services in accordance with the Accreditation Standards and the organisation’s philosophy and objectives. The recruitment, selection and employment of staff is based on required skills, experience and qualifications. Orientation processes include role specific information, mandatory training sessions, competencies and new staff are supported by experienced staff during ‘buddy’ shifts. Staff skills are monitored through observation of staff practice, incident analysis and performance appraisals. A roster is maintained and reviewed as required to ensure that sufficient staff are available to meet care recipients’ needs and to ensure that the environment is maintained. Staff state they have


adequate time to complete their duties. Care recipients/representatives are satisfied with the timeliness of staff response to care recipients’ requests for assistance.

1.7 Inventory and equipment

This expected outcome requires that "stocks of appropriate goods and equipment for quality service delivery are available".

Team’s findings


There are processes to ensure the regular supply of goods and equipment that are stored appropriately. Monitoring and ordering processes ensure specified levels are maintained via communication mechanisms and audits and visual checks confirm equipment and stock supplied are sufficient and suitable for use. Equipment is maintained through both a reactive and preventative maintenance program. Staff and care recipients/representatives are satisfied with the availability of goods and equipment at the home.

1.8 Information systems

This expected outcome requires that "effective information management systems are in place".

Team’s findings


The home utilises organisational processes to gather information through assessments, care planning, care recipient residential agreements, service contracts, staff recruitment and retention, comments and complaints, continuous improvement, surveys, audits, meetings, and electronic and hard copy communications. Management ensures current information is reviewed and maintained and available to relevant individuals as needed. Confidential information is stored securely in restricted areas; electronic information is password protected and backed up regularly and archive and document destruction processes are in place. Stakeholders receive information regarding the home’s policies and procedures as needed. Care recipients/representatives are informed through mechanisms including meetings, agreements, published information, notices and correspondence. Staff are informed through meetings, education, duties lists, position descriptions, handbooks, communication books, electronic communications, notices and forms. Care recipients/representatives and staff are satisfied with the processes used to manage information in the home.

1.9 External services

This expected outcome requires that "all externally sourced services are provided in a way that meets the care residential care service’s needs and service quality goals".

Team’s findings


The organisation has systems to ensure external services are provided in a way that meets the home’s service needs and quality goals. Processes ensure information provided in contract/service agreements remains current regarding relevant licences, insurance details, registration certificates and criminal history certificates. Service agreements are reviewed as required and feedback is provided to ensure consistent quality in service delivery processes.


Care recipients/representatives and staff are satisfied with the quality of services provided by external suppliers.


Standard 2 – Health and personal care

Principle: Care recipients’ physical and mental health will be promoted and achieved at the optimum level, in partnership between each care recipient (or his or her representative) and the health care team.



Team’s findings


Refer to Expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement systems and processes.


Subsequent to an organisational initiative, a new palliative care model has been implemented at the home and education has been provided to staff. Resources are available to support staff in providing emotional and clinical support appropriate to end of life care planning. This has resulted in a supportive palliative care pathway for care recipients and their families.

As a strategy to improve wound care across the organisation and at the home, an organisational agreement has been established with a service provider. An associated wound care advisory group has developed an on-line, self-paced wound care education package. This package includes an overview of the wound assessment process, categories of wounds and relevant treatment products. This has resulted in improved wound care for care recipients.


This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines about health and personal care”.

Team’s findings


Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to maintain regulatory compliance. The home has systems to ensure compliance with legislation relevant to health and personal care. In relation to this Standard, there are established systems to ensure relevant staff have current registration, police checks and reporting guidelines in the event of unexplained absence of care recipients.


2.3 Education and staff development


Team’s findings


Refer to Expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills. In relation to this Standard relevant education includes nutrition and hydration, continence management, hearing aid maintenance, wound management, falls prevention, skin care, oral care, medication management and palliative care.

2.4 Clinical care

This expected outcome requires that “care recipients receive appropriate clinical care”.

Team’s findings


The clinical care needs of care recipients are assessed on entry to the home through interviews with care recipients/representatives, assessment information and discharge summaries as provided. Interim care plans are formulated by registered nurses to guide practice until identified focus assessments are completed and evaluated to provide detailed information for the development of individualised care plans. Case conferences are held with the care recipients and/or their representatives on a regular basis to discuss care needs and preferences. Staff provide input into care and alerts are generated to ensure care reviews occur as scheduled. Shift handover processes, communication diaries and progress note entries provide details about care recipients’ changing needs. Medical officers visit the home on a regular basis and are available for consultation regarding changes in care recipients’ health status at other times. Monitoring of clinical care is undertaken through clinical care audits and review of clinical incident data. Care recipients/representatives are satisfied with clinical care services provided.


2.5 Specialised nursing care needs

This expected outcome requires that “care recipients’ specialised nursing care needs are identified and met by appropriately qualified nursing staff”.

Team’s findings


Care recipients’ specialised nursing care needs are identified during the admission and assessment process or when their health status changes. The clinical team, comprising the Assistant Integrated Services Manager, the Clinical Nurse (CN) and other registered nurses is available to assess, plan, monitor and evaluate specific specialised nursing care requirements. Delegation of aspects of care occurs to enrolled nurses and care staff as determined by their level of competence and scope of practice. Current specialised nursing needs identified include parenteral enteric gastric feeding, stoma care, urinary catheter management, diabetes management, complex wound management and oxygen therapy.

Education/training updates are available should staff be unfamiliar with specific care recipient care needs. Care recipients currently in receipt of specialised nursing are satisfied with the ongoing nursing care provided.

2.6 Other health and related services

This expected outcome requires that “care recipients are referred to appropriate health specialists in accordance with the care recipient’s needs and preferences”.

Team’s findings


Care recipients are referred to appropriate health services when a particular need is identified or on request from the care recipient and/or their representative. Appointments are arranged and allied health professionals who visit the home have access to the care recipients’ clinical file and current care strategies. Health professionals including a physiotherapist, dietitian, speech pathologist, podiatrist and a mobile denture care team visit the home on a regular schedule. Care recipients also have access on an as needs basis to auditory, optical and dementia advisory services and mental health practitioners. Details of assessments and recommendations regarding ongoing management are documented in clinical care notes and where applicable transferred to relevant care plans. Implementation of the recommended care strategies is monitored and the effectiveness of care is evaluated through the scheduled review process. Care recipients are satisfied with referral to health specialists and the care provided under their direction.

2.7 Medication management

This expected outcome requires that “care recipients’ medication is managed safely and correctly”.

Team’s findings


Policies and guidelines ensure care recipients’ medication is managed safely and correctly by appropriately qualified and trained staff. Medication charts display photographic identification of care recipients with individual instructions for assisting care recipients such as crushing and


measures to aid in ingestion. Medications are administered via a sachet packaging system with medication charts used to record medications prescribed by the care recipients’ medical officer. Medications are stored according to legislation and manufacturer’s instructions in locked medication trolleys, cupboards, safes (schedule 8 medications) and designated medication refrigerators. The effectiveness of the medication management system is monitored through completion of internal audits and accredited pharmacist reviews. Staff assisting care recipients with their medications are aware of their responsibilities in relation to medication administration and of the guidelines in place to ensure care recipients’ medications are administered safely and correctly. Care recipients are satisfied with the management of their medications and the assistance provided by staff.

2.8 Pain management

This expected outcome requires that “all care recipients are as free as possible from pain”.

Team’s findings


Consultation occurs with care recipients as part of the initial assessment process in relation to history of any pain, identified triggers for pain and their needs for pain management. Pain monitoring charts are commenced to identify specific care needs and these are addressed within an individualised care plan to inform staff. Re-assessment and monitoring occurs when care recipients experience new/acute pain and assessment tools are also available to assist in the identification of non-verbal cues to pain. Strategies to manage pain are detailed in care plans and include both pharmacological and non-pharmacological interventions including heat packs and massage. Staff liaise with the care recipients’ medical officer and/or physiotherapist where further intervention is required. Care recipients are satisfied their pain is managed effectively and that staff are responsive to their changing needs.

2.9 Palliative care

This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”.

Team’s findings


Palliative care and emotional and spiritual support for care recipients and their representatives are provided in accordance with care recipients/representatives previously identified wishes, cultural/spiritual observances and current nursing care needs. The home has access to organisational palliative care services to offer support and advice to families, care recipients and staff. Staff have access to specialised resources and are aware of how to meet both the physical and emotional needs of care recipients sensitively while supporting care recipients’ families during the end of life stage. Care recipients/representatives commented staff are caring and attentive and respect care recipients’ preferences and their privacy and dignity.


2.10 Nutrition and hydration

This expected outcome requires that “care recipients receive adequate nourishment and hydration”.

Team’s findings


Communication processes between nursing and kitchen staff ensures updated care recipient dietary preference forms are current, allergies are noted and care recipients receive appropriate diets and textures. Care recipients are routinely weighed on a monthly basis, significant weight variances are monitored by the CN and referrals may be initiated to a dietitian and/or a speech pathologist. Where recommended or indicated as appropriate, care plans are modified and interventions including supplements and textured or fortified meals are implemented and regularly evaluated. Care recipients are offered choices to dine in a variety of spaces and staff provide assistance to care recipients during meal times. Care recipients/representatives are satisfied with the quantity and quality of food and fluid received.

2.11 Skin care

This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”.

Team’s findings


Care recipients’ skin integrity is assessed on entry to the home and appropriate interventions are included in the care recipient’s care plan to guide staff. The potential for compromised skin integrity is also assessed and preventive strategies implemented as appropriate; inclusive of pressure reducing/relieving devices and routine pressure area care. Guidelines are in place regarding measures to minimise the occurrence of skin tears as well as how to manage skin tears should they occur. The incidence of injury/skin tears is captured on incident reports and analysed for trends/triggers; interventions are then implemented as appropriate. Wounds and treatments are monitored via wound treatment charts to prompt clinical staff and outcomes are evaluated on an ongoing basis. Care recipients are satisfied with the support provided to maintain their skin integrity.

2.12 Continence management

This expected outcome requires that “care recipients’ continence is managed effectively”.

Team’s findings


Care recipients’ continence status is assessed over a three day assessment period, urinary output and bowel charts are commenced to identify patterns and trends. This information is analysed by a registered nurse and appropriate interventions are implemented including regular toileting programs, selection of appropriate continence aids and medication and dietary reviews. Designated staff monitor continence needs of care recipients and initiate re- assessment, if necessary. Care staff receive regular update training in the management of care recipients’ continence and are able to access advice in the ongoing management of individual care recipients. Bowel management programs are in place and staff respond to any concerns regarding constipation by increase in dietary fibre, additional fluids and prescribed


aperients. Care recipients are satisfied with the level of support received to manage their continence needs.

2.13 Behavioural management

This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”.

Team’s findings


Care recipients are assessed on entry and actual or the potential indicators for challenging behaviours are identified with information collected from families, pre-admission medical and other allied health professionals. Behaviour monitoring assessments are conducted during the settling in period and strategies implemented to reduce the challenging behaviours together with observed triggers that may have led to the behaviour are incorporated within the care plan to provide guidance to staff. Organisational consultants are available and referrals may be made to external agencies to assist in the management of care recipients. A secure unit is available for care recipients who wander to provide them with a safe environment and freedom of movement. Staff receive regular training and both care and activity staff implement strategies to minimise the occurrence of behaviours that are challenging. Care recipients/representatives are satisfied with the way behaviours are managed and staff are discreet and supportive in their interventions.

2.14 Mobility, dexterity and rehabilitation

This expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.

Team’s findings


The home has processes for assessing, planning, delivering and evaluating care recipients needs in relation to their mobility, dexterity and rehabilitation. Care recipients’ mobility and falls risk is assessed by registered staff in association with the physiotherapist to assist in maintaining and/or enhancing a care recipient’s mobility and dexterity. Care recipients’ mobility status is reviewed regularly, individual care recipient falls are monitored and recorded and strategies are implemented to minimise the risks of future falls. Mobility aids and other equipment are available to assist care recipients to continue to mobilise throughout the home. Individual and group exercise and dexterity programs are provided. Staff are trained in manual handling techniques to safely assist care recipients to mobilise and transfer using appropriate mobility aids and lifting devices. Care recipients/representatives are satisfied with the support provided by staff to care recipients in order for them to achieve their optimal mobility and dexterity within and around the home.


2.15 Oral and dental care

This expected outcome requires that “care recipients’ oral and dental health is maintained”.

Team’s findings


Care recipients’ oral and dental history, preferences relating to management of their teeth and dentures and other oral/dental care needs are identified on entry to the home. Care staff monitor care recipients ability to self - manage their oral care and provide assistance as required. A dental and prosthetics service consults to care recipients in the home and care recipients who attend external dental practitioners are provided with support to access these services. Staff receive training in relation to assisting care recipients to manage their oral and dental health. Care recipients are satisfied with the assistance provided by staff in relation to the maintenance of their oral health and dental needs and access to oral care supplies.

2.16 Sensory loss

This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”.

Team’s findings


Information about each care recipient’s care needs in relation to hearing, vision and speech is collected through the initial and ongoing assessment processes. Care interventions reflect identified personal preferences and sensory needs and are linked with other relevant care plans such as hygiene, skin care, behaviour management and leisure activities. Care recipients are referred to specialists including audiologists, optometrists and ophthalmologists as needs indicate and in consultation with the care recipient/representative. Staff provide assistance to care recipients with cleaning and care of sensory aids. Care recipients with identified sensory loss issues are satisfied with the individual management strategies and the assistance provided by care and diversional therapy staff.

2.17 Sleep

This expected outcome requires that “care recipients are able to achieve natural sleep patterns”.

Team’s findings


Information regarding care recipients’ usual sleep patterns including past habits, routines and any aids/rituals that have previously been of assistance to achieve natural sleep is obtained on entry; this information is included in the care recipients’ care plan to guide the provision of care. Night routines maintain an environment that is conducive to sleep and factors that may compromise sleep such as incontinence, pain, excessive light, temperature and noise are identified and addressed to promote sleep. Care recipients are offered warm drinks and/or food and preferred settling and rising times are supported wherever possible. Night time sedation is available as prescribed by the care recipient’s medical officer; however it is used only where non-pharmacological interventions have been ineffective. Care recipients/representatives are satisfied with the support received to establish natural sleep patterns.


Standard 3 – Care recipient lifestyle

Principle: Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve control of their own lives within the care residential care service and in the community.



Team’s findings




A review of the Resident handbook has resulted in a more comprehensive organisational Resident information handbook that is provided to all new care recipients on entry to the home. As a result, new care recipients and their families have an enhanced understanding of care and services available to them from the organisation and at the home.

In response to an organisational initiative, The “Play Up” Program has been introduced at the home. Based on current research, the program incorporates humour as a therapy to reduce agitation and increase positive behaviours in care recipients who may have dementia, who may be self-isolating or depressed. The program has also increased morale by promoting a positive work environment.


This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about care recipient lifestyle”.

Team’s findings


Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to maintain regulatory compliance. The home has systems to ensure compliance with legislation relevant to care recipients’ lifestyle. In relation to this Standard, the home has systems to ensure reportable and non-reportable events are managed according to legislative requirements and organisational procedures.




Team’s findings


Refer to Expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills. In relation to this Standard relevant education includes mandatory reporting, consumer protection, spiritual care, “Play-Up” program and certificate IV in leisure and lifestyle.

3.4 Emotional support

This expected outcome requires that "each care recipient receives support in adjusting to life in the new environment and on an ongoing basis".

Team’s findings


The home provides information and support to care recipients upon entry and on an on-going basis to assist their adjustment to the new environment and as needed after entry to the home. Information is gathered to identify care recipients’ lifestyle preferences, personal history and an assessment of care recipients’ emotional needs is conducted. Information related to their emotional support requirements is shared with relevant staff and additional requirements for support are identified on an on-going basis. Staff and the home’s Chaplain support care recipients who are having difficulty adjusting to their changed circumstances and as critical events occur. Care recipients are given additional assistance to maintain external connections, meet other care recipients within the home, make friendships and participate in the lifestyle of the home at a pace that is suitable to them. Care recipients are satisfied with the support they receive and the care shown by staff.

3.5 Independence

This expected outcome requires that "care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the care residential care service".

Team’s findings


The home supports and assists care recipients to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the home. Care recipients’ preferences and abilities are assessed on entry by registered nurses and the physiotherapist and risks are identified and addressed. Staff assist care recipients to achieve maximum independence, pursue activities of interest, maintain friendships and connections and have an awareness of individual care recipient’s preferences and limitations. Care recipients with special needs are provided with appropriate equipment and support with provision made to access the community for services, appointments or special events.


3.6 Privacy and dignity

This expected outcome requires that "each care recipient’s right to privacy, dignity and confidentiality is recognised and respected".

Team’s findings


Care recipients’ privacy and dignity needs are identified and respected and the preferences of each care recipient are communicated to staff. Staff have an understanding of maintaining care recipients’ privacy, dignity and confidentiality. Staff practice is monitored by senior personnel and staff are required to sign a confidentially agreement on commencement of employment. Staff ensure privacy and respect are provided when recording care recipients’ personal information. Information is stored electronically and computer based files are password protected and hard copy documents are stored in secure locations. Staff are aware of strategies to maintain care recipients’ privacy and dignity when providing care. Privacy and dignity education is provided to staff on commencement of employment and annually thereafter. Care recipients/representatives are satisfied with the level of privacy and respect for dignity provided by staff at the home.

3.7 Leisure interests and activities

This expected outcome requires that "care recipients are encouraged and supported to participate in a wide range of interests and activities of interest to them".

Team’s findings


Care recipients’ social history, leisure interests and lifestyle preferences are identified on entry to the home. Lifestyle staff utilise information from care recipients/representatives to develop activity programs and to stimulate care recipients’ physical, emotional, intellectual, creative, spiritual and social skills. Care recipients are encouraged and supported by staff to participate in a wide range of activities both individually and as a group. Care recipients’ choice not to attend is respected and barriers to participation are managed with appropriate strategies. Lifestyle staff develop a monthly activity calendar and this is distributed to care recipients, displayed on noticeboards, included in the home’s regular newsletter and in the new care recipient information pack. The activity program complements other care needs by including activities such as walking and other exercises programs in consultation with the physiotherapist. Care recipients participate in the development of a variety of group activities and provide feedback individually and in meetings resulting in adjustment of the program.

Lifestyle care plans are reviewed three monthly by the registered nurse with input from the lifestyle staff. Care recipients/representatives have a range of activity opportunities of interest to them and are satisfied with the support provided by the staff.


3.8 Cultural and spiritual life

This expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".

Team’s findings


Care recipients’ cultural and spiritual needs and preferences are identified and information is communicated to staff to ensure these preferences are reflected in the delivery of care, leisure pursuits and in the provision of meals and beverages. The home recognises and celebrates a variety of traditional and religious events throughout the year consistent with care recipients’ preferences and care recipients are assisted to attend. A Chaplain conducts regular religious services and care recipients are supported to attend services of their preference within or outside the home. The Chaplain is also available for private meetings with care recipients and families/representatives as requested and when critical events occur. Care recipients are satisfied their cultural and spiritual needs are respected and staff assist them to maintain their choices and traditions in accordance with their preferences.

3.9 Choice and decision-making

This expected outcome requires that "each care recipient (or his or her representative) participates in decisions about the services the care recipient receives, and is enabled to exercise choice and control over his or her lifestyle while not infringing on the rights of other people".

Team’s findings


The home encourages care recipients to participate in decisions about the services and care they receive and exercise choice regarding their lifestyle preferences. Registered nurses conduct an assessment as needed to ensure care and service needs are understood by care recipients. Care recipients give consent as required for procedures and processes such as displaying their photograph in documents or in a public area. Assessment tools are in place to assist the registered nurse to assess a care recipient’s capacity to make choices and decisions as needed and appropriate referrals are made as required. Care recipients’ preferences for care, lifestyle and routines are identified on entry and reviewed on a regular basis. Care recipients’ enduring power of attorney or information about alternative decision- makers is requested on entry and as needed and this information is then made available to relevant staff. Care recipients have opportunity to express their preferences through daily interactions with staff, care recipient meetings and comments and complaints process. Staff provide opportunities for choice and utilise strategies to incorporate choice into care recipients’ daily care routines and leisure interests. Care recipients/representatives are aware of their rights and responsibilities, have access to information about internal and external complaints processes and are satisfied with their ability to be involved with decision making.


3.10 Care recipient security of tenure and responsibilities

This expected outcome requires that "care recipients have secure tenure within the care residential care service, and understand their rights and responsibilities".

Team’s findings


Care recipients have security of tenure and understand their rights and responsibilities. The Charter of Residents Rights and Responsibilities is provided in the resident agreement/contract. There are organisational processes to provide information to care recipients/representatives in regard to security of tenure and their rights and responsibilities through agreements/contracts, posters, handbooks and other correspondence. Care recipients are also provided with information regarding specified care and services, the terms and conditions of their tenure, care and services available to them, fees and charges and information about advocacy and dispute resolution services. Care recipients/representatives are consulted should any changes in care recipients’ care needs necessitate a room transfer or transfer to an alternative home. Care recipients/representatives are aware of their rights and responsibilities and are satisfied that their tenure at the home is secure.


Standard 4 – Physical environment and safe systems

Principle: Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



Team’s findings




A comprehensive disaster management plan has been developed by senior organisational personnel and this plan has been implemented at the home. This plan has been trialled in simulation scenarios and used in actual critical events. Critical events such as, but not limited to, fire, floods, pandemic and security threats are included. Utilisation of this disaster plan has resulted in positive outcomes for everyone at the home.

Subsequent to input from care recipients and staff, the dining room was recently refurbished. New furniture was purchased, the walls and ceiling were painted, new lighting was installed and an adjoining lounge area was equipped with a new television and furniture. As a result, the number of care recipients attending meals in the newly refurbished dining room has increased and care recipients and their families use this space for social occasions.


This expected outcome requires that “the organisation’s management has systems in place to identify and ensure compliance with all relevant legislation, regulatory requirements, professional standards and guidelines, about physical environment and safe systems”.

Team’s findings


Refer to Expected outcome 1.2 Regulatory compliance for information about the home’s systems and processes to maintain regulatory compliance. The home has systems to ensure compliance with legislation relevant to the physical environment and safe systems. In relation to this Standard, the home has a food safety program and processes for monitoring occupational health and safety requirements and fire safety.




Team’s findings


Refer to Expected outcome 1.3 Education and staff development for information about the home’s systems and processes to maintain staff knowledge and skills. In relation to this Standard relevant education includes infection control, manual handling, safe work procedures, incident investigation, use of chair scales and hoist, food safety, correct use of personal protective equipment, chemical safety, occupational health and safety and fire safety.

4.4 Living environment

This expected outcome requires that "management of the care residential care service is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs".

Team’s findings


The home has policies, processes, flowcharts and education to ensure the environment is maintained in a safe and comfortable manner consistent with care recipients’ needs. Care recipients are encouraged to personalise their rooms; and dining and lounge areas are furnished to provide a home like environment to support care recipients’ lifestyle needs.

Monitoring processes include audits and visual inspections of the environment and equipment and the reporting and investigation of incidents and hazards. Incidents reported by anyone at the home are logged, investigated and corrective actions are discussed with relevant staff. Where the need for restraint has been identified, assessment and authorisation is documented and monitoring is undertaken. Delegated staff and external providers maintain the environment via programmed routine and preventative maintenance and cleaning processes. Care recipients/representatives are satisfied the home ensures a safe and comfortable environment according to the care recipients’ needs and preferences.

4.5 Occupational health and safety

This expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".

Team’s findings


The home is actively working to provide a safe working environment that meets regulatory requirements through its policies, procedures, monitoring mechanisms, maintenance, observation of staff practice and education processes. The home has access to an organisational occupational health and safety (OHS) officer and two OHS representatives are available at the home; OHS issues are discussed at relevant staff meetings. Monitoring systems include audits, identification and actioning of hazards and investigation of incident data. Identified deficits are discussed and actions are taken to minimise the risk of potential and actual hazards related to the physical environment, chemicals, equipment and infection.


Education processes include completion of identified competencies. Forms concerning safe work practices and reporting mechanisms to maintain a safe environment are available to staff electronically and from key personnel. Staff are aware of the process to report maintenance issues, hazards and incidents and the safe use of chemicals.

4.6 Fire, security and other emergencies

This expected outcome requires that "management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks".

Team’s findings


Fire, security and safety systems are maintained through policies, procedures, programmed maintenance by qualified personnel and education processes. Monitoring processes include audits and visual inspections for the identification and reporting of risk, potential and actual hazards related to fire, security and other emergencies. Education processes include information that is provided at orientation and annually or as needed thereafter relating to emergency and disaster procedures and safety and security processes. Care recipients/representatives and staff are satisfied with the safety and security of the physical environment.

4.7 Infection control

This expected outcome requires that there is "an effective infection control program".

Team’s findings


The home demonstrates an effective organisational infection control program that is supported by audits and monitoring of staff practice. Infection control issues are monitored by organisational personnel, a registered nurse monitors and analyses infection data monthly and infection control is discussed at staff meetings. Infection control education is provided to staff at orientation and annually or as needed thereafter. Prevention and monitoring strategies include actions such as education, hand washing/sanitising facilities, surveillance of the environment by senior staff, conducting audits, data analysis by senior nurses, discussion of trends at staff meetings, waste disposal processes, accessible stocks of personal protective equipment, coloured coded equipment, cleaning and laundry practices and equipment and supplies to manage outbreaks and spills. A vaccination program is in place for care recipients based on consent and staff are encouraged to be vaccinated. An organisational pest control program is in place. Sharps containers are available and clinical waste is monitored by senior staff. A food safety program is in place, there are processes to manage infection control in the laundry and cleaning schedules and infection control strategies are in place for the kitchen, laundry and the home’s common areas and care recipients’ rooms. Care recipients/representatives are satisfied with infection control management at the home.


4.8 Catering, cleaning and laundry services

This expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".

Team’s findings


Processes are in place for the provision of catering, cleaning and laundry services that enhance care recipients’ quality of life. Meals are cooked fresh at the home and meet care recipients’ identified dietary needs and preferences. The home has a seasonal, four week rotating menu and care recipients may choose alternatives to the main meals. The menu is a standard organisational menu that is reviewed by a dietitian. Meals and beverages are provided at set times and supper is also available as required. Staff follow food safety protocols, have access to the home’s food safety program and staff have access to a food safety supervisor as needed. Kitchen and general cleaning schedules and coloured coded catering, cleaning and laundry equipment and procedures are available to minimise infection risks. Care recipients’ personal laundry and linen is managed at the home five days a week. There are processes to ensure sufficiency of linen and recovery of lost personal clothing items. Management monitor the quality of catering, cleaning and laundry services through observation by senior personnel and through the home’s quality system including care recipient feedback and audits. Care recipients/representatives are satisfied with catering, cleaning and laundry services provided by the home.

blue care tweed heads amaroo aged care facility · blue care tweed heads amaroo aged care facility...

Documents