marten residential care centre - quality agency · 4.7 infection control met 4.8 catering, cleaning...

Marten Residential Care Centre

RACS ID 6964 110 Strathfield Terrace

LARGS NORTH SA 5016

Approved provider: Allity Pty Ltd

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 10 June 2018.

We made our decision on 21 April 2015.

The audit was conducted on 10 March 2015 to 12 March 2015. The assessment team’s report is attached.

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

Home name: Marten Residential Care Centre RACS ID: 6964 2 Dates of audit: 10 March 2015 to 12 March 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

Marten Residential Care Centre 6964


Introduction

This is the report of a re-accreditation audit from 10 March 2015 to 12 March 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 10 March 2015 to 12 March 2015.

The audit was conducted in accordance with the Quality Agency Principles 2013 and the Accountability Principles 2014. The assessment team consisted of three 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: Sandra Lloyd-Davies

Team members: Joanne Glaze

Catherine Wohling

Approved provider details


Details of home

Name of home: Marten Residential Care Centre

RACS ID: 6964

Total number of allocated places:

123

Number of care recipients during audit:

113

Number of care recipients receiving high care during audit:

99

Special needs catered for: People with dementia or related disorders

Street: 110 Strathfield Terrace

City: LARGS NORTH

State: SA

Postcode: 5016

Phone number: 08 8248 9555

Facsimile: 08 8248 9500

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

Corporate and site management 5

Clinical and care staff 12

Lifestyle staff 2

Care recipients/representatives 15

Ancillary staff 5

Quality and administration staff 1

Sampled documents

Category Number

Care recipients’ files 4

Summary/quick reference care plans 11

Medication charts 6

Electronic care plans and progress notes 12

Other documents reviewed

The team also reviewed:

Activities attendance records

Activities calendar

Cleaning schedules

Compulsory reporting registers

Corrective and preventive maintenance records

Diaries

Dietary preference records

Drugs of dependence register

Duty statements

Emergency care recipient list


External contractor register

Feedback forms

Food safety plan and audit report

Gastroenteritis notifications, monitoring and action plan

Handover records

Hazard register

Incident reports

Knowing our residents documentation

Memoranda

Menu

Outbreak resource kits

Police certificate register

Resident handbook

Resident information package

Restraint documentation

Schedule 4 and 8 Licence

Staff allocation records

Staff education attendance records

Staff education register

Staff information pack

Temperature monitoring records

Various audits and surveys

Various flowcharts

Various meeting minutes

Various monitoring charts

Various policies and procedures

Volunteer training program

Work area inspection schedule and checklists


Wound folder

Observations

The team observed the following:

Activities in progress

Administration of medications

Advocacy brochures

Cleaning in progress

Equipment and supply storage areas

Evacuation maps

Fire prevention equipment

First aid boxes

Interactions between staff and care recipients

Living environment

Meal service

Outbreak kit

Short group observation in lounge area

Storage of medications


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 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

Marten residential care centre is owned and operated by Allity Aged Care Pty Ltd. The home identifies improvement opportunities from feedback forms, care recipient forum meetings, audits, surveys, staff suggestions and verbal feedback. Identified improvements are recorded on a plan for continuous improvement spreadsheet and progress is monitored by the staff services coordinator. Suggestions are discussed at regular leadership meetings. Delegated staff are responsible for actions and meeting timelines generated from continuous improvement activities. Care recipients, representatives and staff interviewed are satisfied the home acts upon their suggestions.

Examples of improvement initiatives implemented by the home over the past 12 months in relation to Standard 1 Management systems, staffing and organisational development include:

Following a care recipient survey, management identified an opportunity to improve communication with care recipients. A monthly newsletter has been developed to inform care recipients of activities in the home. Staff deliver the newsletter to care recipients’ rooms. Care recipients were asked to provide feedback about the newsletter at lifestyle activity sessions. Feedback from care recipients has been positive stating they enjoy reading the newsletter and are kept up-to-date.

In response to a care recipient survey and information obtained from an external course, an opportunity to improve communication was identified. A quality improvement noticeboard has been developed to inform staff, care recipients and representatives of continuous improvement activities. The quality improvement board is brightly coloured and has been placed in a corridor for easy access. Activities relating to all four Accreditation Standards are included on the board. Care recipient feedback has been positive saying the board is very visible and informative.


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 organisation has systems and processes to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. The general manager ensures legislative updates received from corporate office are distributed to relevant staff. Information is disseminated to staff via memoranda, noticeboards and email.

Compliance is monitored through internal and external audits. Results show audits are effective in identifying compliance issues and actions are implemented as required. Staff interviewed said they are updated about changes.

Examples of how the home ensures compliance in relation to Standard 1 Management systems, staffing and organisational development include:

Notification in writing of re-accreditation audit sent to care recipients and representatives

Police certificates are current for staff, external contractors and volunteers

Policies and procedures are updated to reflect legislative and regulatory requirements

Professional registrations are monitored for clinical and allied health staff.


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


The home has processes to ensure management and staff have appropriate knowledge and skills to perform their roles effectively. Education needs are identified through the annual professional development program, audits, meetings and observation of staff practice. An education and staff development program schedules training throughout the year.

Commencing employees undertake mandatory training as part of the induction process. Attendance records are used to monitor staff attendance at mandatory education and reminders are sent by letter and text messages. Staff are encouraged to complete self- directed learning packages through a reward and recognition program. Results show the home provides relevant education across the Accreditation Standards. Staff interviewed said they have access to a range of education sessions.

Examples of education conducted over the past 12 months in relation to Standard 1 Management systems, staffing and organisation development include:

Customer service

Induction

Information technology

Quality and continuous improvement

Self-directed learning packages.

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


Care recipients, representatives and other interested parties have access to internal and external complaints mechanisms. On entry to the home care recipients and/or representatives are provided with information about internal and external complaints mechanisms, including information in the resident handbook and information pack. Feedback forms and information about complaints mechanisms are displayed around the home.

Feedback boxes are available for confidential lodgement of comments or complaints. Complaints are logged on a comments and complaints register and monitored by the general manager. Verbal complaints are documented and monitored by management. Results show care recipients and representatives are aware of internal and external complaints mechanisms. Staff interviewed are aware of the comments and complaints system and feel supported in raising concerns with management. Care recipients and representatives interviewed are satisfied that concerns they raise are managed effectively.


1.5 Planning and leadership

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

Team’s findings


The organisation’s values, vision and model of care are documented in the resident handbook and welcome packs. Documentation containing the home’s values has consistent content. The general manager is responsible to the Chief executive officer who is supported by a senior leadership team. Results show the home’s values, vision and purpose are displayed in the home. Staff are familiar with the home’s values, philosophy of care and commitment to quality care and services.

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 residential care service’s philosophy and objectives".

Team’s findings


The home has processes to ensure there are sufficient numbers of appropriately skilled and qualified staff to deliver care and services. The organisation has recruitment processes to ensure potential employees have appropriate skills and qualifications. Corporate and site processes monitor police certificates and professional registrations. Commencing employees attend an induction program. The home’s management monitors staffing levels and skill mix through staff feedback and care recipients’ needs on an ongoing basis. Vacant shifts are filled by permanent or casual staff, staff from a sister-site or agency as required. Staff are guided in their roles by job descriptions, duty statements, guidelines and policies and procedures. Results show reminder letters are effective in managing staff police certificates to ensure currency. Staff interviewed said they have sufficient time to complete their tasks.

Care recipients and representatives interviewed are satisfied that staff have the appropriate skills to deliver care and services.

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


The home has a system for identifying and monitoring goods and equipment required for providing a quality service for care recipients and staff. The home uses corrective and preventive maintenance processes and external contractors to monitor plant and equipment. Re-ordering and re-stocking of supplies are delegated to relevant staff from various areas within the home. New equipment is trialled prior to purchase. Monitoring processes include observation and feedback from staff. Results show stock levels of goods and equipment are


reviewed and maintained. Staff, care recipients and representatives interviewed said they are satisfied there are adequate and appropriate stocks of goods and equipment for the delivery of quality care and services.

1.8 Information systems

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

Team’s findings


There are information systems to provide management and staff with access to sufficient, accurate and appropriate information to enable them to meet the requirements of their roles. Secure storage and the archiving of care recipient and staff information and records occur. There are electronic communication systems to inform staff of changes to care recipient care plans and needs, and the operations of the home. The reporting, distribution of information, and addressing of issues occurs through a range of care recipient, staff, safety and quality meetings. Work instructions guide staff practice and are available via the organisation’s intranet. Staff said they have access to sufficient information to perform their roles. Results show information is used effectively to communicate with relevant stakeholders. Care recipients and representatives are satisfied they have sufficient access to information to assist them to make decisions about their care and lifestyle needs on an ongoing basis.

1.9 External services

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

Team’s findings


The home uses externally sourced services to assist in meeting the residential care service’s needs and service quality goals. The management of external contracts is overseen by corporate office with day-to-day management delegated to the business services manager. The home has agreements with external contractors in relation to allied health services, linen, pest control, fire safety and pharmacy. Monitoring processes include staff feedback, service reports and observation. Results show external contractors are documented on a contractor register and meet the home’s service quality goals. Service providers are changed if considered unsatisfactory. Staff, care recipients and representatives interviewed said they are satisfied with the external services provided.


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.

In relation to Standard 2 Health and personal care, the home identifies improvements from care recipients, representatives and staff feedback. Other sources of feedback include, comments and complaints, audits, incidents and care reviews. Care recipient incidents are monitored, including falls, wounds, infections, behaviours and medication errors. Care recipients, representatives and staff are satisfied the home supports them to provide feedback and suggestions.

Examples of improvement activities and achievements relating to Standard 2 Health and personal care include:

Following consultation with the clinical advisor, management identified an opportunity to improve the management of challenging behaviours. Input from external service providers was sought. Meaningful activities have been implemented in the memory support unit. The activities include baby doll therapy and a rest period between 1.30 and 3.00pm for care recipients has been introduced. Representatives were informed by letter of changes in the unit. Care staff shifts have been modified to provide better coverage across the day. Representative and staff feedback has been positive stating care recipients are more settled and are sleeping better.

In response to feedback from a care recipient/representative forum meeting, an opportunity to improve health and personal care was identified. Shift times have been changed and the roster reviewed to accommodate a 15 minute handover for the afternoon shift. One registered nurse obtains information from each area of the home and hands over to all staff in a formal handover. Staff were advised of the changes by memorandum. Staff feedback has been positive stating the new process is working well resulting in a better exchange of information and continuity of care.



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 regulatory compliance systems and processes.

Examples of how the home ensures compliance in relation to Standard 2 Health and personal care include:

Care recipients assessed by appropriately qualified and skilled staff

Medication is stored safely and securely

Register for the reporting of absconding care recipients

Schedule 4 and 8 drug licence.

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 education and staff development systems and processes.

Examples of education conducted over the past 12 months in relation to Standard 2 Health and personal care include:

Continence management

Medication competencies

Minimising the risk of falls

Pain management

Safe swallowing

Wound management.


2.4 Clinical care

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

Team’s findings


Care recipients receive clinical care that is appropriate to their individual needs and preferences. There is an ongoing review and evaluation system for identifying and managing care recipients’ clinical care needs. Processes include care recipients who have an interim care plan on entry to the home followed by a clinical care assessment. This information is used to develop individual care plans in consultation with care recipients and their representatives. Care plans are maintained in the home’s electronic care system and through hard copy care plans. The home monitors care recipients’ clinical care outcomes through four monthly reviews of care plans, monthly ‘head to toe’ assessments, clinical incidents and auditing of reporting processes. Changes to clinical needs are communicated to staff through verbal/written clinical handovers, diaries and progress notes. Immediate changes to clinical needs are also provided through the use of the electronic care system. Results show care recipients’ needs are documented and reviewed and that care is consistently provided to meet the individual needs of care recipients. Information provided by staff was consistent with care recipients’ care plans. Care recipients and representatives are satisfied with the level of consultation and that appropriate clinical and personal care is provided to care recipients.

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 receive specialised nursing care from qualified nursing staff that is appropriate to their identified needs and preferences. The home assesses and reviews specialised nursing needs for care recipients’ through consultation with health specialists, allied health staff, medical officers, clinical service advisors, care recipients and representatives. Specialised care needs are documented in care plans, treatment and medication charts. Care is provided as per these documented requirements. Specialised nursing care needs are monitored through the home’s audit process, reporting and evaluations, regular care reviews, clinical surveillance data and informal feedback through the handover process. Observation showed and staff confirmed they have access to appropriate specialised equipment, education, guidelines and clinical practice manuals.

Results show that specialised nursing care needs are identified and met by appropriately qualified staff. Care recipients and representatives are satisfied with the specialised care provided to care recipients.


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 health specialists according to their assessed needs and preferences. Specialist health referrals are identified through care reviews, consultation and observations. Allied health services are provided on-site and assessments are completed on entry to the home and on an ongoing basis. Referrals to a variety of health services, including podiatry, speech pathology, dietitians and extended care paramedics are made as required. Changes to care needs are communicated and documented through the electronic care system that is immediately available in progress notes and care plans are updated to reflect these changes. Monitoring processes include audits, care reviews and consultation with care recipients and representatives. Results show that care recipients are referred to appropriate health specialists and needs are documented and reviewed. Staff said they have access to current information from health specialists. Care recipients said they are satisfied they have access to health specialists according to their individual needs and preferences.

2.7 Medication management

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

Team’s findings


Medication is managed safely and correctly in accordance with relevant legislation, regulatory requirements and professional standards and guidelines. Care recipients’ medication needs are identified on entry to the home and on an ongoing basis. Care recipients who self-administer medication are assessed and monitored for safety. Each care recipient has a medication chart with personal details and administration instructions.

Medication is stored safely and securely in pre-packaged sachets, blister packs and administered by registered and enrolled nurses. Monitoring processes include care reviews, incident reporting, internal and pharmacy audits. Medication issues are discussed at medication advisory meetings. Results show that care recipients’ medications are documented and reviewed. Education records and interviews confirm staff undertake training in relation to medication and are provided with medication information. Care recipients said they are satisfied with the level of consultation and management of their medication.

2.8 Pain management

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

Team’s findings


The home has systems to ensure all care recipients are as free as possible from pain. Care recipients are consulted and assessments conducted by registered staff to identify any issues and care requirements in relation to pain. Assessments are reviewed by medical and allied


health staff and where required referrals are made to pain specialists. Treatment plans are developed; medication charts and treatment directives assist staff in relation to care requirements and treatment needs. Further interventions include positional changes, analgesia orders and massage. Pain interventions are monitored by nursing and allied health staff through audits, regular care reviews, observation and feedback from staff, care recipients and representatives. Results show staff undertake training and are aware of strategies to assist with pain management. Care recipients said they are satisfied that pain issues are managed effectively.

2.9 Palliative care

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

Team’s findings


Care recipients receive appropriate palliative care that maintains their comfort and dignity during the end stage of life. The home has processes to capture individual palliative care wishes and a ‘health and end of life’ care plan is created and reviewed as required. Care recipients are consulted regarding particular preferences to aid comfort and care. The home assists representatives to maintain their comfort and provision of hospitality services is available as required. Consultation occurs with external palliative care services to assist with pain management and pastoral care is arranged according to individual preferences. The home offers continued emotional support to families and staff after a care recipient has passed away. Monitoring of palliative care processes is conducted through observation, consultation with care recipients and representatives, through staff feedback processes, review and evaluation. Results show care recipients’ end-of-life wishes are documented and implemented as required. Staff education is available relating to palliative care and staff are aware of care recipients care needs in relation to palliative care. Complimentary written feedback from representatives expressed satisfaction with the home’s approach to the care provided for terminally ill care recipients.


2.10 Nutrition and hydration

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

Team’s findings


There are systems to ensure care recipients receive adequate nourishment and hydration. Dietary preferences and needs are assessed in consultation with the care recipient and representatives. Nutrition and hydration assessments identify care recipients at risk and nutrition care plans include monitoring guidelines, strategies, supplements, aids and assistance. Fluid intake is monitored and support provided to increase intake as required. Allied health professional referrals are arranged and consultation with the medical officer takes place. Monitoring of care recipients nutritional requirements takes place through regular weight monitoring, observation and clinical and care reviews. Care recipients have the opportunity to comment on the meal service at meetings and on an individual basis.

Training is available for staff in supporting nutrition and hydration. Care and nursing staff provide information consistent with care recipients’ nutrition and hydration care plans.

Results show care recipients receive adequate nourishment and hydration and that needs are documented and reviewed. Clinical staff interviewed said they update care recipients’ nutrition and hydration care plans and communicate changes to kitchen staff. Care recipients are satisfied with nourishment and hydration provided to support their individual needs.

2.11 Skin care

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

Team’s findings


There are systems to ensure care recipients are provided with assistance to maintain their skin integrity. Documentation demonstrates that skin care assessments are initiated on entry and skin integrity is monitored on an ongoing basis. Care recipients at risk are identified and plans include strategies to ensure adequate nutrition, change of position to relieve pressure, use of specialised equipment, skin protection and moisturising. Wound assessment and planning is conducted by registered nurses and healing rates are monitored. Daily care plans include nail and hand care, podiatry and hairdressing services attend the home. Monitoring occurs through documented monthly ‘head to toe’ checks, skin tear reporting, care review meetings and audit processes. Results show that skin integrity management is regularly reviewed and evaluated. Observation and staff interviews confirmed there are sufficient supplies and equipment for the provision of skin care and appropriate staff are trained in wound care. Care recipients said they are satisfied with the care provided to maintain their skin integrity.


2.12 Continence management

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

Team’s findings


There are systems to ensure care recipients continence is managed effectively. Continence assessment processes identify care recipients’ normal patterns, support needs and required aids. Staff interviews and documentation confirm assessment processes include voiding frequency and identification of care recipients’ individual needs and preferences.

Management of care recipients’ continence is supported by the services of an external continence service and dedicated continence staff members monitor and administer the system. The home follows dietary strategies to support natural bowel patterns. Data on infections that may affect continence is collected, analysed and appropriate actions taken. Education is provided to staff in relation to continence management. Results show that care recipients’ needs are documented and reviewed. Information provided by staff is consistent with care recipients’ documented continence needs and preferences. Care recipients are satisfied their continence needs are being met.

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 identified with challenging behaviours are managed effectively according to their individual needs and preferences. Initial and ongoing care plans are developed in consultation with care recipients and representatives. The home refers to clinical services advisors and a range of external professionals as required. Diversional techniques and individual strategies are identified and implemented. The effectiveness of behaviour management strategies are monitored through incident reporting, care plan reviews, audits and observations. Results show that care recipients’ behaviours are documented and reviewed. Interviews and observations confirm staff understand documented strategies to assist with the management of challenging behaviours and that opportunities for training in relation to behaviour management are available. Care recipients said they are satisfied with the home’s approach to behavioural management.

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 systems to assist care recipients to achieve optimum levels of mobility and dexterity. Assessments are completed by registered nurses and allied health staff to capture individual needs in relation to mobility requirements and assistance required to enhance dexterity. Individualised mobility, exercise and transfer plans are developed; these include


assistance and mobility aids. Suitable assistive aids are provided including equipment to promote safety, such as hip protectors whilst supporting mobility. The home provides a range of movement exercise programs to assist care recipients to optimise mobility and dexterity.

Falls are monitored and analysed for trends. Any immediate change to care recipients’ mobility status is documented in the care system. Monitoring occurs through regular care reviews, reassessment by allied health professionals, audits and observation. Results show that care recipients’ needs are documented and reviewed, and that staff provide care consistent with documented care plans. Staff attend manual handling training and observations confirmed staff members’ understanding of individual care recipient’s mobility needs. Care recipients are satisfied their mobility and dexterity needs are maximised.

2.15 Oral and dental care

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

Team’s findings


The home has systems to maintain care recipients’ oral and dental health. Oral health assessments are completed on entry and on an ongoing basis to identify individual oral and dental care needs. Care plans provide individualised oral and dental hygiene strategies. Care recipients are provided with options and support to access dental services of their choice.

Oral equipment is replaced seasonally or earlier and monitored by care staff. Monitoring of care recipients’ oral care is completed through staff observations, regular care plan reviews, audits and feedback from dental specialists. Results show that care recipients’ oral and dental care is documented and reviewed. Staff undertake education in oral hygiene and are aware of strategies to support care recipients’ oral and dental health. Care recipients are satisfied their oral and dental health is maintained.

2.16 Sensory loss

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

Team’s findings


The home has systems to ensure care recipients sensory losses are identified and managed effectively and assessment processes capture care needs in relation to all five senses. Care plans identify strategies and aids to support and improve care recipients’ sensory loss. The home provides a range of activities and devices to enhance sensory enjoyment such as large print books, cooking activities and sensory blankets. Monitoring occurs through regular care reviews, feedback mechanisms and observation. Staff consult and assist with care recipients and representatives regarding referral to the audiologist and optometrist. Results show that care recipient’s sensory needs are documented and reviewed. Staff are aware of care recipients’ sensory care needs. Care recipients are satisfied with the home’s approach to managing their sensory loss.


2.17 Sleep

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

Team’s findings


Care recipients are provided with care to assist them achieve natural sleep patterns. Initial and ongoing assessments and review processes identify and monitor sleep and this information is used to develop individualised care strategies including preferred rising and retiring times. Environmental and other preferences including repositioning, snacks and warm drinks are offered to support natural sleep patterns. Monitoring processes include care plan reviews, incident reporting, observations and audits. Results show that care recipients’ sleep patterns are documented and reviewed. Staff confirm they refer to care recipients’ care plans for individual sleep preferences. Care recipients said they are satisfied the care provided assists them to achieve 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 residential care service and in the community.



Team’s findings


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

In relation to Standard 3 Care recipient lifestyle, the home identifies improvements from activity evaluations, care recipient forum meetings, surveys and comments and complaints processes. Staff encourage and support care recipients and representatives to provide feedback and suggestions. Care recipients, representatives and staff interviewed are satisfied the home supports them to provide feedback and suggestions.

Examples of improvement activities and achievements relating to Standard 3 Care recipient lifestyle include:

In response to feedback from a care recipient survey, an opportunity was identified to improve the exercise program for care recipients with mobility deficits. Chair tai chi was trialled as a new activity. A staff member has been trained in the delivery of the program. Care recipient feedback has been positive stating they feel more relaxed and the breathing techniques are being used by some to aid sleep at night. The success of this activity has resulted in it being included as a regular activity on the lifestyle calendar.

In response to a care recipient incident, the lifestyle coordinator identified an opportunity to improve staff knowledge of care recipients in the home. The lifestyle coordinator attended a spirituality and health conference and developed a ‘knowing our residents’ folder. Care recipient consent was obtained prior to commencing the initiative. Those care recipients who wished to participate were interviewed by a select member of the lifestyle team and asked to respond to two questions. The care recipients’ responses have been documented and are kept in folders in respective wings of the home. Staff feedback has been positive stating the stories are beautiful and heart-warming. Staff have also said this initiative has provided them with greater insight into the lives of care recipients and what is important to them.



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 regulatory compliance systems and processes.

Examples of how the home ensures compliance in relation to Standard 3 Care recipient lifestyle include:

Advance directives documented

Privacy and consent information

Register for reporting allegations of elder abuse

Residential services agreements.



Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes.

Examples of education conducted over the past 12 months in relation to Standard 3 Care recipient lifestyle include:

Dementia: meaningful activities

Elder abuse

Emotional wellbeing

Lifestyle model of care.


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


Care recipients are supported in adjusting to the home on admission and on an ongoing basis. The home has a process of identifying, assessing and monitoring care recipients’ emotional needs. A buddy system ensures new care recipients have support from care staff during the transition process into the home and this provides one-to-one care and emotional support. A referral process is in place for allied health and care recipients have access to general practitioners and pastoral care. Representatives are encouraged to visit and participate in activities. The home evaluates the effectiveness of emotional support provided through comments and complaints processes, lifestyle and care reviews and audits. The home monitors the effectiveness of emotional support through surveys, observation and consultation. Results show care recipients are satisfied with the emotional support they receive. Staff are given education relating to specific illnesses to improve their understanding of the person to help meet emotional needs. Care recipients and representatives said they are satisfied with the level of emotional support being provided by the home.

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 residential care service".

Team’s findings


Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community, within and outside the home. Care assessments are conducted to identify care recipients’ existing abilities to remain independent with everyday living activities. This takes into account choices regarding assistance with care that is provided. Care plans are developed to include social activities care recipients wish to take part in, within the home and in the community. Independence is encouraged through attending external appointments and participating in activities that are meaningful to the individual care recipient. Monitoring of care recipient independence is through allied health review, observations and care plan review. Results show care plans are reviewed and changes made to reflect the level of independence as care recipients’ needs change. Staff interviewed described strategies to support individual care recipient’s independence and this is reflected in care plans. Care recipients and representatives said they are satisfied the home assists their independence according to preferences and needs.


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


The home has processes to ensure care recipients’ right to privacy, dignity and confidentiality is recognised and respected. The home has a structured approach to identifying, assessing and monitoring each care recipient’s privacy and dignity needs and preferences. The home maintains processes to protect care recipients’ privacy and dignity, including consent to collect and disclose information and the secure storage of information. Care recipients are informed of their privacy rights through the resident handbook and residential services agreement. Monitoring processes include feedback mechanisms, resident meetings, surveys, audits, written and verbal feedback. Results show privacy and confidentiality is recognised and respected. Staff interviewed described appropriate practices such as knocking before entering a room and the use of signage to provide privacy. Care recipients and representatives said they were treated with respect and dignity and made to feel welcome and, that staff were courteous and respectful of care recipients privacy, needs and preferences.

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


The home has a process in identifying, assessing, monitoring and communicating each care recipient’s individual interests and activities, which includes aspects of their lifestyle they wish to continue. In home activity attendance records, surveys and feedback contribute to the overall monitoring processes. The lifestyle assessment is reviewed regularly to take into account care recipients’ changing lifestyle requirements. The activities calendar is communicated through a variety of pathways including newsletters, noticeboards and weekly individual activity planners. Staff facilitate external activities and holidays on an individual basis. Results show that leisure interests and activities are documented and reviewed. Staff interviewed said they have access to information about each care recipient’s leisure and lifestyle preferences and they assist care recipients to attend activities as required. Care recipients and representatives interviewed said they are satisfied with the variety of activities offered and the support provided by 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 individual interests, customs, beliefs, cultural and ethnic background is acknowledged and supported. Assessment processes assist to collect information of spiritual


and cultural beliefs and social history on admission to the home. Language specific resources are available to support staff in communicating with individual care recipients.

Care recipients are encouraged to maintain their spiritual and cultural needs through visits from family, friends and community. There are a number of denomination services offered in the home and staff interviewed said care recipients are assisted to attend religious services. Cultural events are celebrated in conjunction with the lifestyle program and care recipients’ preferences. Results show care recipients attend cultural and spiritual activities of importance to them and are consistent with documented plans of care. Staff interviewed are aware of care recipients’ cultural and spiritual needs which affect the provision of care and lifestyle. Care recipients and representatives interviewed said they are satisfied that the home meets their cultural and spiritual needs and 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


Care recipients and representatives are actively involved in decisions and choices relating to their care and lifestyle options. Assessment and admission processes assist the home to identify each care recipients’ preferred needs, authorised representatives and contacts. Care recipients have the opportunity to express their individual wishes through resident forums, surveys, feedback forms and communication with staff members. Care plans outline care recipients’ preferred preferences including preferred name, activities of daily living, meals, drinks and sleep. Information outlining residents’ rights and responsibilities is included in the residential agreement, resident handbook and displayed in the home. The home monitors their processes in relation to choice and decision making through care plan reviews, audits, care recipient and representative feedback. Results show care recipients’ preferences are documented and reviewed. Staff interviewed described their responsibility in providing opportunities for care recipients to make choices about the care and services they receive.

Care recipients and representatives are satisfied with the consultation process that supports care recipients’ choice and decisions.

3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


Care recipients have secure tenure within the home and are assisted to understand their rights and responsibilities. Care recipients and/or representatives are informed of their security of tenure and resident rights and responsibilities on entry to the home. They are provided with a resident handbook, information pack and residential services agreement. Care recipient and representative satisfaction is monitored through meetings, complaints processes and verbal feedback to staff and management. Information regarding independent sources of advice and advocacy are available within the home. Requests to change rooms are considered by


management and implemented where appropriate in consultation with care recipients and representatives. Staff are aware of care recipients’ rights and responsibilities. Care recipients and representatives interviewed are satisfied their tenure is secure and the home supports their individual needs and preferences where possible.


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


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

In relation to Standard 4 Physical environment and safe systems, the home monitors the safety and comfort of the home through work area inspections, incident and hazard reports, comments and complaints processes, maintenance records and audits. Care recipients, representatives and staff interviewed are satisfied the home supports them to provide feedback and suggestions.

Examples of improvement activities and achievements relating to Standard 4 Physical environment and safe systems include:

Following feedback from an external audit, management identified an opportunity to improve care recipients’ dining experience. One day per week a member of the management team has a meal with the care recipients. A schedule has been developed for management. This has provided management with an additional opportunity to obtain feedback from care recipients in relation to the meal service. Any issues raised are discussed with relevant staff and the hospitality coordinator. Care recipient feedback has been positive, stating they enjoy having a member of the management team share a meal with them.

As a result of management sharing meals with care recipients, an opportunity was identified to improve the dining experience. The printed menus placed on the tables were too small for care recipients to read easily. The layout of the menu has been reviewed and to improve how the menu is displayed, a three way menu holder was introduced. This is also used to highlight upcoming events. A memorandum was sent to staff, volunteers, representatives and visitors informing them of this initiative. Feedback from care recipients has been positive stating the menu is easier to read.



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 regulatory compliance systems and processes.

Examples of how the home ensures compliance in relation to Standard 4 Physical environment and safe systems include:

Fire suppression equipment

Food safety plan and audit report

Legionella testing.



Team’s findings


Refer to Expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes.

Examples of education provided to staff in the past 12 months in relation to Standard 4 Physical environment and safe systems include:

Chemical

Fire training

Food safety

Infection control

Manual handling.


4.4 Living environment

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

Team’s findings


Management actively works towards providing a safe, clean and comfortable environment that is consistent with care recipients’ care needs. Care recipients are accommodated in single or shared rooms with en-suite bathroom facilities. Care recipients have access to communal living and dining areas, including courtyard gardens. Care recipients are encouraged to personalise their rooms to reflect individual preferences. The home has a minimal restraint approach and physical restraint is risk assessed and used in consultation with the care recipient and/or representative. The living environment is monitored through work area and safety inspections, incident and hazard reporting, audits and preventive and corrective maintenance processes. Results show visual inspections are effective in identifying and addressing environmental issues. Staff interviewed said they are aware of their roles in assisting to maintain a safe and comfortable environment. Care recipients and representatives interviewed said they are satisfied with the safety and comfort of the home.

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 has systems and processes to provide a safe working environment that meets regulatory requirements. A Work, Health and Safety Committee meet to discuss audit outcomes and incident and hazard data. Work, health and safety representatives provide support to staff on-site. Monitoring processes include audits, incident and hazard reporting, work area inspections and preventive and corrective maintenance. Results show work area inspections are effective in identifying safety issues. Staff receive training regarding their work, health and safety responsibilities at induction and manual handling education is provided on an annual basis. Staff interviewed said they have access to personal, protective equipment, standard operating procedures and guidelines.

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


The home has systems and processes to provide a safe environment through the minimisation of fire, safety and security risks. Evacuation maps are located throughout the home and emergency procedures are accessible to staff. Contracted external services and internal maintenance processes monitor the security, fire and emergency systems. The maintenance officer undertakes electrical testing and tagging for care recipients’ equipment. The home’s


security is maintained through keypad operated doors and evening lock down procedures. Monitoring processes include audits, incident and hazard reporting and work area inspections. Results show fire safety records are up-to-date and maintenance requests are actioned promptly. Staff interviewed said they attend annual fire training and are aware of their responsibilities in the event of an emergency. Notices on what to do on hearing a fire alarm are posted in care recipients’ rooms.

4.7 Infection control

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

Team’s findings


There is an effective infection control program in the home. Infection data is collated, analysed, trended and interventions implemented as needed. Infection control is managed through the home’s polices and guidelines, outbreak management procedures and resources available. Staff and care recipients have access to an annual flu vaccination program. There are processes for the appropriate disposal of contaminated waste and sharps. A food safety plan guides catering staff practice and an external contractor provides a pest management program. Management monitors infection control by scheduled audits, infection data analysis and staff competency completion. Results show an effective infection control system is in place. Staff said there is adequate personal protective equipment available and they are aware of infection control guidelines. Care recipients and representatives said they are satisfied staff maintain infection control practices when needed.

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


The home provides hospitality services in a way that enhances each care recipients’ quality of life and the staff’s work environment. Care recipient needs are assessed on entry and hospitality services are planned, implemented and monitored. Catering staff use a four week rotating, seasonal menu which has been reviewed by a dietitian. Meals are prepared in a central kitchen and delivered to site. Catering staff are guided by a food safety plan and colour coded dietary requirement records. Cleaning and laundry services are guided by infection control procedures, cleaning task lists and safety data sheets. Cleaning is scheduled throughout the week for care recipients’ rooms and communal areas. Laundry services are available on-site for care recipients’ personal clothing. Monitoring of hospitality services includes care recipient and representative feedback, forum meetings, comments and complaints. Results show care recipients’ needs in relation to catering, cleaning and laundry are documented and reviewed on a regular basis. Staff interviewed said they are aware of care recipients’ needs and preferences and are satisfied with their working environment. Care recipients and representatives interviewed said they are satisfied hospitality services are provided in a manner that meets care recipients’ needs and preferences.

marten residential care centre - quality agency · 4.7 infection control met 4.8 catering, cleaning...

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