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Waterview Aged Care FacilityRACS ID: 2391

Approved provider: Hunter Valley Care Pty Ltd

Home address: 16 Cumberland Street TERALBA NSW 2284

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 09 September 2021.

We made our decision on 02 August 2018.

The audit was conducted on 19 June 2018 to 21 June 2018. The assessment team’s report is attached.

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

Most recent decision concerning performance against the Accreditation StandardsStandard 1: Management systems, staffing and organisational developmentPrinciple: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 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 carePrinciple: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.




2.4 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 MetHome name: Waterview Aged Care Facility Date/s of audit: 19 June 2018 to 21 June 2018RACS ID: 2391 2

Standard 3: Care recipient lifestylePrinciple:Care recipients retain their personal, civic, legal and consumer rights, and are assisted to achieve active control of their own lives within the residential care services 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 Care recipient security of tenure and responsibilities Met

Standard 4: Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, 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

Home name: Waterview Aged Care Facility Date/s of audit: 19 June 2018 to 21 June 2018RACS ID: 2391 3

Audit ReportName of home: Waterview Aged Care Facility

RACS ID: 2391

Approved provider: Hunter Valley Care Pty Ltd

IntroductionThis is the report of a Re-accreditation Audit from 19 June 2018 to 21 June 2018 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.

During a home’s period of accreditation there may be a review audit where an assessment team visits the home to reassess the quality of care and services and reports its findings about whether the home meets or does not meet the Standards.

Assessment team’s findings regarding performance against the Accreditation StandardsThe information obtained through the audit of the home indicates the home meets:

44 expected outcomes


Scope of this documentAn assessment team appointed by the Quality Agency conducted the Re-accreditation Audit from 19 June 2018 to 21 June 2018.

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

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

Details of homeTotal number of allocated places: 97

Number of care recipients during audit: 97

Number of care recipients receiving high care during audit: 92

Special needs catered for: N/A


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

Interviews

Position title Number

Care manager 1

Executive care manager 1

Community services manager/acting quality manager

1

Human resources manager 1

Registered nurses 5

Staff supervisor 1

Care staff 10

Administration assistant 1

Visiting medical officer 1

Physiotherapist 1

Podiatrists 2

Activities coordinator 1

Chef and catering staff 4

Care recipients and/or representatives 22

Chaplains/pastoral carers 2

Laundry staff 1

Cleaning staff 5

Maintenance supervisor and staff 2

Sampled documents

Document type Number

Care recipients’ files 10

Summary and/or quick reference care plans 10

Medication charts 8


Other documents reviewedThe team also reviewed:

Activities records, assessments and program evaluations

Audit schedule, audits, survey results, audit results and reports

Care recipient agreements

Care recipient information and welcome packs including residential handbook

Care recipients’ list

Cleaning schedules, duty lists, work sign off sheets

Clinical assessment and observation tools: physiotherapy, speech pathology, behaviour, continence, skin, wound, mobility, pain verbal and non-verbal, sensory loss, meal consumption, oral care, falls risk, specialised nursing care, bowel charts, weight charts, personal care charts, and others

Clinical care tools: specialist and allied health referral and review documents, accidents and incidents, assessment guidelines, care communication diaries, handover lists

Comments, complaints and compliments register

Communication records including memorandum, newsletters and other publications

Consolidated record (mandatory reporting register)

Continuous improvement documentation including, clinical indicator reports, continuous improvement plan (quality plan), improvement form register

Education records, attendances and matrixes (including mandatory training records), staff survey

Fire and emergency documentation including interim fire safety statement, evacuation plans, fire equipment audits and testing records

Handbooks (care recipient and staff)

Human resources material (electronic) including personnel files, position descriptions, work schedules, roster, daily staff allocation sheets and replacement daily log

Infection control information: infection control and outbreak management folder, infection control monitoring, vaccination records (residents and staff), hand washing information (family and visitors), preventative management of influenza outbreaks, gastroenteritis management, information outbreak handbook, outbreak management resources and monthly reports

Maintenance schedules, maintenance request logs, preventative and active maintenance documentation, equipment registers and lists, Legionella testing records, thermostatic mixing value and electrical testing records, water backflow valve monitoring

Medication documentation: drugs of addiction (S8) registers, medication incident forms, medication refrigerator temperature records, nurse initiated medication forms, medication profiles, medication charts, pharmacy reviews of care recipient medications, cytotoxic precautions

Menu, records of care recipients’ food and beverage preferences and allergies, HACCP folder, NSW Food Authority licence and annual audit report, food and equipment temperature records, care recipients diet preference information and allergen information

Palliative care documentation: advance care planning, end of life pathway palliative care plan

Policies and procedures, flowcharts


Privacy and confidentiality consent to disclose care recipient personal information

Self-assessment report for re-accreditation and associated documentation

ObservationsThe team observed the following:

Activities and entertainment in progress including, bus trip, men’s choir and singer, activities calendar and activities resources

Aged Care Quality Agency re-accreditation audit notices on displayed throughout the home

Brochures, pamphlets and Charter of Care Recipients’ Rights and Responsibilities displayed

Care recipients interacting with staff, visitors and other care recipients

Care recipients mobilising with mobility aids

Care staff handover

Chaplain visiting care recipients

Chemical storage, chemical dispensing systems, safety data sheets

Cleaning in progress, staff using colour coded cleaning equipment and wearing appropriate personal protective equipment, trolleys and supplies

Clinical care equipment: air mattresses, cushions, limb protectors, mobility and transfer equipment, incontinence aids, wound care products and equipment in use and storage

Dining environments during midday meal service, morning and afternoon tea, care recipient seating, staff serving/supervising, use of assistive devices for meals and care recipients being assisted with meals, daily menus displayed

Electronic data based system message board

Equipment and supplies in use and in storage including manual handling equipment, mobility, protective equipment, hand rails, safe chemical and oxygen storage, safety data sheets, clinical and continence supplies

Equipment and supply storage areas

External veranda and tiled area

Fire safety systems and equipment, fire panel, sprinkler system, evacuation kit, security systems, in/out signing sheets

Infection control: infection control flip charts, hand washing facilities and hand sanitisers, personal protective and colour coded equipment, spills kits, sharps containers, contaminated waste disposal, outbreak management kits,

Living environment internal and external, free from clutter and comfortable communal areas available to care recipients and visitors

Medication trolleys, storage of medication, blister packed and original packed medications, medication administration, medication refrigerator temperature monitoring, cytotoxic spill kits and waste disposal system

NSW Safe Food Authority certificate (current)

Nurse call system in operation including care recipient access

Secure storage of confidential care recipient and staff information


Staff access to information systems including computers, message board, electronic and hard copy record keeping systems – clinical and administration, secure storage of documentation including care recipient and staff information, archives storage

Staff work practices and work areas, including clinical, lifestyle, administration, catering, cleaning, laundry and maintenance

Storage of S8 medications and registers

Vision and mission statement

Walking exercises and podiatrist assessing foot movement


Assessment informationThis 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 developmentPrinciple:Within the philosophy and level of care offered in the residential care services, 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 improvementThis expected outcome requires that “the organisation actively pursues continuous improvement”.

Team’s findingsThe home meets this expected outcome

The home and organisation’s management demonstrated they actively pursue continuous improvement across all four Standards. A comprehensive continuous improvement plan is in use and was seen to be regularly updated and reviewed. A system of information management supports continuous improvement drawing from a range of inputs including changes in legislation or practice guidelines, meeting minutes, audits, clinical indicators, feedback, suggestions and comments and complaints. A review of the continuous improvement plan showed a range of initiatives across stakeholders including care recipients, their representatives, staff, the organisation and allied health and other aged care services. Improvements were seen to be evaluated for effectiveness. Improvements were seen to be communicated by meeting minutes, memos, newsletters and management identified also by word of mouth. Examples of recent improvements of management systems, staffing and organisational development under this Accreditation Standard include:

Staff identified there were problems in access to the home’s one weigh chair. In particular as given the layout of the home, it was time consuming for staff to find and move the chair throughout the home. Senior nursing staff were concerned this could have an impact on the routine monitoring of care recipient weights. A second weigh chair was purchased and both chairs allocated to different areas of the home. Staff said they are satisfied this outcome has addressed the problem of access and availability.

The catering manager raised issues with the paper based supplies ordering system saying it was inconsistent and not always effective. An electronic based software application was purchased which has streamlined the ordering system with a program that stores order forms and lists of products. Including for catering, recipes where there is the ability to order exact ingredients and amounts required to create a dish. Staff received training in the new system which identified some staff required more training and support in use of information technology. In catering ordering precise ingredients and amounts has led to less food wastage and more consistent recipes. Management said this application has resulted in a more effective and efficient ordering system and has been expanded to include other ordered stock in the home.

Following staff suggestions, staff uniform requirements were reviewed. In particular from female staff the request to be able to use shorts with their uniform as being more practical than skirts. For example in assisting to lift care recipients, shorts or trousers were seen as a more practical clothing item. The decision was to use three quarter length shorts, available from the organisations preferred uniform supplier. This is to


ensure consistency in length. Staff have an added choice in style of uniform and some staff said they prefer wearing shorts in the workplace as these are more suitable dress items for the work they do on a day-to-day basis.

1.2 Regulatory complianceThis 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”.


The organisation and home’s management has a range of policies, systems and processes in place to identify and ensure compliance with all relevant legislation, regulation, professional standards and guidelines. The organisation monitors industry standards and guidelines and subscribes to a range of organisations and agencies that provide current and updated regulatory information. This includes its peak body Leading Aged Services Australia (LASA), Department of Health, local authorities and Australian Aged Care and Quality Agency. Staff are provided with information, memos, training and education to ensure regulatory compliance is maintained across all Standards. This includes completion of annual mandatory training requirements. Regulatory compliance under Standard One includes maintaining privacy requirements and ensuring currency of police certificates for staff, volunteers and allied health professionals through a register.

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


Staff and management were able to demonstrate they have the appropriate knowledge and skills to effectively perform their roles. The organisation has an overarching structure of education which includes both mandatory training and professional development. The annual staff survey identifies further educational and training opportunities. Annual competencies are completed in areas where appropriate to maintain work skills. The organisation has quality and human resources managers who oversee education and there is a comprehensive training matrix used to track and update ongoing staff education. Staff said they are satisfied with the learning opportunities available and this supports them in the delivery of care and services. This includes staff saying they are currently undergoing qualification based training such as registered nursing degrees. Care recipients said staff are competent in their work roles. Education provided under Standard One includes: Accreditation, Aged Care Funding Instrument, customer service, finances in aged care and orientation.

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


The organisation and home demonstrated it has an internal and external complaints system in place accessible to care recipients, their representatives and staff. There are systems for formal and informal issues/feedback and complaints to be raised including a process for the lodgement of confidential complaints. The home maintains a register which shows how


complaints are managed including actions taken to address the concerns raised. This register also includes compliments. Comments, concerns, suggestions and complaints were seen to be discussed at care recipient, representative and staff meetings. The facility manager operates an open door policy and this was seen in practice during this visit. Care recipients, their representatives and staff are familiar with the complaints processes available in the home. Care recipients provided examples of where they have raised concerns and said on the whole they were confident these matters would be addressed. One care recipient said sometimes they have to wait for staff to follow up on things when they are raised with them. Another care recipient said they have never had a need to raise matters with staff that requires follow up.

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


Waterview Aged Care Facility displays the organisation’s vision, values and philosophy throughout the service and in relevant documentation. Staff said this is covered in their orientation and is used to guide their work practices. The home’s leadership team received many compliments from care recipients, representatives, staff and allied health providers regarding leadership and demonstrating the organisation’s core values.

1.6 Human resource managementThis 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".


The organisation has a comprehensive human resources framework supported by a dedicated human resources manager. There are systems in place to ensure consistency of practice and to ensure there are appropriately skilled and qualified staff who deliver care and services to care recipients. Analysis of changing care recipient needs informs staff recruitment. Reference checks and police certificate clearance are attended prior to employment. New staff receive a comprehensive workplace orientation and complete ‘buddy’ shifts and a period of probation. Position descriptions and work schedules support delivery of care and services. Management regularly review rosters and staff numbers to ensure care and service needs are being met. The home does not use agency staff but has a pool of staff to draw on for sudden absences or leave requirements. Staff appraisal is by line manager support and feedback and staff provided many examples of the organisation’s strong commitment to professional development. Staff said they have sufficient time and skills to complete their duties. One care recipient said new staff took too long to get to know care recipients and another thought the home should recruit more staff. Overall care recipients and representatives interviewed said there are sufficient and appropriately skilled staff available to meet care recipient needs.

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



The home’s management demonstrated there is a system in place for ordering all appropriate goods and equipment. Goods are ordered monthly and monitored at both organisational and home level. Auditing processes are through key staff with designated authority to do so. They ensure all ordered stock is appropriate for use in the home, is useable and matches what was ordered. Systems were seen to be used to return goods which were unsuitable, faulty or below the required standard (such as fresh food supply). A review of inventory and equipment showed adequate supplies and appropriate storage including a system, where required, of stock rotation and when goods needed to be replenished or replaced. The facility manager and organisation monitor inventory and equipment to ensure sufficiency is maintained. Care recipients expressed their satisfaction with the sufficiency of and access to appropriate goods and equipment.

1.8 Information systemsThis expected outcome requires that "effective information management systems are in place".


The organisation has a structured information management system in place. The organisation’s management team monitors this to ensure it is effective and consistent in application. The main care system is electronic but hard copy supports some documentation procedures. Policy and procedures support core delivery of all aspects of care and services. Management and staff have access to accurate and controlled information sufficient to help them perform their roles. These include care plans, clinical documentation, work schedules, position descriptions, information packs and handbooks. Care recipients and representatives have access to information appropriate to their needs. This includes agreements, welcome packs, handbooks, newsletters, brochures, meeting minutes, and noticeboard information. Information was seen to be stored in a way which is secure. Computer systems are password protected and accessible to only those with authority to do so. The computer system is backed up. Staff and care recipients said they are satisfied with the information available to them. Two care recipient representatives said communication could be improved in the home and as a result of this management are going to actively ensure case management processes are being applied.

1.9 External servicesThis 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".


The organisation has preferred contractors used by the home to ensure external services are provided in a way which meets the needs of the service and care recipients. The organisation and key personnel monitor contracts to ensure currency and that they meet required legislative requirements such as police certificates, insurances, indemnities, qualifications and registrations. There is a system in place to gather feedback around satisfaction with the quality and standard of the contracted services provided. The maintenance officer monitors contractors when they are on site and evaluates completed work. Staff and care recipients said they are confident in raising any concerns regarding the quality of the external services.


Standard 2 – Health and personal carePrinciple: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.



See expected outcome 1.1 Continuous improvement for information regarding the quality improvement system. Examples of recent improvements under Standard Two include:

The care manager reviewed the home’s system of wound management. They identified wound care practices and documentation was being inconsistently applied. It was decided to commence a weekly clinical nurse wound specialist led wound clinic based on wound care best practice principles. This involved reviewing all wounds in the facility and in the context of information from clinical indicators with the objective to ensure addressing wounds effectively to reduce deterioration or the onset of complications. Since the recent introduction of the weekly wound clinic the care manager has already identified a decrease in care recipients needing antibiotics as part of wound care. Following best practice principles has also resulted in accessing more current wound care products.

A pool of thirteen certificate III staff have competency in medication management to support registered nurses in the administration of medications. Staff identified this was insufficient to cover all shifts and a further five staff were identified who wanted to take on this role and who had demonstrated ability to work in this area. The staff selected attended two classroom modules with an external trainer. On completion of training the trainer came to the home and observed the staff member complete a medication round. Staff then completed an internal medication management competency. Management said this has provided a larger pool of trained staff to carry out this role.

The care manager wanted to find non-pharmaceutical interventions to manage anxiety for care recipients diagnosed with Alzheimer’s. In liaison with an external Alzheimer’s focused service they decided to trial a weighted blanket or lap pad that had been found to reduce agitation and poor sleep patterns in this cohort. In particular, it has a calming effect and promotes deep sleep. The trial, on one care recipient, was successful in reducing agitation, behaviours and anxiety. Staff said this care recipient is sleeping better and is more refreshed following sleep. The care manager said they will expand the use of this intervention for other care recipients who may benefit from its use.

2.2 Regulatory complianceThis 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”.


See expected outcome 1.2 Regulatory compliance for information regarding the home’s overall system for managing regulatory compliance. Under this Standard the home’s management demonstrated there are systems in place to report the ‘missing’ care recipients,


to ensure the currency of professional registrations and safe systems for the administration of medications and delivery and storage of S8 medications.



See expected outcome 1.3 Education and staff development for further information on how the home manages education and professional development. Examples of education and training delivered under Standard Two include: Palliative care, ear irrigation, nutrition and hydration, medication competencies, wound care, continence and pain management.

2.4 Clinical careThis expected outcome requires that “care recipients receive appropriate clinical care”.


Waterview Aged Care Facility has systems, processes, policies and procedures to ensure that care recipients receive appropriate clinical care. On entry to the home, each care recipient is assessed by the health, allied health and lifestyle teams to establish individual care recipients’ needs and plans of care. Review of care needs is regularly undertaken in consultation with the care recipient and their representatives. Communication of information across shifts is managed through a handover process where changes in resident care are communicated verbally and through the computerised system. Changes in care needs are identified and general observations are taken as required. Incidents are reported, acted upon and referred if required. Care staff demonstrated an understanding of care recipients’ individual needs. Care recipients/representatives said they were very satisfied with the clinical care received by care recipients.

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


There are systems to ensure appropriately trained staff are utilised to meet the needs of care recipients who require specialised nursing care. Registered nurses are responsible for the assessment of care recipients requiring specialised nursing care. Care plans are to be evaluated every three months and/or as needed. There is documentation relating to consultation with other health care specialists regarding care recipients’ care needs. Care staff demonstrated awareness of care recipients’ individualised specialised nursing care needs. Care recipients/representatives said they are satisfied with the level of specialised nursing care provided for care recipients.

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



The home has a system to ensure care recipients are referred to appropriate health care specialists in accordance with their assessed needs. A review of care recipients’ clinical documentation indicates assessments and reviews have occurred by various health specialists. These include a dietician, physiotherapist, podiatrist and speech pathologist. Care staff are aware of specialist input into care recipients’ care planning. Changes in care are communicated to staff by the manager/registered nurses as well as at staff handovers. Care recipients/representatives are aware of the availability of other health specialists if needed.

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


Systems are in place at the home to ensure care recipients’ medication is managed safely and correctly. This includes safe and correct medication administration by staff who have received training, secure medication storage and incident reporting systems. Medication incidents are investigated and all incidents reviewed were actioned appropriately. The home uses a medication management system of blister packs and original packaging provided by several local pharmacies. Safe and correct medication administration by care staff was observed and staff displayed understanding of the home’s medication management system, protocols, policies and procedures. Care recipients/representatives stated their medication is administered consistently and in accordance with their needs and preferences.

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


The home has a system for assessing, monitoring and treating care recipients’ pain when they enter the home and as needed. Care plans are formulated with individual pain management strategies. A multidisciplinary approach involving medical, nursing, physiotherapy support a care recipient’s pain management program. A combination of treatment options is available to manage care recipients’ pain, which includes but is not limited to heat, massage and pain relieving medication. Staff demonstrated knowledge of the processes required to effectively manage care recipients’ pain. Care recipients/ representatives said they are satisfied with care recipients’ pain management treatment and with staff response to care recipients’ needs for pain management.

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


The home has processes for identifying and managing care recipients' individual palliative care needs and preferences. Assessments are completed with the care recipient and/or representative to identify end of life care wishes and this information is documented in an end of life plan. The home uses a multidisciplinary approach that addresses the physical, psychological, emotional, cultural and spiritual support required by care recipients and their representatives. The home has access to the local Palliative Care Nurse Practitioner who attends care recipients case conferences with the multidisciplinary team and liaises with the


care recipient and or representative. The home has a supportive environment which provides comfort and dignity to the care recipient and their representatives. Care recipients remain in the home where ever possible, in accordance with their preferences. Referrals are made to medical officers, palliative care specialist teams and other health specialist services as required. Staff practices are monitored to ensure the delivery of palliative care is in accordance with the end of life plan. Staff follow end of life plans and respect any changes which may be requested. Care recipients and representatives interviewed are satisfied care recipients' comfort, dignity and palliative care needs are maintained.

2.10 Nutrition and hydrationThis expected outcome requires that “care recipients receive adequate nourishment and hydration”.


The home has a system to ensure each care recipient receives adequate nourishment and hydration. When a care recipient enters the home, an assessment is completed and the relevant information regarding nutrition and hydration is provided to the kitchen. Care recipients’ weights are recorded by care staff monthly and in line with their individual assessed need. Nutritional supplements are available for care recipients who require extra nutritional support. Documentation indicates and staff said care recipients receive appropriate special diets, dietary supplements, extra fluids and allied health referrals. The majority of care recipients/representatives said they are satisfied with the meals and drinks provided at the home. Two care recipients said choice of alternate meals could be improved.

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


The home can demonstrate care recipients are provided with care and services, which promote health and wellbeing ensuring skin integrity is maintained. Each resident receives an assessment of their skin integrity on entry to the home. If any alteration to skin integrity is assessed, it is reported and care plans are reflective of the change. Referral processes are available. The homes wound management clinical nurse specialist reviews all wound management plans on a weekly basis with the registered nurses. The team observed a number of pressure relieving mattresses in use, and other skin protection equipment available for use. The home has access to appropriate skin protection devices and skin care wound dressings. A podiatrist visits the home regularly. Interviews with care recipients /representatives demonstrate satisfaction with skin care interventions provided.

2.12 Continence managementThis expected outcome requires that “care recipients’ continence is managed effectively”.


The home has systems to ensure care recipients’ continence needs are managed effectively. Continence management strategies are developed for each care recipient following an initial assessment of urinary and bowel patterns. Care staff assist care recipients with their continence programs as required and care recipients’ bowel management programs are monitored daily. The clinical supervisor liaises with the staff in relation to the individual continence needs of care recipients. Care staff said there is a sufficient supply of continence


aids to meet care recipients’ needs. Care recipients/representatives said they are satisfied with the continence care provided to care recipients.

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


The needs of care recipients with challenging behaviours are identified through assessment processes and in consultation with the care recipient, their representative and/or allied health professionals. Individual strategies to manage challenging behaviours are identified and documented in the care plan and are regularly evaluated to ensure they remain effective. The home aims to be restraint free, with strict policies and procedures in place for the use of restraints and bed rails. Any form of restraint is implemented in accordance with legislation. The home's monitoring processes identify opportunities for improvement relating to behaviour management; this includes the collection and analysis of behavioural incident data. Staff understand how to manage individual care recipients' challenging behaviours, including those care recipients who wander and may be intrusive to other care recipients at times. Care recipients and representatives interviewed said staff are responsive and support care recipients with behaviour which may impact on others.

2.14 Mobility, dexterity and rehabilitationThis expected outcome requires that “optimum levels of mobility and dexterity are achieved for all care recipients”.


The home has processes to optimise care recipients’ levels of mobility and dexterity. Care recipients’ mobility and dexterity is assessed by the physiotherapist on their arrival at the home and on a needs basis. The physiotherapist develops individual programs and attend individual physiotherapy management plans for care recipients with the physiotherapy aide. The physiotherapist arranges walking groups and group exercise programs for the care recipients and these were observed and are conducted by the recreational officers. The accident and incident reporting system includes analysis of incidents to identify trends and strategies to be implemented to reduce the number of falls a care recipient incurs. Care staff demonstrate an understanding of their responsibilities in relation to optimising care recipients’ mobility and dexterity. Care recipients/representatives said they are satisfied with care recipients’ mobility program.

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


The home has a system to ensure care recipients’ oral and dental health is maintained. This includes initial and ongoing assessment of care recipients’ oral and dental needs. Care recipients’ day-to-day oral care is attended in line with individual care plans and referral to specialists is arranged according to care recipients’ needs and preferences. A dental technician attends the care recipients at the home on a needs basis. Care staff demonstrate an understanding of oral and dental care practices used in care recipients’ care. Care recipients/representatives said they are satisfied with the way in which care recipients’ oral health is maintained.


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


Care recipients’ sensory losses are identified and managed by staff at the home. The assessment process ensures any sensory loss is identified and referrals to appropriate specialists are made where required. The activity program incorporates activities to promote stimulation of the senses. Staff demonstrate an understanding of individual care recipients’ sensory needs. Care recipients/representatives report general satisfaction with the assistance provided by staff in relation to care recipients’ sensory losses.

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


The home ensures care recipients are able to achieve natural sleep patterns. An assessment of care recipients’ normal sleep routines is undertaken on entry to the home. From the assessment an individual sleep management plan, including the number of pillows, blankets, preferred settling time and other items are included. Interviews with staff confirm care recipients individual needs are assessed and met. Care recipients are encouraged to settle quietly in their rooms at night and staff can offer snacks and drinks during the night when required. Care recipients said they are able to have a good night’s sleep and the night staff are attentive to their needs.


Standard 3 – Care recipient lifestylePrinciple: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.



See expected outcome 1.1 Continuous improvement for information regarding the quality improvement system. Examples of recent improvements under Standard Three-Care recipient lifestyle include:

The activities coordinator identified men were not readily attending the activities offered. In response they decided to initiate a men’s focus activity group (Secret Men’s Business) and encourage the men to identify activities they would like to participate in. This has been run in conjunction with another of the organisation’s home’s located nearby. It has resulted in bus trips on outings to the local hardware store for coffee and a browse of the aisles. A fishing trip was also very popular. Likewise a visit to the local mines as this was a familiar occupation to many of the care recipients local to the area. During this reaccreditation visit the men met at Waterview Aged Care Facility and collectively made birdhouses. The activity officer said this initiative has been particularly successful in encouraging men in the home to take ownership of their activity program and join in. It has also resulted in men being more socially active and engaged with others.

The activities coordinator has initiated a sensory engagement activity which is particularly supportive of care recipients requiring one-on-one contact. This includes touch, taste and smell. Resources include water beads, rocks, sea shells and different fabrics for touch. Staff bring in fresh garden flowers for colour, texture and smell. Small figurines and coloured sands allow care recipients to make mandala’s in trays. This project has been successful in encouraging reminiscing with the activities coordinator saying one person who was non-verbal was following this activity able to reminisce about going to the beach and some continue to talk of the sensory experiences for days following the activity.

At a care recipients’ meeting it was raised that care recipients would like to get off the bus in an outing to have a morning tea. When not stopping somewhere that had a café it was identified care recipients only had an option of a cold drink with their cake or biscuits when on bus trips. To assist with this the home purchased two hot water urns and new containers for tea, coffee and sugar. This is in place and being used and appreciated by care recipients, particularly as it has occurred in time for use over the winter bus trips.

3.2 Regulatory complianceThis 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”.


See expected outcome 1.2 Regulatory compliance for information regarding the home’s overall system for managing regulatory compliance. As an example of meeting regulatory compliance under this Standard the home maintains a consolidated record. This shows


incidents where mandatory reporting has occurred or discretion not to report has been used. All incidents are reported up through the organisation and decisions on appropriate action are made by the designated key person. Staff demonstrated an understanding of how they would report alleged assaults and said they had received mandatory education on reporting elder abuse. The home (through its organisation) has the link to the updated reporting form as is now required by the Department of Health for missing care recipients and the reporting of alleged assaults.



See expected outcome 1.3 Education and staff development for further information on how the home manages education and professional development. Examples of education and training delivered under Standard Three Care recipient lifestyle include: Secret men’s business, loss and grief, reporting and managing elder abuse, choice and decision making and supporting independence.

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".


There are effective systems to ensure each care recipient receives initial and ongoing emotional support. These include orientation to the home, staff and services for new care recipients and their families; visits from the chaplain and recreational activities officers, care recipient/representatives meetings. Front of the house staff and organisation staff are trained in assisting care recipients and their families familiarise themselves with the service and entry to the home such as through showing them their room and layout of the home. Emotional needs are identified through the lifestyle assessments (social profile) including one-to-one support and family involvement in planning of care. Care recipients are encouraged to personalise their living area and visitors are welcomed and encouraged to participate in the life of the home. Care recipients provided many examples of how staff support them emotionally to adjust and maintain their life in the home. Two care recipients identified they did not require emotional support from staff.

3.5 IndependenceThis 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".


The home’s management and staff ensure care recipients are assisted to maintain maximum independence, friendships and participate in all aspects of community life within and outside the home. There is a range of individual and general strategies implemented to promote independence including mobility and lifestyle engagement programs. Care recipients decide on venues for bus trips and to take part in shared outings with a nearby home. Visitors, volunteers are welcomed and encouraged to join in with care recipients. Management actively support care recipients and representatives to speak openly and participate in the life


of the home. Documentation, observation, staff practices and care recipient and representative feedback confirms care recipients are actively encouraged to maintain their independence. Many care recipients expressed how much they can do for themselves with one care recipient saying they don’t require support to be independent as they can still do everything by them self.

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


There are systems to ensure privacy and dignity is respected in accordance with care recipient’s individual needs. The assessment process identifies each care recipient’s personal, cultural and spiritual needs that address privacy and dignity, including how the care recipient prefers to be addressed. For example, activity staff respect a care recipient’s right and choice not to socialise if they are by nature a private person by providing a range of one-on-one contact and engagement. Privacy screens are used in shared rooms. Permission is sought from care recipients for the display of photographs. Staff education promotes privacy and dignity and all staff sign to acknowledge confidentiality of care recipients’ information. Confidential information is discussed in private and care recipients’ files securely stored. Care recipients and representatives said staff are very respectful and they are satisfied with how privacy and dignity is managed at the home.

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


Care recipients’ past recreational interests and preferences are assessed on entry to the home and monitored on an ongoing basis and this includes creating a detailed social profile. There is an extensive monthly calendar of activities and staff were seen encouraging care recipients to participate in a wide range of entertainment. Regular entertainers are booked and care recipients were observed enjoying a solo artist and a men’s choir during this visit. Word games, DVD films, music and exercise programs including a walking program, are offered. Activities are assessed for effectiveness and feedback sought form care recipients and this information documented. Care recipients are given the choice of whether or not to take part in activities. One-on-one activities including newspaper reading, puzzles and word games, conversation and hand massage are promoted to ensure care recipients are not isolated. Weekend activities are supported by care staff. Care recipients said they very much enjoy the activities provided and that they are consulted with about what is provided.

3.8 Cultural and spiritual lifeThis expected outcome requires that "individual interests, customs, beliefs and cultural and ethnic backgrounds are valued and fostered".


Care recipients’ cultural and spiritual needs are fostered through the identification and communication of care recipients’ individual interests, customs, religions and ethnic backgrounds during the assessment processes. The home recognises and celebrates culturally specific days such as recently a royal wedding, Christmas and Easter festivities,


Australia Day. Care recipients are asked about end of life wishes and this information is documented in their file. The home has a pastoral care service and chaplains and pastoral carers were observed interacting with care recipients. Religious services are held on site. Care recipients and representatives confirm care recipients’ cultural and spiritual needs are being met. Staff and care recipients said they appreciate the services provided by the pastoral carers and chaplains.

3.9 Choice and decision-makingThis 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".


Management and staff actively support care recipient to exercise choice in decision making around care and services. This includes consultation processes with care, attendance at activities and choices around meals and waking and sleeping times. At entry to the home care recipient’s preferences are identified and documented. Observation of staff practices and staff interviews show care recipients have choices available to them. Care recipients/representatives meetings occur regularly and provide opportunity for care recipients to discuss and provide feedback about the services provided. Care recipients said they are satisfied with the support of staff in the home relative in assisting them in their choice and decision making processes.

3.10 Care recipient security of tenure and responsibilitiesThis expected outcome requires that "care recipients have secure tenure within the residential care service, and understand their rights and responsibilities".


The home’s management were able to demonstrate care recipients and their representatives have been provided with information about security of tenure and understand care recipient rights and responsibilities. The care recipient welcome pack and care recipient agreement outlines security of tenure and potential care recipients are carefully taken talked through the contents of the agreement before signing and becoming a care recipient in the home. Any change of room is only done in consultation with the care recipient and/or their designated representative and seeking their agreement to the change. The Charter of Care Recipients’ Rights and Responsibilities is on display around the home and included in documentation where relevant. Care recipients said they feel secure in the home and understand their rights and responsibilities.


Standard 4 – Physical environment and safe systemsPrinciple:Care recipients live in a safe and comfortable environment that ensures the quality of life and welfare of care recipients, staff and visitors.



See expected outcome 1.1 Continuous improvement for information regarding the quality improvement system. Examples of recent improvements under Standard Four include:

It was identified an outdoor veranda area of the home was during heavy rain holding surface water; making tiles in this area unsafe to walk on. This area was recognised as a being a popular outdoor area for care recipients and their visitors to use. Holes were drilled in the grout between tiles to ensure greater drainage and the tiles repainted with non-slip paint. We were at the home during a period of heavy rain and observed this intervention has been successful in reducing surface water on the tiles and that the surface was no longer slippery.

In the same location it was identified a set of steps leading to the outside road area had become unsafe and were providing an unsecured entry point to the home. The steps were removed and replaced with fencing and handrails along the veranda deck. Entry through this point was removed and visitors now come into the home on this side of the building at an entry point that passes the nurse’s station. Staff are now more aware of visitors entering the building in this location and the handrail along the veranda makes this a safer area in which care recipients can walk around the outside of the home.

Previously care recipients had a choice of one hot meal per serving. This was raised at a care recipient meeting as the alternate meal tended to be salad or sandwiches. Care recipients said they would like a choice from two hot meals. Since this has been introduced, care recipients have expressed their satisfaction at care recipient/ representative meetings. We observed on the days of this visit care recipients had choice of two hot meals, in large portions and were seen enjoying the fresh cooked food.

4.2 Regulatory complianceThis 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”.


See expected outcome 1.2 Regulatory compliance for information regarding the home’s overall system for managing regulatory compliance. The home has a current fire certificate and NSW Safe Food Authority certificate. The home has a work, health and safety committee. Catering staff have completed safe food handling training. Education registers show the majority of staff have completed their annual mandatory training under this Standard including fire and emergency, manual handling and infection control.




See expected outcome 1.3 Education and staff development for further information on how the home manages education and professional development. Examples of education and training delivered under Standard Four include: Infection control, use of and management of chemicals, safe food handling, work, health and safety, fire and emergency and manual handling.

4.4 Living environmentThis 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".


The home’s management is actively working to provide a safe and comfortable environment consistent with care recipients’ care needs. The home’s comfort and safety are enhanced through mechanisms such as regular environmental safety inspections, audits, cleaning, maintenance and other safety-related checks, and incident and accident reporting. There are also care recipient feedback mechanisms, such as residents/relatives’ meetings, surveys, and direct discussions with management, in relation to the comfort and safety of the living environment. Care recipients and representatives stated the home is safe and comfortable. This view was also supported by various safety monitoring and reporting data we reviewed. One care recipient said they do not feel entirely safe living in the home.

4.5 Occupational health and safetyThis expected outcome requires that "management is actively working to provide a safe working environment that meets regulatory requirements".


Management is actively working to provide a safe working environment that meets regulatory requirements. The home’s workplace health and safety committee monitors the safety system. The system includes regular staff induction and regular training (including manual handling), regular safety-related audits and inspections, hazard reporting, accident and incident reporting and risk assessments. A preventative and routine maintenance program is in operation in the home, which helps ensure the overall safety of the environment and equipment. There have been minimal incidents relating to staff safety, thereby indicating the effectiveness of the home’s approach to work health and safety.

4.6 Fire, security and other emergenciesThis 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".


The home’s management and staff are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks. Fire safety systems in the home include fire detection and alarm systems, a sprinkler system, firefighting equipment, exit signs and evacuation plans. The home has formal, external contractual arrangements for the monitoring and maintenance of all its fire safety equipment and systems. We sighted fire safety certification appropriately displayed on the homes monitor. The home maintains an evacuation kit and regularly updates care recipient evacuation lists for immediate use should


the need arise. Staff training records confirm staff participate in regular mandatory fire safety training. Staff interviewed were aware of fire safety and emergency procedures. The home provides a secure environment including secured doors, lock up procedures, CCTV monitoring, and appropriate overnight staffing and security arrangements.

4.7 Infection controlThis expected outcome requires that there is "an effective infection control program".


The home has processes to support an effective infection control program. The infection control program includes regular assessment of care recipients' clinical care needs in relation to current infections, susceptibility to infections and prevention of infections. Staff and management follow required guidelines for reporting and management of notifiable diseases. Care plans describe specific prevention and management strategies. The home's monitoring processes identify opportunities for improvement in relation to infection control; this includes observation of staff practices, analysis of clinical and infection data and evaluation of results. Preventative measures used to minimise infection include staff training, a food safety program, cleaning regimes, vaccination programs, a pest control program, waste management and laundry processes. Staff are provided with information about infections at the home and have access to policies and procedures and specific equipment to assist in the prevention and management of an infection or outbreak. Care recipients/representatives and staff interviewed are satisfied with the prevention and management of infections.

4.8 Catering, cleaning and laundry servicesThis expected outcome requires that "hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment".


The home provides hospitality services in a way that enhances care recipients’ quality of life and the staff’s working environment. The hospitality services are subject to regular monitoring and audits to ensure they are operating at desired levels. The catering system ensures care recipients’ preferences are taken into account in the food planning process, and appropriate choices and alternatives are offered. Care recipients and representatives have input into menu through meetings, regular feedback directly to staff and other communication. Two care recipients said they do not always get a choice of meal they would like in the evening meal service. One care recipient said there was too much chicken on the menu and occasionally the meat was too tough. One care recipient said they would prefer a smaller meal portion. However, the majority of care recipients expressed satisfaction with the choice, quality and portion of meal sizes.

We noted the cleaning system is well organised and effective, with common areas and each care recipient’s room being cleaned regularly. Laundry services are provided effectively with care recipients’ personal items are washed and returned to them within a reasonable turnaround time. Care recipients/representatives confirmed their satisfaction with the level of cleanliness and the laundry services at the home.


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