rosary gardens - aged care qualityrosary gardens racs id 8416 85 creek road new town tas 7008...

Rosary Gardens

RACS ID 8416 85 Creek Road

NEW TOWN TAS 7008

Approved provider: Southern Cross Care (Tas) Inc

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 22 March 2018.

We made our decision on 20 January 2015.

The audit was conducted on 09 December 2014 to 10 December 2014. The assessment team’s report is attached.

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

Home name: Rosary Gardens RACS ID: 8416 2 Dates of audit: 09 December 2014 to 10 December 2014

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

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





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

Rosary Gardens 8416


Introduction

This is the report of a re-accreditation audit from 09 December 2014 to 10 December 2014 submitted to the Quality Agency.

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

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

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

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

Assessment team’s findings regarding performance against the Accreditation Standards

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

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 09 December 2014 to 10 December 2014.

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: Adrian Clementz

Team members: Amanda McFarlane

Anne Osman

Approved provider details


Details of home

Name of home: Rosary Gardens

RACS ID: 8416

Total number of allocated places:

143

Number of care recipients during audit:

109

Number of care recipients receiving high care during audit:

Not applicable

Special needs catered for: Dementia specific wing

Street: 85 Creek Road

City: New Town

State: Tasmania

Postcode: 7008

Phone number: 03 6214 9700

Facsimile: 03 6228 3856

E-mail address: Nil

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


Audit trail

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

Interviews

Category Number

Management 3

Quality, staff development and administrative staff 4

Registered nurses and enrolled nurses pharmacology 6

Extended care assistants and lifestyle staff 8

Care recipients 16

Representatives 6

Catering, cleaning, laundry and maintenance staff 10

Sampled documents

Category Number

Care recipients’ files 22

Summary/quick reference care plans 10

Medication charts 14

Personnel files 12

Other documents reviewed

The team also reviewed:

Activity calendar

Annual maintenance statement

Approved supplier list

Audit results

Residents’ information package

Chaplaincy and pastoral care program

Cleaning and laundry documentation

Clinical observations and reportable limits

Complaints documentation

Continuous improvement plan and associated records


Education and staff development records

Education monitoring records

Emergency evacuation documentation

Emergency management plan

Essential servicing records

External contractor records

Fire and emergency documentation

Handover documentation

Hazard reports

Health and safety documentation

Incident reports

Infection control records, audits and graphs

Kitchen audits, duties and records

Lifestyle planning documents

Lifestyle program evaluation

Meeting minutes

Memoranda

Menus

Newsletters

Noticeboards

Nursing registration records

Performance appraisals

Pest control records

Police certificate folders and renewal lists

Policies and procedures

Position descriptions

Preventative and routine maintenance records

Purchase records


Reportable incidents register

Residential agreements

Risk assessments

Roster

Self-assessment

Specialised nursing care plans and charts

Staff information booklet

Statements of strategic intent

Statutory declarations

Strategic plan

Surveys

Wound charts.

Observations

The team observed the following:

Activities in progress

Charter of residents’ rights and responsibilities

Chemical storage

Egress and exit routes

Emotional support visits

Equipment and supply storage areas

External and internal comments and complaints information on display

Fire and emergency equipment

Hairdresser on site

Hand hygiene facilities

Interactions between staff and residents

Internal and external living environment

Lodgement box

Meal preparation and service


Mobility aids and equipment

Noticeboards

Notification of reaccreditation visit

Security

Short group observation

Staff assisting residents with activities

Storage and administration of medications

Test and tagged equipment.


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

Management has systems and processes to identify, plan, implement and evaluate continuous improvement across all the Standards including management systems, staffing and organisational development. The home uses resident and representative feedback, results from scheduled and targeted audits, staff feedback, improvement logs, hazard forms and data analysis to identify trends to identify areas for proposed improvements. The continuous improvement plan outlines actions, progress and evaluation. The progress of each initiative is assessed progressively and outcomes for residents and staff are assessed through observation, audit results, staff and resident feedback. Residents and representatives contribute to the improvement plan. Management and staff inform residents of initiatives and progress at regular resident meetings and in newsletters.

Recent improvements in relation to Standard 1include:

Management responded to staff feedback and initiated a review of the orientation process for new staff to identify gaps and introduce corrective measures. The plan included allocating orientation of staff to a registered nurse as a portfolio and implementing measurable outcomes for the program. This process was trialled in November 2014. Evaluations are ongoing and incorporate feedback from staff post orientation and observations to measure employee satisfaction and benefits to residents care. Management indicate that feedback to date has been positive. Residents are satisfied that staff have the skills necessary for their roles.

Management responded to feedback about staff morale and wellbeing following a restructure. Management introduced a forum incorporating staff from continuous improvement and safety representatives. At forum meetings stakeholders identify issues of importance to staff wellbeing and morale and recommend strategies to address these issues. In November 2014 a staff survey was undertaken to evaluate ongoing wellbeing and morale. Management indicate that outcomes have been positive as a result of this forum.


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, with the support of the parent organisation, has a generally effective system to identify, respond to and meet relevant legislation, regulatory requirements, professional standards and guidelines across the Accreditation Standards. Management receive information through legislative update services, peak bodies and government departmental bulletins. This information is interpreted by key personnel and discussed at relevant forums. As part of this process, management review existing or develop new policies and procedures. Management provide information to staff about changes to policy and procedure through meetings, memoranda and education. Staff said they receive information about regulatory compliance matters and demonstrated knowledge relevant to their role.

Examples of responsiveness to regulatory compliance relating to Standard 1 include the following:

Management processes ensure ongoing self-assessment of the home.

The home has an effective system to manage police certificates for staff, volunteers and contractors.

The home has an effective process to manage statutory declarations in regard to citizenship or permanent residence of a country other than Australia since turning 16 years of age.

Stakeholders have access to information about advocacy services and external complaint mechanisms.


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


There is a system to ensure management and staff have the appropriate knowledge and skills to perform their roles effectively across the Accreditation Standards. Management develop an education program based on resident care needs, performance appraisals, surveys, benchmarking results and competency requirements. The education program incorporates both internal and external education sessions covering a wide range of topics. The home actively participates in research projects undertaken by local higher education institutions. There are processes to advise staff of upcoming training and to track attendance at mandatory education. Staff are satisfied with the range of education and professional development opportunities available to them. Residents and representatives are satisfied staff have the skills and knowledge to meet residents’ care needs and preferences.

Examples of education provided in relation to Standard 1 include:

customer service

electronic care documentation

mentoring: listening, coaching and feedback

strategies for dealing with conflict

workplace coaching.

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


Management has systems which ensure care recipients and representatives have access to internal and external complaints mechanisms. Management captures complaints and comments through feedback forms, resident meetings, audits and verbal feedback which are recorded in a register for analysis and trending. Complaints and feedback are actioned in a timely manner and handled with sensitivity. Information in the resident information pack explains the process for providing feedback and complaints mechanisms. Management displays brochures for external complaints bodies in public areas at the home. Residents and representatives are comfortable raising issues of concern with staff and management and satisfied with the resolution of complaints.


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’s vision, mission and values are documented in a consistent way and shared with residents, representatives, staff and visitors. A commitment to quality care is articulated through these statements of strategic intent.

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


Management demonstrates there are sufficient numbers of appropriately skilled and qualified staff to provide care recipient care and services. The home bases their recruitment process on skill and qualification requirements outlined in position descriptions. Interviews and reference checks are completed and the organisation has an induction process for new staff. Resources to support staff in their roles include position descriptions, policies and procedures, handbooks and ongoing education. Staff performance is monitored during a probation period and thereafter through observations of practice, incidents, feedback and an annual performance appraisal. There are processes to replace staff for planned and unplanned leave. Residents and representatives are satisfied with the care and services provided by staff.

1.7 Inventory and equipment

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

Team’s findings


The home has effective systems to ensure stocks of appropriate goods and required equipment is available for staff and residents. Management ensure approved suppliers deliver consumables to a regular order cycle and there are processes to maintain adequate stock holding levels. Management identifies equipment needs through feedback mechanisms, meeting structures, observations and visiting professional services. There are processes to ensure staff receive required education in the safe and effective use of new products, inventory and equipment. The home maintains a preventive maintenance program and a structured process to manage unscheduled repairs and maintenance. Storage areas are sufficient, organised and secure. Staff and residents are satisfied adequate and quality supplies of inventory and equipment are available at the home.


1.8 Information systems

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

Team’s findings


Management and staff have access to information that is accurate and appropriate to perform their roles. Residents and representatives receive information on entry to the home including a handbook and resident agreement. Individual meetings, newsletters, resident meetings and noticeboards keep residents and representatives informed of the home’s operations. Processes to keep staff informed include policies and procedures, education, staff meetings, handover meetings and duty statements. Education, health and safety and other information is communicated via staff memoranda or posted on noticeboards. There are processes in place to ensure the security of resident and staff information and for archiving and retrieving documents. Staff and management report the system provides accurate and relevant information for resident care. Staff have access to results of data routinely collected during audits and analysed. The team observed secure storage of confidential staff and resident information.

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


Management ensures externally sourced services are provided in a way that meets the home’s needs and quality goals. The home maintains service agreements with a wide variety of external service providers. External contractors provide evidence of qualifications, certification and insurances as part of the contractual engagement and review process.

Management has processes to ensure external service providers meet their contracted obligations as scheduled. Management monitors the quality of services through audits, surveys and meeting mechanisms. Residents and staff are satisfied with the services provided by external contractors.


Standard 2 – Health and personal care

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



Team’s findings


Management and staff actively pursue continuous improvement in relation to resident health and personal care. Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement system and processes.

Recent improvements in relation to Standard 2 include:

Management identified an opportunity to improve resident health and personal care by providing alternative therapies. The home implemented a clinic for residents provided by allied health professionals which includes massage, heat therapies and other interventions to assist residents with circulation, movement and pain management. Residents are assessed to participate in the program and attend clinics in a social setting. Resident feedback indicates they are satisfied that the program has positive health benefits including socialisation, pain management, enhanced moods and improved range of movement. Clinical care reports and staff observations also identify these benefits to residents. Evaluation is ongoing.

A wound care specialist provided consultation to management regarding the disadvantages of using a particular type of cream to hydrate residents’ skin. A new product was recommended as an alternative. The product was trialled in the home and clinical care staff noted significant improvement in wound care outcomes and skin integrity. The cream has since been introduced throughout the home, along with an education program for staff. Quality performance systems statistics support that the change has provided benefits for residents care.

Management identified an increased need for palliative care options that could accommodate the privacy, dignity and emotional support needs of residents and their representatives. A number of shared rooms were reclassified and reconditioned to provide a palliative care suite that allows increased personal space and a sofa bed/ lounge for guests. Feedback from residents and representatives has been positive.



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 has a system to identify and meet regulatory compliance obligations in relation to health and personal care. For a description of the system refer to expected outcome 1.2 Regulatory compliance.


Appropriately qualified staff manage clinical care.

Professional registrations of staff are monitored and maintained.

The home demonstrates compliance with policy and legislative requirements in relation to medication storage and management.

There are effective processes to manage and report the unexplained absence of a care recipient.



Team’s findings


The home has a system to enable management and staff to have the appropriate knowledge and skills to perform their roles effectively relative to health and personal care. For a description of the system refer to expected outcome 1.3 Education and staff development.


heat pack management

older people and diabetes

palliative and end of life care

repositioning, feeding and choking management

wound management.


2.4 Clinical care

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

Team’s findings


On the resident’s entry to the home, and ongoing, staff identify and assess the resident’s individual care needs and preferences in consultation with the resident. This information is enhanced by further consultation with the resident’s representative, if required, and other health professionals on an as needs basis. An electronic care planning system underpins care planning. Staff assess and manage clinical issues, specialist advice is sought where indicated and changes in the resident’s condition are noted, reviewed and acted on. Staff were observed to be meeting the individual resident’s care needs and were able to articulate knowledge about this. Residents and representatives are complimentary with the clinical care provided to residents and appreciative of the staff that deliver this care.

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


General practitioners, medical specialists, registered nurses and allied health practitioners assess and manage residents’ specialised care needs. Current specialised care needs managed by the home includes diabetic management, catheter care, complex wounds and oxygen therapy. Assessed specialised care instructions are recorded in the resident’s electronic care plan, relevant charting is maintained and care is reviewed as required. Staff state they are informed of changes in the residents’ specialised care needs promptly and the home’s education and training program support them in maintaining the appropriate skills and knowledge in this area. Residents and representatives are satisfied with how residents’ specialised care needs are managed.

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


Effective systems exist at the home to support residents in accessing health specialists as indicated. Documentation demonstrates health specialists are actively involved in the delivery of resident care in areas such as mental health, physiotherapy, pathology, wound management and podiatry. Health specialists’ recommendations are recorded, discussed and implemented by the home. Staff are aware of the need to seek external expertise when indicated. Residents expressed satisfaction with how the home manages this area of care and supports them to access these services.


2.7 Medication management

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

Team’s findings


The home has systems in place to ensure care recipients’ medications are managed safely and correctly. Registered nurses oversee administration of medications to residents and competency tested enrolled nurses, with pharmacology registration, assist in this process. Medications are stored safely and securely and in accordance with regulatory guidelines.

Monitoring processes of medication management include audits, competency testing and an incident reporting system. Staff are aware of the need to ensure the safe delivery, monitoring and review of resident medication. Residents state staff administer their medications on time, in a safe manner and are satisfied with the way staff manage this process.

2.8 Pain management

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

Team’s findings


A resident’s susceptibility to pain is assessed on entry to the home and a care plan is developed which identifies both non-chemical and chemical interventions to manage resident’s pain, if present. Staff undertake comprehensive assessments of residents’ pain and conduct care plan reviews so as to ensure the resident’s pain levels are monitored to facilitate optimum comfort. As necessary medication is available, reported, monitored and referred to resident’s general practitioner or specialists as required. Alternative therapies, such as heat therapy, massage and exercise are offered to residents. Staff describe the individual resident’s pain needs and the way they assist residents in the management of this. Residents report satisfaction with the way the home assists them to manage any pain they may have.

2.9 Palliative care

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

Team’s findings


Management has undertaken a comprehensive review of residents’ end of life needs so as to ensure maximum comfort for the resident and their representatives is maintained during this time. A dedicated suite of rooms is available for residents and their representatives, which allows residents to remain in close contact with their representatives at all times. Systems exist to support residents during this time such as consultancy with external palliative care services and pastoral care. End of life wishes plans are developed, respected and inform the care provided for the resident at this time of life. Pain management, spiritual and pastoral support for the resident is both fostered and practiced by staff together with pastoral care being made available for representatives. Staff know how to access external palliative care services if


required. Documentation assists and supports staff in delivering care for the dying resident. At the time of this audit there were no residents receiving palliative care.

2.10 Nutrition and hydration

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

Team’s findings


The home has systems to ensure residents receive appropriate nourishment and hydration. Residents’ needs are assessed on entry and a care plan developed which is regularly reviewed thereafter. Dietary needs are noted, along with food likes and dislikes, special diets and consistency of fluids. Referrals to specialists are made in the event of significant weight change, decreased appetite or swallowing difficulties. Residents were observed being assisted by staff in an appropriate manner when eating and drinking. The home offers a number of meal choices for each meal. Residents and representatives are satisfied with how the home meets each resident’s nutritional needs. Staff have an understanding of the importance of choice for residents in regard to the resident’s food and fluid intake and were observed fostering this during meals times.

2.11 Skin care

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

Team’s findings


On entry to the home an initial skin assessment is undertaken and a care plan developed to ensure the resident’s skin integrity is managed according to their requirements. An additional, more comprehensive, assessment is also undertaken with final care plans developed and reviewed as required. Residents have access to specialised equipment to prevent and manage their skin and a wound consultant is available when indicated. Staff are highly aware of resident’s skin care needs, expressed pride in the home’s low rate of complex wounds and demonstrated considerable expertise in this area of care. Residents stated they are satisfied with how their skin needs are managed.

2.12 Continence management

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

Team’s findings


Rosary Gardens demonstrates systems, which support residents to maintain optimum continence. Nursing staff assess the resident’s individual continence needs on entry to the home and ongoing, an individual continence plan is developed, implemented and reviewed regularly to meet the changing needs of the resident. Staff are aware of the resident’s individual continence programs and facilitate these. Residents and representatives state satisfaction with the way the home assists residents in facilitating the residents’ continence needs.


2.13 Behavioural management

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

Team’s findings


Residents and representatives express satisfaction in the way the home manages the needs of residents who exhibit complex behaviours. The home has a specialist area where residents living with dementia reside that has access to garden areas, a spacious dining room and lounge areas in which a specific lifestyle program is delivered for these residents. When required, residents are referred to the aged person’s mental health team, private psychiatrist or memory support services. Resident behavioural assessments are commenced on entry to the home, care plans are developed and regular review occurs as required. Staff describe the individual needs of residents in regard to behavioural management and were observed to assist residents whilst they were participating in the lifestyle program.

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


Residents report they are assisted and supported by staff to maintain their maximum mobility and dexterity. On entry to the home residents undergo a mobility and falls risk assessment, an individualised care plan is developed, implemented and thereafter regularly reviewed. If indicated, a physiotherapist will make recommendations for care directives, specialised equipment and safety management strategies to ensure optimal outcomes for each resident. Residents’ manual dexterity is optimised through passive, active exercises and use of specialist aids. Staff were observed assisting residents to mobilise, were able to articulate each resident’s individual mobility needs and were aware of the importance of ensuring maximum mobility maintenance for residents.

2.15 Oral and dental care

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

Team’s findings


Rosary Gardens has systems to ensure residents maintain optimal dental and oral health. Assessments for dental and oral health needs and preferences are conducted on entry to the home and appropriate referrals made to external dental service providers if indicated. Oral care plans are generated to assist care staff in delivering mouth hygiene to residents. Staff have an understanding of the importance of maintaining residents’ dental and oral care needs. Residents are supported to access dental services external to the home and residents and representatives indicate they are satisfied with how residents’ oral and dental needs are managed by staff.


2.16 Sensory loss

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

Team’s findings


On entry to the home the residents’ sensory needs are assessed, care plans developed and ongoing reviews undertaken to ensure residents’ sensory needs are maintained. Residents were observed to be wearing sensory aids. Residents and representatives expressed satisfaction with the home’s processes to manage residents’ sensory need requirements.

Identification, assessment and evaluation of residents’ senses occur to optimise residents’ sensory functions. Staff are aware of residents who require assistance to fit and clean their aids. Specialist services are available to manage residents’ sensory decline and referrals are made where indicated.

2.17 Sleep

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

Team’s findings


Residents report the home is quiet at night, which assists them to achieve natural sleep patterns. Staff assess residents’ individual needs and preferences for sleep and settling times. Assessment, care planning and review processes support residents in obtaining quality sleep. Residents’ general practitioners monitor the use of sedation and strategies to assist residents in obtaining natural sleep are known by staff. Staff are aware of residents’ individual settling routines. Residents express satisfaction in the support offered by staff in helping them achieve natural sleep.


Standard 3 – Care recipient lifestyle

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



Team’s findings


Management and staff actively pursue continuous improvement in relation to resident lifestyle programs. Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement system and processes.


Staff from lifestyle and catering collaborated to introduce a café style dining program for residents to invite family members to dinner. Residents are assessed to participate in the program and invited to the café with their guests. The café offers food prepared by the main kitchen. Residents and guests get to choose from a café style menu and lifestyle staff are attired as waiting staff and provide the meal service. The program offers new independence to residents who are unable to visit relatives or friends outside of the home. The program has received positive feedback from residents and representatives including letters of compliment.

Management initiated the replacement of lounge furniture in the living areas of the facility. During this process the height of lounge chairs was considered as a factor to enable resident mobility and independence and to reduce the potential for falls. Chairs were selected with a higher seat level to improve the experience for residents so that standing is easier and there is less risk of overbalancing, In addition, residents participated in the choice of fabrics for the lounge areas. Management are satisfied with the improvements based on statistics and observations.



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 has a system to identify and meet regulatory compliance obligations in relation to care recipient lifestyle. For a description of the system refer to expected outcome 1.2 Regulatory compliance.


Management provides information about privacy and confidentiality to residents, their representatives and staff.

The home has a policy, procedure and guidelines in relation to elder abuse and compulsory reporting and there are processes to make staff aware of their responsibilities.

The Charter of residents’ rights and responsibilities is displayed within the home.

The home provides a residential agreement to residents or their nominated representative at the time of entry.



Team’s findings


The home has a system to enable management and staff to have the appropriate knowledge and skills to perform their roles relative to care recipients’ lifestyle. For a description of the system refer to expected outcome 1.3 Education and staff development.


colour reminiscing

elder abuse and mandatory reporting

leisure, lifestyle and pastoral care workshop

privacy principles

sexuality, ageing and dementia.


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 has a system to ensure each care recipient receives emotional support while they are adjusting to life in the home. On entry all residents are orientated to their new surroundings and introduced to staff and other residents. Clinical staff, lifestyle officers and pastoral carers identify residents’ emotional needs through initial assessment and ongoing interaction. Personalised care plans reflect residents’ emotional needs. Residents are encouraged to personalise their rooms and visitors are welcomed to the home. Staff interact with residents in a respectful manner. Residents and representatives expressed satisfaction with the assistance given to adjust to life at the home and the ongoing support they receive.

3.5 Independence

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

Team’s findings


Care recipients are assisted to achieve maximum independence, maintain friendships and participate in the life of the community within and outside the residential care service.

Residents’ independence is fostered and encouraged. During the entry process, staff make an assessment of independence goals and consider resident’s individual preferences and needs. Staff also assess for physical, cognitive, emotional and social needs and interests. Residents are assisted to maintain their physical independence using mobility aids and other devices. Residents maintain links with the local community including regular church services, school visits, coffee mornings and outings to local shops. Residents also attend activities and events held within the home including concerts and family dinners.

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


Management and staff recognise and respect the care recipients’ right to privacy, dignity and confidentiality. Staff and volunteers are provided with information relating to confidentiality and respect for residents’ privacy and dignity through orientation, meetings, staff education and policy. Electronic information is stored securely with password protection and access limited according to roles. Files containing residents’ personal information, along with resident agreements, are stored in locked areas with access limited to authorised staff. Staff described ways to promote residents’ privacy and dignity such as, knocking before entering rooms,


addressing residents by their preferred names and ensuring privacy when delivering personal care. Residents are satisfied staff are respectful of their confidentiality, privacy and dignity.

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


Management and staff encourage and support care recipients to participate in a wide range of interests and activities of interest to them. Clinical staff and lifestyle officers collaborate to assess the preferences and needs of residents on entry to the home. The home offers a range of programs to suit the individual needs of residents and fosters links to the community. Programs include outings, the option to invite guests for dinner, men’s group, walks, garden therapy and massage clinics to assist with pain management. The home celebrates cultural and social events with strong support from staff. Regular visits from music and school groups further enhance this program for residents. The calendar of events of the activities program is provided to residents and displayed in the home. Residents are satisfied with the support they receive to participate in interests and activities to enhance their lifestyle.

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


Management has systems to ensure residents individual cultural beliefs and spiritual customs are valued and fostered. Residents’ cultural preferences, spiritual beliefs and customs are assessed and included in their care plan when they move into the home and reviewed on an ongoing basis. Special occasions, cultural events and practices that are important to residents are noted and events such as birthdays are celebrated according to resident’s preferences. Pastoral care staff provide support for residents to discuss and maintain their wellbeing and spiritual beliefs. Management and lifestyle officers encourage visits from multiple religious denominations to meet residents’ spiritual needs. There are regular church and communion services at the home. Residents are satisfied with the support provided to them to maintain their cultural and spiritual beliefs and customs.

3.9 Choice and decision-making

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

Team’s findings


Care recipients or their representative participate in decisions about the services they receive and are enabled to exercise choice and control over their lifestyle while not infringing on the


rights of other people. Management and staff support and encourage residents to exercise choice and control over their care and lifestyle. Residents and representatives are provided with information to assist them in making informed decisions about each residents’ care needs, rights and responsibilities. The home consults with residents and completes individual assessments to identify residents’ preferences for assisted daily living, meal choices, lifestyle program, clinical and palliative care. Personalised care plans guide staff about resident choices. Residents are encouraged to personalise their rooms with memorabilia and furniture of their choice. Resident and representative feedback is encouraged via formal mechanisms such as feedback forms, resident meetings and surveys. Residents and representatives expressed satisfaction with the choices and decisions they are able to make about their lifestyle and care.

3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


Care recipients have secure tenure within the home and there are processes to ensure they understand their rights and responsibilities. The home communicates information about residents’ rights and responsibilities, security of tenure, advocacy services and specified care and services. This is achieved at the time of entry and through the residential agreement and information packs. The Charter of residents’ rights and responsibilities is displayed within the home. A process of consultation and agreement precedes any change in a resident’s room. Residents and their representatives said security of tenure is respected at the home.


Standard 4 – Physical environment and safe systems

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



Team’s findings


Management and staff actively pursue continuous improvement in relation to physical environment and safe systems. Refer to expected outcome 1.1 Continuous improvement for information about the home’s continuous improvement system and processes.


As a result of injury rates relating to manual handling and inconsistent training for staff in manual handling over a period of time, management recognised the potential for staff to sustain an injury. To mitigate this, management facilitated the introduction of injury prevention management and targeted training for staff undertaking manual handling. The program was comprehensive and included three part days training for staff. As a result there has been a significant improvement in staff and resident safety and reduction in injuries to staff. Feedback from observers, residents and staff was positive.

To improve the dining experience for residents at the home, new dining furniture was purchased for two wings. The furniture offers standard tables for four people and can be moved to suit the requirements of activities and events therefore providing greater flexibility in resident care options. In addition, the furniture provides for a homelike dining experience and residents can choose to sit in smaller groups. The dining experience was observed by the team to be positive.



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 has a system to identify and meet regulatory compliance obligations in relation to the physical environment and safe systems. For a description of the system refer to expected outcome 1.2 Regulatory compliance.


Staff store chemicals safely and current material safety data sheets are available.

The home follows relevant protocols in relation to compliance with food safety regulations and guidelines.

The essential services maintenance program includes completion of the Annual maintenance statement.



Team’s findings


The home has a system to enable management and staff to have the appropriate knowledge and skills to perform their roles in relation to the physical environment and safe systems. For a description of the system refer to expected outcome 1.3 Education and staff development.


fire and emergency

manual handling

safe food handling

workplace safety refresher.


4.4 Living environment

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

Team’s findings


Management is actively working to provide care recipients with a safe and comfortable environment consistent with the care needs of those living at the home. Residents are accommodated in single rooms with shared bathroom facilities. The rooms of residents and communal areas are light filled, appropriately furnished, well maintained and kept at a comfortable temperature and noise level. Residents have access to comfortable outside areas and established gardens. Management ensures the buildings, grounds and equipment are maintained through regular servicing and maintenance programs by maintenance staff and external contractors. Feedback mechanisms, regular audits, meetings and incident and hazard reporting are used to monitor the living environment for safety and comfort. Residents and representatives are satisfied the home provides a comfortable, safe and secure 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, with the support of the parent organisation, has a system to support a safe working environment that is aligned to regulatory requirements. There are policies and procedures in relation to safe work practice. Staff are informed of their responsibilities through displayed information, at meetings and during induction and mandatory education. The home’s education program includes training for staff in manual handling, infection control and chemical safety. Health and safety representatives attend accredited external training.

Staff and management identify work hazards through audits, maintenance requests, staff incidents and observations. These are actioned in a timely manner and discussed at regular meetings as appropriate. There are processes to ensure regular testing of electrical equipment. Staff are satisfied management work actively to create a safe work environment and are responsive to any issues raised.

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


Management and staff work actively to provide an environment and safe systems of work that minimise fire, security and emergency risks. There are procedures and guidelines to respond to a range of internal and external emergencies. Qualified external contractors maintain fire equipment and there are processes to monitor the maintenance of essential services


equipment. Management displays emergency evacuation plans and ensures emergency exits and egress routes are free from obstruction. There are effective processes to maintain emergency evacuation packs and access to evacuation lists. All staff are required to complete mandatory fire and emergency training. Mock evacuation drills form part of the fire response education program. Arrangements for providing a secure environment include keypad entry points, closed circuit television monitoring, sign in processes and an after hour lock up procedure. Residents and representatives are satisfied the home provides a safe and secure environment.

4.7 Infection control

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

Team’s findings


Management and staff have an infection control program that includes education, provision of personal protective equipment for staff and infection auditing processes. Care plans and progress notes are updated each time a resident infection is identified and resolved. Staff attend regular infection control education. Staff knowledge of standard precautions and infection control principles is consistent with the home’s policies and procedures. Staff hand- washing education and competencies are undertaken. Hand sanitisers and hand washing stations are available to staff and visitors throughout the home. Laundry and cleaning procedures and processes meet infection control standards and supports the home’s infection control program and policies. Residents’ feedback, documentation and statistics support that the home’s program is effective.

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


Hospitality services are provided in a way that enhances care recipients’ quality of life and the staff’s working environment. Residents and representatives are informed about catering, cleaning and laundry services prior to entry and in their handbook. The home has a process for catering including stock control, kitchen and service management and certification.

Catering staff have relevant resident information identifying specific nutrition and hydration requirements, food allergies, food preferences and choices. The home has cleaning procedures and practices that meets the residents’ and home’s needs for hygiene and infection control. Personal laundry services provided by the home were observed to be thorough and feedback from residents and representatives was positive. Residents and representatives confirm their satisfaction with the hospitality services provided by the home.

rosary gardens - aged care qualityrosary gardens racs id 8416 85 creek road new town tas 7008...

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