published decision (sa and ra) - aged care quality...adventist retirement village - victoria pt racs...

Reconsideration Decision

Adventist Retirement Village - Victoria Pt RACS ID: 5480

Approved Provider: Seventh-Day Adventist Aged Care (South Queensland) Ltd

Reconsideration of decision regarding the period of accreditation of an accredited service under section 2.19(1)(a) of the Quality Agency Principles 2013.

Reconsideration Decision made on 23 April 2018

Reconsideration Decision An authorised delegate of the CEO of the Australian Aged Care Quality Agency has decided to vary the decision made on 14 October 2015 regarding the period of accreditation. The period of accreditation of the accredited service will now be 04 December 2015 to 04 September 2019.

Reason for decision Under section 2.69 of the Quality Agency Principles 2013, the decision was reconsidered under ‘CEO’s own initiative’.

The Quality Agency is seeking to redistribute the dates for site audits for a number of services that have demonstrated consistent and sustained compliance with the Accreditation Standards to achieve a more level distribution of the timing of accreditation site audits over a three year period. More information is available on our website at http://www.aacqa.gov.au/publications/news-and-resources/redistribution-of-aged-care-accreditation-program.

The Australian Aged Care Quality Agency will continue to monitor the performance of the service including through unannounced visits.

This decision is effective from 04 December 2015

Accreditation expiry date 04 September 2019

http://www.aacqa.gov.au/publications/news-and-resources/redistribution-of-aged-care-accreditation-program



Adventist Retirement Village - Victoria Pt RACS ID 5480

571 Cleveland-Redland Bay Road VICTORIA POINT QLD 4165

Approved provider: Seventh - Day Adventist Aged Care (South Queensland) 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 04 December 2018.

We made our decision on 14 October 2015.

The audit was conducted on 31 August 2015 to 03 September 2015. The assessment team’s report is attached.

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

Home name: Adventist Retirement Village - Victoria Pt Date/s of audit: 31 August 2015 to 03 September 2015 RACS ID: 5480

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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

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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.


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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


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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.


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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.


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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


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Audit Report

Adventist Retirement Village - Victoria Pt 5480


Introduction This is the report of a re-accreditation audit from 31 August 2015 to 03 September 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


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Audit report

Scope of audit An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 31 August 2015 to 03 September 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: Dee Kemsley

Team members: Andrea Hopkinson

Felette Dittmer

Approved provider details


Details of home

Name of home: Adventist Retirement Village - Victoria Pt

RACS ID: 5480

Total number of allocated places:

176

Number of care recipients during audit:

154

Number of care recipients receiving high care during audit:

125

Special needs catered for:

Dementia and related conditions

Street/PO Box: 571 Cleveland-Redland Bay Road State: QLD

City/Town: VICTORIA POINT Postcode: 4165

Phone number: 07 3820 5709 Facsimile: 07 3820 5799

E-mail address: [email protected]

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


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Audit trail The assessment team spent three and a half days on site and gathered information from the following:

Interviews

Number Number

Director of Care and Services 1 Care recipients/ Representatives (interview and correspondence)

19

Clinical Nurse Consultant 2 Acting Executive Care Manager

1

Registered staff 8 Care Recipient Liaison Officer 1

Care staff 5 Catering Contractor – Management

2

Funding Coordinator 1 Catering Contractor – Chef 1

Physiotherapist 2 Housekeeping Supervisor 1

Physiotherapist Assistant 1 Support Services staff 3

Nurse Educator 1 Maintenance Officer 1

Continence Nurse 1 Maintenance Supervisor 1

Administration Team Leader 1 Operations Manager 1

Administration staff 2 Education Consultant 1

Volunteer 2 Lifestyle Coordinator 1

Sampled documents

Number Number

Care recipients’ files 17 Medication charts 16

Personnel files 3

Other documents reviewed The team also reviewed:

Activities calendars, participation/evaluation records and professional resources

Agency registered nurse folder

Alleged assault/missing resident summary

Archiving register

Asset register

Audit schedule, tools and analysis

Buddy shift checklist

Care recipient and accommodation agreement

Care recipient listing

Care recipient satisfaction surveys


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Care recipients’ information handbook

Care reviews and case conferences

Catering contractor staff records

Checklist for new employees

Cleaning schedules

Clinical focus assessments and monitoring charts

Clinical incidents and analysis

Compliments, concerns and complaints folders

Controlled drug register

Diaries

Dietary summary sheets

Doctor’s folders

Duty statements

Education and training calendar and records

Emergency procedures booklet and folder

Emergency response manual

Employee leave request form

End of life care pathway

Entry notification slip

External service agreements and registration information

External service provider folder

Feedback forms

Fire defect folder

Fire/smoke detection and firefighting equipment inspection and maintenance records

Food, goods and equipment temperature monitoring records

Handover notes

Hazard alert form

Hazardous chemicals list

Home’s self-assessment

Infection data and analysis

Kitchen whiteboard – care recipient dietary needs, allergies and preferences

Maintenance system – electronic

Mandatory reporting requirements flowchart

Mandatory training reports

Meetings schedule

Minutes of meetings

Modified diet/drinks guide

Multi lists (clinical cares)


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Newsletters

Orientation program

Outbreak management plan

Plan for continuous improvement

Police check matrix

Policies, procedures, guidelines and flow charts

Position descriptions

Preferred supplier list

Preventative maintenance schedule

Professional nursing staff registration register

Regulation compliance external contractor update bulletin

Request for internal transfer form

Resident self-medication authorisation form

Restraint assessment, authorisation and monitoring chart

Safety data sheets

Staff allocation sheet

Staff orientation book – includes handbook and competencies

Working roster

Wound assessments and treatments

Observations The team observed the following:

Activities in progress

Administration and storage of medications

Advocacy and complaints agencies’ brochures on display

Allied health and medical specialists attending to care recipients

Charter of care recipients’ rights and responsibilities on display

Chemical storage

Daily menu displayed

Emergency exits, lighting and egress routes

Equipment and supply storage areas

Evacuation ‘grab pack’

Falls prevention aids in use

Feedback form lodgement box

Feedback forms on display

Fire evacuation diagrams

Fire panel

Fire/smoke detection and firefighting equipment and inspection tags


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Information boards

Interactions between care recipients/representatives, staff and volunteers

Internal and external living and working environments

Maintenance shed and fuel storage shed

Midday meal, setting, service and practices

Mobility and dexterity aids in use

Morning and afternoon tea service

Notice of reaccreditation displayed

Palliative care kit

Personal protective equipment in use

Safety signage

Short group observation

Sign in/out registers

Signage – how to access online policies and procedures

Staff work practices

Swipe card access to secure areas

Vision, mission and philosophy statement on display

Waste disposal


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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 Adventist Retirement Village – Victoria Point (the home) has a framework to assist in actively pursuing continuous improvement. This system is comprised of processes to support the input and consultation with various stakeholders through the feedback form (inclusive of hazards, suggestions and complaints), meetings, one-to-one feedback and satisfaction surveys. An electronic system is used to assist in the management of continuous improvement, with identified opportunities for improvement captured in registers/action plans. Improvements are actioned, monitored and feedback provided through relevant meetings or forums to ensure their effectiveness. A program of internal monitoring activities such as audits, self-assessments and incident analysis is undertaken to monitor the home’s performance against internal requirements and the Accreditation Standards. Management and staff provided examples of improvement across all four Accreditation Standards. Care recipients/representatives and staff are satisfied with being able to raise suggestions and feedback for improvement. Examples of recent improvements in management systems, staffing and organisational development include, but are not limited to:

Following a review of education opportunities at the home, a ‘nurse educator’ role was developed to provide in-service orientation, mandatory and professional development education and training to groups and/or individuals. The role is designed to assist in the review of incidents, and to establish the ‘buddy’ system for new workers. This initiative has been evaluated as increasing skills of staff; improving clinical and care practices; supporting performance management; facilitating timely proactive and reactive education, and supporting staff to achieve education and skill goals.

In response to the care recipient survey and feedback from staff and representatives, there is coverage by Clinical Nurse Consultants (CNC) seven days a week. The CNCs drive the handover process and are available on-site to liaise with staff to enable clinical support to be provided throughout the home between 0645 and 1500. This enables timely review of incidents or clinical events; increases continuity of care; facilitates ongoing clinical support (especially for newly graduated registered staff), and enables timely management of mandatory reporting/discretion not to report incidents.


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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 meets this expected outcome The organisation has implemented systems to identify and ensure compliance with relevant legislation, regulatory requirements, professional standards and guidelines. Management personnel identify legislation and regulations to be complied with and accesses resources including external support for notification and advice of any relevant changes. Documents incorporate legislative and regulatory requirements and policies/procedures and guidelines are available to staff. A system to communicate changes is implemented and inclusive of meetings, newsletters, electronic messaging, notices and education relevant to staff roles. Monitoring of compliance occurs through the use of internal registers, the home’s auditing program and external reviews. Particular to this Standard, management and key personnel are aware of their regulatory responsibilities in relation to staff and contractors having a current police certificate and care recipients/representatives being advised of scheduled re-accreditation audits. Processes are in place to ensure these requirements are met. 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 meets this expected outcome Systems ensure management and staff have the appropriate knowledge and skills to perform their roles effectively. Recruitment and selection processes are undertaken to identify the suitability of the staff member for the position. New staff are orientated, provided with ‘buddy’ shifts and ongoing support to ensure an understanding of their roles and responsibilities. Training needs are identified and provided as part of the home’s education program, with opportunities for skill development through accessing external education providers. A program of staff training and assessment is undertaken on commencement, annually or as required. Staff performance is monitored through an appraisal process, observations, internal audits and feedback mechanisms; a process to address performance issues is implemented. Staff are satisfied with the opportunities and access to training to assist them to undertake their roles. Examples of information topics relevant to Standard 1 include: Aged care funding instrument, Leadership skills, What to expect at accreditation, Duty of care in aged care, Strong management ethics – the moral DNA of performance.


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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 meets this expected outcome Care recipients/representatives have access to the home’s internal comments and complaints system and to external complaints and advocacy mechanisms. The home provides relevant information to care recipients, their representatives and other stakeholders through a variety of communication channels including care recipient entry processes, the residential care agreement, care recipient handbook, meetings, and via external complaints management and advocacy brochures. Care recipients are invited to raise issues at meetings and/or privately with management and staff. Care recipients have access to confidential suggestion/complaints boxes and there are processes for the regular retrieval of feedback forms from assigned receptacles. There is a process to manage informal and formal comments and complaints and to provide feedback whilst maintaining confidentiality. Care recipients/representatives and staff are familiar with the mechanisms available to initiate a suggestion or raise a concern and are satisfied that management is responsive to their suggestions and responds to their requests in a timely manner. 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 home meets this expected outcome The organisation’s vision, values, philosophy, objectives and commitment to quality have been documented. These documents are available to care recipients, staff and others through information provided on entry such as handbooks and information on display within the home. 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 meets this expected outcome The home has processes for ensuring there are appropriately skilled and qualified staff sufficient to provide care and services. The recruitment and selection of staff is undertaken based on the relevant skills, qualifications and experience held. Staff are orientated and provided with ongoing educational opportunities to support skill development. Internal processes ensure staff skills are monitored and evaluated through competency assessments, performance reviews and feedback mechanisms. A process is used to ensure the currency of police certificates and nursing staff registrations. Rosters are adjusted to ensure a mix of staff skills and qualifications to provide relevant services and strategies implemented for the replacement of staff. The sufficiency of staff is monitored through feedback mechanisms, observations and review of call bell response times; action is taken as required. Care recipients/representatives and staff are generally satisfied in the sufficiency of staffing to meet individual care and service delivery needs.


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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 meets this expected outcome The home has processes to ensure there are stocks of appropriate goods and equipment available for service delivery. Key staff are responsible for the monitoring and ordering of supplies through the use of impress systems and preferred suppliers. Equipment needs are identified through various mechanisms, with appropriate action undertaken inclusive of equipment trials and input from relevant staff as to the suitability of equipment. Goods are checked on receipt, rotated and securely stored. Staff are provided with instruction on the correct use of equipment and supplies through the use of external service providers. An electronic system is used for the management of both preventative and reactive maintenance to ensure equipment is safe and in good working order. Care recipients/representatives and staff are satisfied there are appropriate goods and equipment available for service delivery. 1.8 Information systems This expected outcome requires that "effective information management systems are in place". Team’s findings The home meets this expected outcome The organisation and home have established processes to ensure information is managed in a secure and confidential way. The home uses both hardcopy and electronic information systems. Staff and care recipient information is stored in secured areas and is accessible only to authorised personnel. Electronic information is secured by passwords, with restricted access depending on your role in the organisation. Electronic information is regularly backed up to prevent loss of information. There is a system to archive information appropriately. Verbal and written strategies (communication diaries, electronic mail, notices) are used to disseminate information. Staff have access to information relevant to their position and changes to care recipients’ needs are communicated to them in a timely manner. Care recipients/representatives are satisfied with internal communication processes and have access to information about care and service delivery. 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 meets this expected outcome There are processes to ensure that externally sourced services are provided in line with the home’s needs and service requirements. The home identifies and sources preferred suppliers for the provision of services across both clinical and operational areas. Service requirements, including relevant terms, conditions and quality standards are specified through the use of agreements and provision of contractor documentation. Designated staff are responsible for the monitoring of external providers to ensure the ongoing currency of agreements, police certificates, insurance and relevant licensing/registrations. There are processes to monitor the performance of providers and action is undertaken where


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performance is not to the required standard. Management, care recipients and staff are satisfied with the provision of externally sourced services.


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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. 2.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome The home has a continuous improvement system in relation to care recipients’ health and personal care. Refer to Expected outcome 1.1, Continuous improvement, for details on the home’s overall system.

Examples of recent improvements in health and personal care include but are not limited to:

Following a review of weight management strategies, a matrix was developed with inbuilt formulas to calculate variance; actions added to the ‘comments’ column are transferred through to progress notes. The CNCs meet monthly and discuss weight data with relevant documents amended with updates and actions and distributed to relevant dietary documents and the kitchen, and referrals generated as required. Since this matrix was introduced in January 2015, management and staff report consistency in weight management; facilitates improved analysis and timely review; provides “real” evidence as opposed to “snapshots” of care recipients’ weights, and enables staff to ensure all care recipients have been weighed and in accordance with the required regime.

In response to a review of the home’s palliative care process, a joint initiative with the local health service district palliative care team commenced – end of life care pathway form was developed, toolbox talks conducted, and palliative care assistance boxes established for family/friends, and a separate one for care recipient. Visiting medical officers have been advised by letter of the revised process. This initiative has increased staff interest and knowledge of palliation and the associated care; streamlined the process; improved the support for families/friends; provided more cohesion between clinical and lifestyle teams, and increased the comfort of care recipients.

2.2 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 about health and personal care”. Team’s findings The home meets this expected outcome Refer to Expected outcome 1.2, Regulatory compliance, for information about the organisation’s systems used to identify and ensure compliance. The home has systems to ensure compliance with legislation relevant to health and personal care. Particular to this Standard, management and key personnel are aware of their regulatory responsibilities in relation to specified care and services, professional staff nursing registrations and unexplained absences of care recipients. There are processes to ensure these requirements are met.


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2.3 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 meets this expected outcome The home provides management and staff with a learning and development program to enable the maintenance and improvement of care and clinical skills. Education in clinical issues is derived from changing care recipient needs and through continual review of training needs. Competencies for clinical skills are conducted annually or as required. Staff are assisted to attend external tertiary education. Refer to Expected outcome 1.3 Education and staff development for details on the home’s overall system. Examples of information topics relevant to Standard 2 include: Training from pharmacy on medication chart type, Dementia, Huntington’s Chorea, Continence management, Wound management, Palliative and end of life requests, Neuropathic pain, Managing violent behaviour, New drugs – aged care focus. 2.4 Clinical care This expected outcome requires that “care recipients receive appropriate clinical care”. Team’s findings The home meets this expected outcome The home has processes to assess care recipients’ initial and ongoing clinical care needs and preferences. Care recipients’ interim care plans are completed on entry to the home from information provided by the care recipient/representative, hospital discharge and/or medical referral notes. Comprehensive and focus assessments are then completed to form individualised care plans to direct the provision of care. Care plans are evaluated every three months, or as care needs change. Registered and care staff contribute towards care recipient progress notes on an exceptional reporting basis. Care recipients/representatives have input into the ongoing provision of the care recipients’ care through care plan reviews and/or care conferences. Monitoring the effectiveness of clinical care is undertaken through the three monthly care plan review process, analysis of clinical incidents and infection data, scheduled audits, regular monitoring activities undertaken by the Clinical Nurse Consultants, observation and feedback from care recipients/representatives and staff. Staff have an understanding of individual care recipient care needs. Care recipients/representatives are satisfied with the clinical care 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 The home meets this expected outcome The needs of care recipients requiring ongoing specialised nursing care are identified on entry to the home and/or as their care needs change. This information is detailed in the care recipient’s individualised care plans to guide staff practice. Registered nurses are available on-site 24 hours a day, seven days a week, to assess and oversee specific care requirements. These currently include diabetic management, catheter care, stoma care, care recipients requiring dialysis, complex pain and chronic wound management. Monitoring and review of care recipients’ specialised care needs are conducted by registered staff in


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conjunction and consultation with the CNCs. The use of external specialist services is also available to support staff to care for care recipients with their specialised needs. Appropriate equipment and sufficient stock is accessible to enable care recipients’ specialised nursing care needs to be met. Care recipients/representatives are satisfied with the quality of care provided at the home and the support received by care recipients with their specialised care needs. 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 The home meets this expected outcome Care recipients have access to and/or are referred to a wide range of health specialists who provide services such as physiotherapy, speech pathology, podiatry, dietetics, optometry, dental care, audiology, pathology and other medical specialities (for example psychogeriatrician and mental health services). A referral mechanism is initiated by registered staff, in conjunction with the Care Coordinator and the medical officer as appropriate. Health specialists regularly attend the home and registered staff, in consultation with the care recipient/representative, coordinate and manage external appointments as required. The outcome of referrals including instructions for ongoing care are documented, actioned and retained in clinical records with changes incorporated into the care recipients’ care plan as identified. Care recipients/representatives are satisfied with the choice and access to other health specialists. 2.7 Medication management This expected outcome requires that “care recipients’ medication is managed safely and correctly”. Team’s findings The home meets this expected outcome Registered nurses, enrolled nurses and competency assessed care staff assist with administering care recipients’ medications. Registered nurses are available onsite 24 hours per day, seven days per week for consultation regarding administration of ‘as required’ (PRN) medication. Care recipient medications are supplied in sachet packs and individual containers delivered to the home on a weekly basis and/or as required. Medications are stored securely and registered staff are aware of procedural and legislative requirements relating to the safe and correct administration and storage of medications and controlled drugs. Care recipients’ medical officers review care recipients’ medications at least three monthly. The home has processes to assess, authorise and review care recipients who wish to self-administer their medication. Evaluation of the medication management system is conducted through monitoring of medication incidents, medication advisory committee (MAC) meetings, chart audits conducted by the pharmacist, observation of staff practice and the internal auditing processes. Care recipients/representatives are satisfied care recipients’ medication is administered safely and correctly.


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2.8 Pain management This expected outcome requires that “all care recipients are as free as possible from pain”. Team’s findings The home meets this expected outcome Care recipients’ pain management needs are generally identified and assessed on entry to the home, and monitored on an ongoing basis. The physiotherapist further assesses care recipients’ complex pain management needs and interventions are recorded on care plans to guide the provision of care by the physiotherapy assistant and clinical staff. Strategies to manage care recipients’ pain include the provision of heat packs, the application of transcutaneous electrical nerve stimulation (TENS), individual and group exercises, massage, assisted walks and regular repositioning. Medication measures include PRN medication, regular prescribed oral pain relief and topical slow-release pain relief patches. Effectiveness of pain management strategies is generally assessed and monitored by registered staff with any changes being recorded in care recipients’ progress notes or pain assessment charts and referred to the physiotherapist and/or medical officer for further review. Care recipients/representatives are satisfied care recipients’ pain is managed effectively and staff respond to requests for assistance if care recipients experience pain. 2.9 Palliative care This expected outcome requires that “the comfort and dignity of terminally ill care recipients is maintained”. Team’s findings The home meets this expected outcome The home has processes to provide care and comfort for terminally ill care recipients. Care recipients' end-of-life wishes are discussed with the care recipient/representative as the care recipients’ health status changes. An end-of-life care pathway is completed through consultation with the care recipient and family members, clinical staff, medical officer and allied health specialists as identified. Care recipients are supported to remain in the home during the palliative phase of care and family are able to visit and/or stay with care recipients during this time. Spiritual support is offered and provided according to care recipients’ preferences and specially selected volunteers and the chaplains are available to provide support to care recipients/representatives and staff. Care recipients have access to organisational palliative care resources and specialised clinical supplies and equipment are available to assist care recipients to remain as free from pain as possible. Staff are aware of the care needs and measures required to provide comfort and dignity 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 The home meets this expected outcome Care recipients’ dietary requirements are identified and assessed on entry to the home including their personal likes, dislikes and medical dietary needs. Strategies to support care recipients’ nutrition and hydration needs are incorporated into their care plans and communicated to all staff, including catering staff. Care strategies include assistance with meals, provision of dietary aids, regular beverage rounds and the provision of thickened fluids and modified texture diets. Care recipients are routinely weighed on entry to the home


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and then monthly. The CNCs monitor care recipients’ weights and variances in weight are analysed for causative factors. Strategies to manage weight loss include implementation of increased weight monitoring, provision of fortified diets, provision of supplements and referral to the medical officer or speech pathologist for further review as identified. A dietitian is consulted for care recipient review and/or follow-up as required. The effectiveness of nutrition and hydration management is evaluated through observation of staff practice, review of weights, the audit process and feedback from staff and care recipients. Care recipients/representatives are satisfied the home provides adequate nourishment and hydration for care recipients. 2.11 Skin care This expected outcome requires that “care recipients’ skin integrity is consistent with their general health”. Team’s findings The home meets this expected outcome Care recipients’ skin integrity and the potential for compromised skin integrity are assessed on entry to the home. Maintenance and/or preventative strategies are implemented as appropriate. Strategies include the use of aids/equipment such as pressure relieving devices (for example air mattresses), limb and heel protectors, application of moisturising and/or barrier creams and regular repositioning. Wounds and treatments are generally monitored via wound assessment and treatment records, with registered staff providing wound care. Review of more complex wounds are regularly undertaken by the CNCs and referred to the medical officer as required. The incidence of injury/skin tears is captured and analysed for trends and/or triggers and interventions are implemented as identified. Staff receive education in manual handling at orientation and annually with the view to ensuring care recipients’ skin integrity is not compromised in any way. The effectiveness of skin care is evaluated through analyses of clinical indicators, the audit process, staff observation and feedback. Care recipients/representatives are satisfied care recipients receive care and assistance to maintain their skin integrity. 2.12 Continence management This expected outcome requires that “care recipients’ continence is managed effectively”. Team’s findings The home meets this expected outcome Care recipients’ continence status is assessed on entry to the home with urinary and bowel assessment charts commenced to identify patterns. Care recipients’ individual continence programs are developed and are detailed on care plans. A daily bowel record is maintained for care recipients that staff monitor and action as required, unless care recipients have been identified as able to self-manage this aspect. Bowel management strategies include the provision of prunes and pear juice, a high fibre diet, increased fluids are encouraged and aperients are administered as prescribed. Care plans record strategies to promote and manage care recipients’ continence needs including regular toileting programs, assistance with personal hygiene and provision of appropriate continence aids. The continence nurse, in conjunction with registered staff, monitor care recipients’ ongoing continence aid use for appropriateness and ensure continence supplies are ordered and distributed. Staff have an understanding of care recipients’ individual toileting schedules and continence needs. Care recipients/representatives are satisfied with the level of assistance and aids provided to manage care recipients’ continence needs.


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2.13 Behavioural management This expected outcome requires that “the needs of care recipients with challenging behaviours are managed effectively”. Team’s findings The home meets this expected outcome The needs of care recipients with challenging behaviours are identified during the initial assessment phase on entry to the home and on an ongoing review basis. Behavioural assessments identify the types of behaviours exhibited, possible triggers and management strategies. Strategies implemented to manage challenging behaviours are individualised and may include the provision of a secure environment, participation in group activities, one-on-one interactions, increased monitoring (for example sensor beams and visual observation), redirection, doll therapy and medication review as required. Care recipients are also referred to mental health and/or dementia behaviour specialists as the need is identified. The home has processes to assess and authorise the need for care recipients’ individual physical restraint. Staff have an understanding of managing care recipients with challenging behaviours and interact with care recipients in a manner that encourages positive outcomes. Care recipients/representatives are satisfied the activities and behaviours of other care recipients do not infringe on care recipients’ life at the home. 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 meets this expected outcome An initial assessment in relation to each care recipient’s specific mobility, transfer and therapy needs is conducted by the physiotherapist on entry to the home and/or as their care needs change. Individualised mobility care plans are developed which include transfer and manual handling instructions. Care recipients and staff are instructed in the use of mobility and transfer aids and staff undergo mandatory manual handling training on an annual basis. Care recipients at risk of falls are assessed and identified and this is recorded on their care plans. Strategies to manage and/or minimise falls include the provision of sensor beams, provision of low low beds with padded bedside mats, floatation chairs, increased monitoring and observation by staff and reviewing the environment and medication. Care recipient falls are documented on incident forms and are monitored further, with changed mobility care needs including increased falls, referred to the medical officer and/or physiotherapist for further review. The Physiotherapy Assistant assists care recipients with individual exercise, walking programs and ensures they have the correct equipment for their mobility and dexterity care needs. Care recipients/representatives are satisfied with the level of support and assistance provided to maintain care recipients’ mobility and dexterity levels. 2.15 Oral and dental care This expected outcome requires that “care recipients’ oral and dental health is maintained”. Team’s findings The home meets this expected outcome Care recipients’ history and preferences relating to the management of their oral and dental health is identified on entry to the home. This includes the level of assistance needed and is documented on care recipients’ care plans. Care staff monitor care recipients’ ability to self-manage their oral care and assist when required. They inform registered staff of any


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concerns which initiates further referrals as appropriate. A dentist will visit the home on request and the local hospital dental clinic is accessible for care recipients with more complex needs. Registered staff, in consultation with the care recipient/representative, co-ordinate and arrange dental referrals when a need is identified. The home maintains stocks of equipment and products to meet care recipients’ oral hygiene needs and care recipients are provided with new tooth brushes every three months. Care recipients/representatives are satisfied with the level of support provided to assist care recipients with the maintenance of oral hygiene and their access to dental health services. 2.16 Sensory loss This expected outcome requires that “care recipients’ sensory losses are identified and managed effectively”. Team’s findings The home meets this expected outcome Assessment of care recipients’ sensory needs and/or losses occurs on entry to the home or as care needs change. Care interventions reflect care recipients’ identified sensory needs and personal preferences in order to guide the provision of assistance by staff. Care staff provide support with activities of daily living and assist care recipients to manage assistive devices such as spectacles and hearing aids (including cleaning, care and replacing of batteries) to maximise sensory function. Care recipients are referred to specialists such as audiologists, optometrists and speech pathologists based on their assessed needs and in consultation with the care recipient/representative and medical officer. Clinical staff coordinate external appointments when required with any changes being incorporated into the care recipient’s care plan. Care recipients/representatives are satisfied with the assistance provided by staff to identify and manage the care recipients’ sensory care needs and preferences. 2.17 Sleep This expected outcome requires that “care recipients are able to achieve natural sleep patterns”. Team’s findings The home meets this expected outcome Each care recipient is assessed on entry about their usual sleep patterns, settling routines and personal preferences are documented to form part of their individualised care plan. Night routines maintain an environment that is conducive to sleep. Staff implement support and comfort measures which may include for example, a settling routine, provision of supper and snacks, lighting and temperature adjustment, repositioning and attending to continence, hygiene and pain management needs. Medication interventions are administered according to the care recipient’s attending medical officers’ orders. Staff are aware of care recipients’ sleep and rest patterns and personal preferences and check on care recipients overnight. Care recipients are able to sleep comfortably and are satisfied with the support provided by staff.


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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. 3.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome The home has a continuous improvement system in relation to care recipients’ lifestyle. Refer to Expected outcome 1.1, Continuous improvement, for details on the home’s overall system. Examples of recent improvements relating to care recipient lifestyle include, but are not limited to:

A project has commenced to highlight the importance of privacy and dignity of care recipients through labelling strategies. Consultation between the administration staff and care recipients resulted in discreet labelling of mobility aids and signage on doors with education provided to staff. Small laminated labels have been attached to wheelie walkers and wheel chairs to support easy but discreet identification of the owner. Pictures of colour-coded leaves are placed on care recipients’ entry doors to signify the care recipient has a condition which is infectious or is on cytotoxic medication. There is also a push fluids’ picture available for doors when required. Appropriate care recipients who are able to self-monitor their bowel management have been removed from the daily ‘bowel charts’ list. Care recipients and staff report these initiatives increase privacy and dignity and promote independence.

Staff identified that, not all care recipients could manage the steps on the campus bus which resulted in them choosing not to go on bus outings. To support these care recipients and their desire to attend the bus outings, the home arranges taxis and transport vehicles with wheelchair access and suitable steps. This initiative has resulted in more care recipients going on outings more often, and improved satisfaction with the leisure and lifestyle activities.

3.2 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, about care recipient lifestyle”. Team’s findings The home meets this expected outcome Refer to Expected outcome 1.2, Regulatory compliance, for information about the organisation’s systems used to identify and ensure compliance. The home has systems to ensure compliance with legislation relevant to care recipient lifestyle. Particular to this Standard, management are aware of their regulatory responsibilities in relation to compulsory reporting, privacy and security of tenure. There are processes to ensure these requirements are met.


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3.3 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 meets this expected outcome The lifestyle staff and care staff support care recipients in relation to their leisure and lifestyle interests, needs and preferences. Education in leisure and lifestyle issues is derived from changing care recipient needs and/or desired outcomes, and through review of training needs. Staff are assisted to attend external education and are offered opportunities in accessing continuing education reflecting leisure and lifestyle. Refer to Expected outcome

1.3 Education and staff development for details on the home’s overall system. Examples of information topics relevant to Standard 3 include: Grief, loss and dying, Dementia and activities, Elder abuse, Dementia support skills set. 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 meets this expected outcome The home has processes to ensure care recipients are supported in adjusting to their new home and on an ongoing basis. Prior to or on entry the care recipient receives a ‘welcome’ pack and an information pack which explains their rights and responsibilities and the services offered. Care recipients and their representative/s are oriented with a tour of the home, assisting them to meet staff and other care recipients. In consultation with the care recipient and representative/s, lifestyle staff commence a detailed assessment of the care recipient’s lifestyle that captures social, cultural and spiritual histories. A leisure/lifestyle/diversional therapy care plan is developed and documents preferences and strategies to assist care recipients in enjoying life at the home. Care recipients are satisfied with the emotional support provided to them. 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 The home meets this expected outcome Care recipients are encouraged and supported to maintain their independence at a level that is appropriate to their individual needs and abilities. The lifestyle program offers a range of activities designed to maximise care recipients’ independence and includes exercise programs and outings. Care recipients are assisted and encouraged to maintain friendships and participate in the life of the community within and outside the home. Care recipients are encouraged to use aids such as hearing aids and walking frames to maintain their independence. They are also encouraged to participate in decisions about their physical, intellectual, spiritual, financial and social care. Care recipients are satisfied with the support and encouragement given by staff to enable them to remain as independent as possible.


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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 meets this expected outcome There are systems to support care recipients’ privacy and dignity. Care recipients’ privacy, dignity and confidentiality wishes and preferences are identified and documented in care plans. Information on care recipients’ right to privacy is contained in the ‘resident information book’ and explained to care recipients during their initial entry to the home. Information is stored and archived securely and handover is conducted in a confidential manner. Staff practices maintain care recipients’ confidentiality and staff are discreet when managing care needs. Care recipients are satisfied staff are respectful of their privacy and dignity when caring for them. 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 meets this expected outcome The home offers care recipients a lifestyle program that incorporates a wide range of interest and activities of interest to them. A leisure and lifestyle assessment is completed for each care recipient, capturing information that assists with their individual participation levels. The home offers one-to-one options for care recipients who choose not to be involved in group activities. Group activities are designed around care recipients’ preferences and suggestions. A copy of the monthly activities program is provided to each care recipient and is displayed in communal areas throughout the home. Care recipient participation and level of interest is monitored and evaluated. Review of the activity program occurs through observation, surveys, care recipient feedback and regular meetings. Care recipients are assisted to participate in activities of choice and are satisfied with the lifestyle program offered at the home. 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 The home meets this expected outcome Care recipients’ specific cultural and spiritual needs are identified on entry to the home and a care plan developed in consultation with the care recipient and/or their representative. Staff and volunteer services provide emotional support; religious services are held regularly on site, and attendance at external religious observances is encouraged and facilitated. Celebrations are held to mark days of cultural and religious significance, with the kitchen able to provide special meals on these occasions, as well as catering for the specific cultural and religious group requirements of individual care recipients as required. Staff receive information to increase their awareness of cultural and religious considerations when providing personal care. Care recipients are satisfied their cultural and spiritual needs and preferences are respected and supported.


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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 meets this expected outcome The rights of each care recipient and/or their representative to make decisions and exercise choice and control over lifestyle and care planning are recognised and respected. The home uses consultative processes to actively obtain information from care recipients and representatives including surveys, meetings, suggestions and one-to-one communication. Monitoring processes include personal care and activity plan reviews, and evaluation of feedback through the continuous improvement system. Staff encourage and assist care recipients to participate in choice and decision-making about the services provided to them. Care recipients/representatives are satisfied with their participation in making choices and decisions about issues that affect care recipients’ daily life. 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 The home meets this expected outcome Care recipients have secure tenure within the residential care service and understand their rights and responsibilities. On entry to the home, care recipients are provided with an information pack which details information relating to their rights and responsibilities, feedback mechanisms and privacy and confidentiality. Care recipient and accommodation agreements are offered to all care recipients and include details regarding security of tenure and documents care and services provided. Care recipients/representatives are consulted where changes may require a change of room within the home. Staff are informed of care recipient rights through orientation and ongoing training with care recipient satisfaction monitored through surveys and feedback. Care recipients are satisfied they have appropriate access to information regarding their rights and feel secure in their tenure.


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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. 4.1 Continuous improvement This expected outcome requires that “the organisation actively pursues continuous improvement”. Team’s findings The home meets this expected outcome The home has a continuous improvement system in relation to the physical environment and safe systems. Refer to Expected outcome 1.1 Continuous improvement for details on the home’s overall system. Examples of recent improvements in the physical environment and safe systems include, but are not limited to:

With an increase in care recipient acuity, the infection surveillance system was reviewed to ensure optimal coverage. The system has been developed to generate monthly reports which identify care recipients with infections and those with a pre-disposition to infections. Staff and care recipients and other interested parties were notified of the new system. Infection trending has increased, and access to online pathology results has resulted in early intervention/response, as well as timely consultations with medical officers, families and care recipients.

To support the plan for a comprehensive maintenance system, the online asset register has been modified to enable the history of an asset to be captured when work to be carried out on equipment is logged via the assigned asset number. The system works in tandem with the colour-coded preventative maintenance tracking system (coloured dots on equipment). While the online asset register has only had this capacity to undertake this action for one month, the maintenance team and management report the application facilitates improved decision-making in relation to repair/replace; enables trends in equipment or resource brands/types to be identified, and increases the opportunity for the purchase of quality equipment.

4.2 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, about physical environment and safe systems”. Team’s findings The home meets this expected outcome Refer to Expected outcome 1.2, Regulatory compliance, for information about the organisation’s systems used to identify and ensure compliance. The home has systems to ensure compliance with legislation relevant to physical environment and safety systems. Particular to this Standard, management and key staff are aware of their regulatory responsibilities in relation to fire and building compliance, food safety and work health and safety. Processes are in place to ensure these requirements are met.


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4.3 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 meets this expected outcome Management has systems to monitor and enhance the skills and knowledge of staff in relation to the physical environment and safe systems. In conjunction with the mandatory safety education program, staff are afforded the opportunity to attend in-service and external courses or information sessions conducted by specialist educators. Refer to Expected outcome 1.3, Education and staff development, for details on the home’s overall system. Examples of information topics relevant to Standard 4 include: Fire (mandatory and warden training) evacuation exercise, Chemicals and usage, working at heights, Food safety, Infection control.

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 The home meets this expected outcome The home is collocated with a retirement village and has a designated ‘extra services’ area. The living environment and care recipient safety and comfort needs are assessed and reviewed through regular care recipient and staff meetings, audits, incident reports, risk assessments, maintenance requests and staff observation. The home consists mainly of single rooms and the environment provides safe access to clean and well maintained internal and external communal areas with appropriate furniture sufficient for care recipients’ needs. Handrails are throughout the home and walkways facilitate care recipient mobility outside. The on-site maintenance officer implements and oversees a preventative maintenance program on buildings, infrastructure and equipment, with external contractors being utilised as required. Restraint is utilised for care recipients with an assessed need to do so and appropriate authorisation and monitoring is undertaken. Staff check that all external entrances to the home are secure in the evening; regular security rounds are undertaken, and staff have access to police and emergency telephone numbers in the event of a security breach. Care recipients/representatives are satisfied with the maintenance, safety and comfort of their living environment. 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 meets this expected outcome The organisation and management at the home have implemented a safety system to manage regulatory requirements. The home’s safety system is coordinated by organisational health and safety staff in association with the on-site work health and safety representative, maintenance and management teams. There are processes which enable notification and control of hazards; to manage exposure to risks; for reporting and investigation of staff incidents; management of chemicals; regular safety and environmental audits, and the


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rehabilitation of injured staff to support their return to work. Staff receive education on their responsibilities in relation to work health and safety in their working environment. 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 meets this expected outcome The home’s fire safety system and installations have been assessed and records of inspection identify that the fire detection, alarm and firefighting system have been inspected and maintained in accordance with relevant standards. Fire exits and pathways to exit are free from obstacles. The home has emergency response guidelines available at key points in the home to support the management of adverse events such as a fire/smoke, bomb scare, intruder, loss of utilities. Staff are provided with initial and annual instruction in fire safety and evacuation procedures and have access to emergency procedures, firefighting equipment and evacuation diagrams. A care recipients’ evacuation list (updated on entry/exit), coupled with sign in/out registers and staff roster, assist with evacuation headcounts. There are procedures to ensure security (day and night) of care recipients, staff and site visitors. 4.7 Infection control This expected outcome requires that there is "an effective infection control program". Team’s findings The home meets this expected outcome The home has an effective infection control program and staff are aware of infection control principles relevant to their role. Hand washing facilities and hand sanitiser solutions are located throughout the home; an outbreak management system, provision of personal protective equipment and sufficient cleaning supplies assist to minimise the incidence of infection. The home promotes vaccinations for staff and care recipients annually and issues relating to infection control are discussed at relevant staff meetings as an outcome of the infection surveillance system, including collection, collation, analysis and trending of infections data. Care recipients with suspected infections are reviewed by their medical officer and monitored by clinical staff with appropriate treatment implemented. Regular pest control services are provided and there are processes for the disposal of general and clinical waste. The food safety program, cleaning and laundry practices support the infection control program and regular relevant training is provided to staff. 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 meets this expected outcome Care recipients/representatives and staff are satisfied with the catering, cleaning and laundry services provided. Care recipients’ dietary needs are assessed on entry to the home and reviewed as necessary to identify allergies, likes, dislikes and preferences. This information is communicated to staff of the external catering contractor who works out of the home’s kitchen and serving stations. The home has a cook fresh system with the capacity to cater for individual dietary needs and preferences. Care recipients are presented with options for main


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meals and may provide feedback. The cleaning program includes duty lists and schedules to guide staff in the cleaning of care recipients’ rooms and the environment. Manchester is laundered off site, and personal clothing is laundered on site with care recipients encouraged to name personal clothing items to facilitate satisfaction with the laundry service. Regular stock-takes are conducted to ensure linen and crockery is replaced as necessary. The effectiveness of hospitality services is monitored through feedback, meetings, audits and

surveys.