west beach residentialaccredited residential aged care homes receive australian government subsidies...

West Beach Residential

RACS ID 6235 655-671 Burbridge Road WEST BEACH SA 5024

Approved provider: Southern Cross Care (SA & NT) Incorporated

Following an audit we decided that this home met 44 of the 44 expected outcomes of the Accreditation Standards and would be accredited for five years until 01 November 2020.

We made our decision on 14 September 2015.

The audit was conducted on 03 August 2015 to 04 August 2015. The assessment team’s report is attached.

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

Home name: West Beach Residential RACS ID: 6235 2 Dates of audit: 03 August 2015 to 04 August 2015

Most recent decision concerning performance against the Accreditation Standards

Standard 1: Management systems, staffing and organisational development

Principle:

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

Expected outcome Quality Agency decision

1.1 Continuous improvement Met

1.2 Regulatory compliance Met

1.3 Education and staff development Met

1.4 Comments and complaints Met

1.5 Planning and leadership Met

1.6 Human resource management Met

1.7 Inventory and equipment Met

1.8 Information systems Met

1.9 External services Met


Standard 2: Health and personal care

Principle:

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





2.4 Clinical care Met

2.5 Specialised nursing care needs Met

2.6 Other health and related services Met

2.7 Medication management Met

2.8 Pain management Met

2.9 Palliative care Met

2.10 Nutrition and hydration Met

2.11 Skin care Met

2.12 Continence management Met

2.13 Behavioural management Met

2.14 Mobility, dexterity and rehabilitation Met

2.15 Oral and dental care Met

2.16 Sensory loss Met

2.17 Sleep Met


Standard 3: Resident lifestyle

Principle:

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





3.4 Emotional support Met

3.5 Independence Met

3.6 Privacy and dignity Met

3.7 Leisure interests and activities Met

3.8 Cultural and spiritual life Met

3.9 Choice and decision-making Met

3.10 Resident security of tenure and responsibilities Met

Standard 4: Physical environment and safe systems

Principle:

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





4.4 Living environment Met

4.5 Occupational health and safety Met

4.6 Fire, security and other emergencies Met

4.7 Infection control Met

4.8 Catering, cleaning and laundry services Met


Audit Report

West Beach Residential 6235


Introduction

This is the report of a re-accreditation audit from 03 August 2015 to 04 August 2015 submitted to the Quality Agency.

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

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

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

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

Assessment team’s findings regarding performance against the Accreditation Standards

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

44 expected outcomes


Scope of audit

An assessment team appointed by the Quality Agency conducted the re-accreditation audit from 03 August 2015 to 04 August 2015.

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

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

Assessment team

Team leader: David Stevens

Team member: Joanne Glaze

Approved provider details


Details of home

Name of home: West Beach Residential

RACS ID: 6235

Total number of allocated places:

80

Number of care recipients during audit:

78

Number of care recipients receiving high care during audit:

74

Special needs catered for: People with dementia and related disorders

Street: 655-671 Burbridge Road

City: WEST BEACH

State: SA

Postcode: 5024

Phone number: 08 8353 3044

Facsimile: 08 8353 3066

E-mail address: [email protected]

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

mailto:[email protected]


Audit trail

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

Interviews

Category Number

Residential Care Manager 1

Care Manager 1

Care Coordinators 1

WH&S co-ordinator 1

Nursing and Care Staff 9

General practitioner 1

Administration officer 1

iCare Co-ordinator 1

Clinical Educator 1

Chief Executive Officer 1

Director of Workforce 1

Manager Risk Services 1

Hotel Services Manager 1

Human Resource Manager 1

Quality Manager 1

Director of Operations 1

Workforce Development Manager 1

Care Recipients/Representatives 10

Maintenance Staff 1

Lifestyle Staff 1

Chef 1

Ancillary Staff 4

Quality assurance coordinator 1

Volunteer co-ordinator 1

Group Manager Residential 1

Deputy Chief Executive Officer 1

Procurement Manager 1

Property and Assets Manager 1


Category Number

General Manager, Research And Development 1

Director of Strategy 1

Financial Compliance and Business Improvement Manager 1

Operations Co-ordinator 1

Financial Controller 1

Contracts Manager 1

Sampled documents

Category Number

Care recipients’ assessments, care plans and progress notes 6

Summary/quick reference care plans 4

Medication charts 4

Personnel files 5

Other documents reviewed

The team also reviewed:

Advisory committee meeting minutes

Agency staff orientation folder

Allied health records

Archive system documentation

Audit schedule and audit reports

Authority to crush documents

Call bell response time reports

Checklists

Chemical log

Cleaning schedules

Clinical monitoring data

Clinical skills matrix

Complaints management flowchart, register and analysis

Connected leaders program documentation


Continuous improvement log and records

Contracts/contractor register and records

Council food safety audit

Criminal history check procedure and records

Critical incident management documentation

Dietician and speech pathology documentation

Document change reports

Drugs of dependency records

Education and training schedules, attendance and evaluation records

Electrical tagging records

External suppliers performance records

Fire safety certificate

Food and fluid preference lists

Food safety education records

Food safety plan

Fridge monitoring charts

Graduate aged care worker program, evaluations and recommendation report

Handovers records

Hotel services catering manual

Incident analysis reports

Infection surveillance records

Inventory/assets registers

Job descriptions

Language, literacy and numeracy skills testing

Leadership and development plan

Lifestyle activity evaluations

Managing feedback flowchart

Mandatory staff training records and follow up letters


Medication incident reports

Medication manual

Menus

Newsletters

Nurse initiated medication data

Nurse registration records

Organisational reporting structure

Orientation and induction information and checklists

Outbreak management resources

Pest management documentation

Preventative and corrective maintenance records

Probationary and performance appraisal procedure and guidelines

Project management tool kit

Recruitment selection check list

Referrals to allied health professionals

Regulatory compliance log and records

Research and innovation centre governance flow chart and project plan

Resident and staff handbooks

Resident information package and agreements

Restraint documentation

Restraint documentation and monitoring data

Risk and improvement group records

Risk management strategy 2014-2016

Safety Data Sheet log and records

Schedule 4 and 8 drug licence

Self-administration assessments

Self-assessment

Southern Cross Care 2014 staff engagement survey


Southern Cross Care key achievements

Southern Cross Care key risk report

Staff communication books

Staff competency records

Staff handover sheets

Staff rosters, and performance appraisal records

Strategic plan, Vision and Mission

Temperature records

Training evaluations

Training needs analysis

Various meeting minutes

Various memoranda and emails

Various policies and procedures

Various surveys

Volunteer induction and training records

Volunteer police clearance data

Work health and safety plans and reports, audit schedule and strategic plans

Observations

The team observed the following:

Activities in progress

Activity calendars

Archive storage

Care in progress door signs

Care recipients’ rooms decorated with their own memorabilia and furnishings

Charter of care recipients rights and responsibilities

Chemical storage and protective equipment

Cleaning in progress

Clinical palliative kit


Contractor sign in/out book

Critical incident management flip chart

Do not disturb door signage

Education bulletins in staff areas

Equipment and supply storage areas

External advocacy brochures and posters in multiple languages

Feedback forms

Firefighting equipment, egress routes, evacuation kit and fire panel

Group exercise programs

Hand washing stations

Handover records

Hypo Kits

Infection control resources

Interactions between staff and care recipients

Internal and external complaints information

Internal and external living environment

Key pads for doors

Meal service

Medication administration

Memory support unit

Mission statement on display

Mobility aids/pressure relieving equipment

Notice boards

Notification to stakeholders of re-accreditation audit

Outbreak kits

Personal protective equipment in use

Short group observation in the memory support unit

Specialised aids in use


Storage of care recipients’ information

Storage of medications

Suggestion boxes

Various flow charts

Visitors in the home


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

West Beach Residential is part of Southern Cross Care SA & NT. The home follows the organisation’s systematic and planned approach to continuous improvement. The quality framework includes:

A corporate continuous improvement plan

Site specific improvement plans

A central quality committee

Site specific quality committees

An annual schedule for reviewing compliance with the Accreditation Standards

Continuous improvement initiatives arise out of internal audits, care recipient and staff meetings, incident and hazard data, audits, suggestions, and evaluations.

The corporate quality committee oversee the continuous improvement system including monitoring the progress, inputs, and outcomes of continuous improvement activities. The site managers oversee continuous improvement on each residential site, update the plans for continuous improvement, and set actions, responsibility and timeframes for completion. The home has a local quality committee which reviews progress and outcomes of improvement initiatives.

The quality systems in place at the home demonstrate a planned approach to continuous improvement across all four Standards. The results show there is an ongoing focus on continuous improvement which includes all stakeholders and a cycle of identifying improvement initiatives and evaluating the benefits to care recipients and staff.

The home and organisation has implemented the following improvement initiatives in the last 12 months relating to Standard 1 - management systems, staffing and organisational development:

The director of operations identified the need to bring together all senior operations managers to promote sharing of ideas and learning, and discuss changes in practice and legislation. A regular series of ‘Operation Days’ has been set up which includes site managers, heads of department and clinical managers. This initiative has been added to the organisation’s corporate plan for continuous improvement and evaluated. Feedback from the operations managers indicates they find the operation days increase their understanding and promote sharing of ideas between homes for improvement in practice and the environment.

Staff and managers on residential sites were challenged by the comprehensiveness of the electronic care management system ‘iCare’. The corporate iCare co-ordinator developed a four part procedure manual in consultation with staff and the software supplier which provides a highly detailed guideline in picture and written form to assist


staff to use the care planning system at each home. This initiative has been added to the organisation’s corporate plan for continuous improvement and evaluated. Feedback from staff shows the iCare manual is effective in providing clear direction on how to use the electronic care management system and problem solve issues that arise.

1.2 Regulatory compliance

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

Team’s findings


The organisation has corporate systems and processes in place to capture changes to relevant legislation, regulatory requirements, professional standards and guidelines relevant to all four Standards, including police checks and missing residents, access to appropriately qualified professionals, mandatory reporting of assaults and fire safety and food safety plans. The organisation has networks with external services and organisations that provide information on relevant changes and subscribes to aged care bodies and legislation services to maintain current information. There is a central regulatory compliance log that captures all changes to legislation and guidelines. Information received is reviewed by corporate personnel and is then distributed to individual regional managers and residential site managers, who then determine the relevance to staff roles. Procedures are in place to guide the dissemination of changes to regulatory requirements.

At West Beach Residential management pass on relevant information to staff about changes in legislation through meetings, noticeboards and education sessions. Regulatory compliance is a standing agenda item at all quality, staff and care recipient meetings.

Compliance by the corporate division with legislation and regulations is monitored through the residential site based audit processes, surveys and management meetings.

Results show the home’s processes are effective in identifying compliance with legislation and actions taken to address any deficits. Staff interviewed stated they were regularly informed about legislative updates and could identify examples of recent changes to legislation.

Examples of regulatory compliance being met by the home in Standard 1: Management systems, staffing and organisational development include:

Police checks for all staff and volunteers

Care recipients and representatives notified in writing of re-accreditation audit

Ongoing monitoring of professional registration of clinical staff


1.3 Education and staff development:

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

Team’s findings


The organisation has an extensive education and staff development framework to support staff knowledge and skills at each residential site. All staff participate in central mandatory training, manual handling training, and care support team education. Corporate personnel maintain training records and monitor staff attendance. Each training course is evaluated for effectiveness. The Southern Cross Care education and training plan development guide assists residential site managers to develop a training plan that provides all employees with appropriate knowledge and skills to perform their duties competently.

The organisation actively encourages all staff to advance their skills and knowledge and have developed and introduced training programs that include:

The development and implementation of a Connected Leaders training program

Graduate program for new Certificate Three in Aged Care graduates which includes an additional six week on site training package

Language and literacy training for cultural and linguistically diverse staff

At West Beach Residential there is a comprehensive education program that provides ongoing development of the large, diverse workforce. There is a system in place that ensures staff receive mandatory training on commencement and refresher training at required intervals. In addition, a calendar of training is drafted every three months which includes key compulsory modules and optional programs to advance knowledge and skills. Methods of training include on-line modules, group learning on site, group learning off-site, and individual tuition by a trained educator. The content of the training program is influenced by assessment of current care recipient conditions, and feedback from care coordinators regarding the skills needed by staff to maintain quality care standards. Training is also provided to build staff skills in leadership and management. Quality of training is maintained via assessment of formal feedback following each session and by use of professional trainers sourced from Southern Cross Care and peak bodies. Results show staff attend a variety of training and increase their skills and knowledge based on training records and evaluations. Staff said they are satisfied with access to training and education which is relevant to their roles. Care recipients expressed satisfaction with the level of skill maintained by staff.

Examples of education and training provided in relation to Standard one include:

Connected Leaders course

Use of the iCare Software system

Volunteering


1.4 Comments and complaints

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

Team’s findings


The organisation has a feedback system and mechanisms for staff, care recipients, families and interested stakeholders to access and use. This includes feedback forms for capturing written complaints, central feedback log, a site specific feedback log, and an action plan for monitoring the system and capturing verbal complaints. Feedback forms and suggestion boxes are located in the main areas of each residential site for care recipients and representatives. All feedback, including verbal feedback, is logged on a central electronic system and monitored for any trends. Identified trends are analysed and feed into corporate improvement initiatives. To support better practice in complaint handling Southern Cross Care has developed template letters to “acknowledge a complaint” and “confirming a complaint has been resolved” based on the Better Practice Guide to complaint handling in aged care. Comments and complaints information is outlined in a resident handbook, quality and residential meeting minutes, and surveys.

At West Beach Residential care recipients, representatives and other interested parties have access to internal and external complaints mechanisms. On entry to the home care recipients and/or representatives are provided with information about internal and external complaints mechanisms, including information in the resident handbook and information pack. Feedback forms and information about complaints mechanisms are displayed around the home. Feedback boxes are available for confidential lodgement of comments or complaints. Feedback, including verbal, is logged on a central electronic system and monitored for trends. Results show care recipients and representatives are aware of internal and external complaints mechanisms. Staff are aware of the comments and complaints system and feel supported in raising concerns with management. Care recipients and representatives interviewed are satisfied that concerns they raise are managed effectively.

1.5 Planning and leadership

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

Team’s findings


The organisation has documented its commitment to quality residential care through the organisation’s vision, values, philosophy and objectives. These are displayed in the foyer of central office and in each home, in addition they are contained within new employee packs, care recipient and staff handbooks, job descriptions and annual reports. Corporate management teams, regional managers and residential site managers have responsibility for the sharing of information with stakeholders in relation to planning and leadership and this is achieved through consultation, the quality system, training and meetings. Care recipient and stakeholder information is documented to corporate standards in alignment with the organisation’s vision.


1.6 Human resource management

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

Team’s findings


The organisation has processes to ensure there are sufficient numbers of appropriately skilled and qualified staff to deliver care and services. The organisation has recruitment processes to ensure potential employees have appropriate skills and qualifications and commencing employees are provided with an organisational and site specific induction.

The Corporate Workforce team has developed systems for:

Recruitment and orientation of new staff and volunteers, including:

Systematic processes for police/visa checks, letters of offer, contracts and induction.

Central and site based induction programs.

Replacing staff on leave and filling vacancies.

Southern Cross Care has its own internal casual support team to enable prompt coverage of all planned and unplanned leave, ensuring continuity of care.

The care support team are provided with an additional comprehensive six week training program to be able to understand the organisation’s values.

Police certificates for staff and volunteers, and professional registrations for nursing staff are monitored by the organisation centrally using a register and reminder system. Vacant shifts are filled by permanent staff and the casual support team staff using an electronic messaging system. Staff are guided in their roles by job descriptions, duty statements, guidelines, policies and procedures and through senior staff supervision.

At West Beach Residential management have processes for reviewing staffing levels, and adjusting the staffing roster in accordance with changes in care recipient requirements.

Management conduct regular performance appraisals for all staff positions and seek feedback from staff to enable them to meet the requirements of their role.

Results show staffing levels and skill mix in the home is appropriate to the level of care recipient acuity and needs. Staff said they work together as a team to complete their required tasks. Care recipients and their representatives are satisfied with the responsiveness of staff and the level of care provided to them.


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 organisation has an inventory system to ensure goods and equipment within each of their residential sites is appropriate to deliver quality care and services. This includes:

A central asset management system for all equipment

A central provider of assistive devices, mobility equipment and lifters

Chemical supplier for maintenance, cleaning and laundry services

Hospitality and catering supplies

Supplier of clinical care products for dressings, personal protective equipment and continence products

Supplier of medications

The procurement manager oversees the asset management system and manages suppliers. Facility managers and clinical leaders provide daily input to these systems.

The overall inventory system is monitored through reports, audits and feedback on supplier efficiency, quality and inventory levels. The electronic asset management system tracks supplier related maintenance requirements. This system is centrally evaluated to determine the effectiveness of equipment. The clinical and continence product system monitors product use and alerts on changes, prompting assessment.

There is a system for preventative maintenance and repairs to provide plant and equipment that is fit and appropriate for use. Each residential site uses an electronic preventative maintenance log to track programmed and remedial maintenance items. This is monitored at the site and corporate level, and reports are generated each month on closed and ongoing items.

Procurement of all equipment is managed through a centralised committee and trials are undertaken to ensure the selection and/or replacement of equipment is fit for use. Staff and care recipients’ feedback is sought on equipment and goods through feedback processes. Calibration of equipment is undertaken through central suppliers which service all residential sites.

At West Beach Residential management are able to monitor the sufficiency of goods and equipment relative to the services and needs of the care recipients. Results show the home has suitable goods and equipment appropriate for the delivery of care and services. Staff and care recipients are satisfied they have access to appropriate and sufficient goods and equipment to meet their needs.


1.8 Information systems

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

Team’s findings


The organisation has effective information management systems in place. The information management systems ensures all care recipients, staff and stakeholders have access to current, accurate and appropriate information relating to processes, general activities and events within each facility.

The main information management systems include:

Policies and procedures, work instructions, duty lists, delegations

Electronic care management system and associated instruction manual for iCare

Records management systems

Archiving systems

Electronic Databases

Logs for regulations, critical incidents, suppliers, inventory

Intranet and common drives

Audit framework

There is a common schedule of meetings and staff forums including:

Operations meetings

Staff meetings

Quality, Medication Advisory, Work Health and Safety Committee meetings

Specific staff and care recipient forums/working groups

Information is communicated to staff, care recipients and representatives via:

Resident and staff handbooks

Resident and staff newsletters

Resident and staff meetings

Resident and staff noticeboards

Communication books

Electronic systems are password protected and access to information is determined based on delegations of authority. There is a centralised IT helpdesk to respond to any electronic


information issues. The archiving of information follows regulatory guidelines and is archived off site through a central contractor. Recent records are archived on each residential site and then centrally stored after a period of time. Information systems are monitored through common audits and the comments and complaint processes.

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

1.9 External services

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

Team’s findings


The organisation has processes for the identification and selection of external suppliers based on care recipients’ needs and operational requirements.

This includes:

A central suppliers/contractors register

Centralised screening and induction process for capital works suppliers

Common site induction process

Common feedback process for monitoring suppliers/contractors performance

Formal agreements and contracts with external suppliers stipulate the service requirement, price and quality. There are processes for checking the compliance requirements for external suppliers.

There are processes for monitoring the ongoing performance of external suppliers through collecting feedback from care recipients and staff, and checking tasks are complete. The review process for external contractors and suppliers involves ongoing monitoring through feedback mechanisms, meetings and surveys. Changes occur to supplier arrangements based on feedback from care recipients and staff.

At West Beach Residential observations indicated the external services provision occurs according to the service contracts. Results show the external suppliers meet the organisation’s performance requirements and provide goods and services on a consistent basis. Staff said external contractors regularly visit the home and complete tasks as required in a timely


manner. Care recipients, their representatives, and staff are satisfied with the quality and delivery of the external services provided.


Standard 2 – Health and personal care

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



Team’s findings


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

The home generates continuous improvement initiatives through analysis of clinical data, incidents, observation, staff and care recipient feedback, audits, and care evaluations. Care recipients and staff are aware of the continuous improvement program and the home acts on their suggestions.

The home has implemented the following improvement initiatives relating to Standard 2 - care recipients’ health and personal care in the last 12 months:

The clinical nursing team identified an opportunity to improve oral and dental care for care recipients. A nursing staff member now coordinates regular dental assessments for all care recipients and arranges appointments with their private dentist. A visiting dental service now comes into the home to conduct assessments and monitor care recipients dental hygiene. Care recipients tooth brushes are now rotated on a seasonal basis or sooner as required and electric toothbrushes used if appropriate for improved cleaning. Staff received additional education on oral and dental care. Results show reduced occurrence of tooth infections. Feedback from care recipients shows they are satisfied with access to the dentist onsite and ongoing assessment of their dental hygiene. Staff feedback indicates they are more aware of the interventions, routines, and techniques for assisting care recipients maintain good dental hygiene.

Care recipients who cannot sit upright in a shower chair were having difficulty being showered. Staff were also at risk of manual handling injuries in trying to reposition them. The home researched possible options for equipment and purchased an electric shower chair. The new electric shower chair is fully adjustable and the staff can change the position of the care recipient whilst in the shower without having to physical handle them, reducing the potential for injury in the wet and slippery environment. Feedback from care recipients shows the electric shower chair is more comfortable and dignified. Staff feedback indicates the electric shower chair is very easy to manoeuvre the care recipient in and they are at less risk of suffering an injury.



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

Team’s findings


Refer to expected outcome 1.2 Regulatory compliance for information about the home’s regulatory compliance systems and processes.

In relation to Standard 2: Health and personal care, there are processes within the home for monitoring regulatory compliance relating to health and personal care. Management communicate to relevant staff changes to legislation and standards relating to health and personal care. Staff said they are aware of regulatory requirements relating to care recipients’ health and personal care, including the provision of prescribed care and services, medication storage and administration and the professional registration of nurses and allied health providers.

Examples of regulatory compliance being met by the home in Standard 2: Health and personal care include:

Assessments are carried out by an appropriately qualified staff member

Care plan assessments and reviews undertaken by appropriately skilled staff

Medication is stored safely and securely


2.3 Education and staff development


Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. Management ensure staff have the knowledge and skills required for effective performance in their roles. Clinical policies and procedures, duty lists and care plans guide staff practices. Staff attend education pertaining to various clinical topics and the completion of clinical competencies occurs. Staff state they are satisfied that the education provided assists them in their role and allows them to expand their skills.

Recent education sessions relevant to Standard 2: Health and personal care, include:

Neurological observations

Peg feeds

Pain management

Oral health care

Working with challenging behaviours

2.4 Clinical care

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

Team’s findings


Care recipients receive clinical care that is appropriate to their individual needs and preferences. There is an ongoing review and evaluation system for identifying and managing care recipients’ clinical care needs. Processes include care recipients have an interim care plan on entry to the home followed by a clinical care assessment. This information is used to develop extended care plans in consultation with care recipients and their representatives.

Care plans are maintained in the home’s electronic care system and through hard copy care plans. The home monitors care recipients’ clinical care outcomes through six monthly reviews of care plans, monthly ‘care day’ assessments, clinical incidents and auditing of reporting processes. Changes to clinical needs are communicated to staff through verbal/electronic care system handovers, diaries, communication books and progress notes. Immediate changes to clinical needs are also provided through the use of the electronic care system and care plan changes highlighted in the area communication books. Results show care recipients’ needs are documented and reviewed and that care is consistently provided to meet the individual needs of care recipients. Information provided by staff was consistent with care recipients’ care plans. Care recipients and representatives are satisfied with the level of consultation and that appropriate clinical and personal care is provided to care recipients.


2.5 Specialised nursing care needs

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

Team’s findings


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

Care recipients and representatives are satisfied with the specialised care provided to care recipients.

2.6 Other health and related services

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

Team’s findings


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


2.7 Medication management

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

Team’s findings


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

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

2.8 Pain management

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

Team’s findings


The home has systems to ensure all care recipients are as free as possible from pain. Care recipients are consulted and assessments conducted by registered staff to identify any issues and care requirements in relation to pain. Assessments are reviewed by medical and allied health staff and where required referrals are made to pain specialists. Treatment plans are developed; medication charts and treatment directives assist staff in relation to care requirements and treatment needs. Further interventions include positional changes, heat packs, analgesia orders and massage. Pain interventions are monitored by nursing and allied health staff through audits, regular care reviews, observation and feedback from staff, care recipients and representatives. Results show staff undertake training and are aware of strategies to assist with pain management. Staff interviewed were aware of care recipient’s pain management needs. Care recipients said they are satisfied that pain issues are managed.

2.9 Palliative care

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

Team’s findings


Care recipients receive appropriate palliative care that maintains their comfort and dignity during the end stage of life. The home has processes to capture individual palliative care wishes through advance care directives and good palliative care plans. An end of life care plan


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

2.10 Nutrition and hydration

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

Team’s findings


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

Care recipients have the opportunity to comment on the meal service at forums and meetings and on an individual basis. Training is available for staff in supporting nutrition and hydration. Care and nursing staff provide information consistent with care recipients’ nutrition and hydration care plans. Results show care recipients receive adequate nourishment and hydration and that needs are documented and reviewed. Clinical staff said they update care recipients’ nutrition and hydration care plans and communicate changes to kitchen staff.

Care recipients are satisfied with nourishment and hydration provided to support their individual needs.

2.11 Skin care

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

Team’s findings


There are systems to ensure care recipients are provided with assistance to maintain their skin integrity. Documentation demonstrates that skin care assessments are initiated on entry and skin integrity is monitored on an ongoing basis. Care recipients at risk are identified and plans include strategies to ensure adequate nutrition, change of position to relieve pressure, use of specialised equipment, skin protection and moisturising. Wound assessment and planning is conducted by registered nurses and healing rates are monitored. Referrals to specialised


wound consultants are accessed as required. Daily care plans include nail and hand care, podiatry and hairdressing services are available. Monitoring occurs through documented monthly ‘care days’, skin tear reporting, care review meetings and audit processes. Results show that skin integrity management is regularly reviewed and evaluated. Observation and staff interviews confirmed there are sufficient supplies and equipment for the provision of skin care and appropriate staff are trained in wound care. Care recipients said they are satisfied with the care provided to maintain their skin integrity.

2.12 Continence management

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

Team’s findings


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

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

2.13 Behavioural management

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

Team’s findings


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


2.14 Mobility, dexterity and rehabilitation

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

Team’s findings


The home has systems to assist care recipients to achieve optimum levels of mobility and dexterity. Assessments are completed by registered nurses and allied health staff to capture individual needs in relation to mobility requirements and assistance required to enhance dexterity. Individualised mobility, exercise and transfer plans are developed; these include assistance and mobility aids. Suitable assistive aids are provided including equipment to promote safety whilst supporting mobility. The home provides a range of movement exercise programs to assist care recipients to optimise mobility and dexterity. Falls are monitored and analysed for trends. Any immediate change to care recipients’ mobility status is documented in the care system. Monitoring occurs through regular care reviews, reassessment by allied health professionals, audits and observation. Results show that care recipients’ needs are documented and reviewed, and that staff provide care consistent with documented care plans. Staff attend manual handling training and observations confirmed staff members’ understanding of individual care recipient’s mobility needs. Care recipients are satisfied their mobility and dexterity needs are maximised.

2.15 Oral and dental care

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

Team’s findings


The home has systems to maintain care recipients’ oral and dental health. Oral health assessments are completed on entry and on an ongoing basis to identify individual oral and dental care needs. Care plans provide individualised oral and dental hygiene strategies. Care recipients are provided with options and support to access dental services of their choice, including a visiting dental service. Oral equipment is replaced seasonally or earlier and monitored by care staff. Monitoring of care recipients’ oral care is completed through staff observations, regular care plan reviews, audits and feedback from dental specialists. Results show that care recipients’ oral and dental care is documented and reviewed. Staff undertake education in oral hygiene and are aware of strategies to support care recipients’ oral and dental health. Care recipients are satisfied their oral and dental health is maintained.


2.16 Sensory loss

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

Team’s findings


The home has systems to ensure care recipients sensory losses are identified and managed effectively and assessment processes capture care needs in relation to all five senses. Care plans identify strategies and aids to support and improve care recipients’ sensory loss.

Communication assessments are undertaken on entry to the home and preferred communication methods and interventions are identified in care plan domains. The home provides a range of activities and devices to enhance sensory enjoyment such as large print books, cooking activities and magnifying screens. Monitoring occurs through regular care reviews, feedback mechanisms and observation. Staff consult and assist with care recipients and representatives regarding referral to the audiologist and optometrist. Results show that care recipient’s sensory needs are documented and reviewed. Staff are aware of care recipients’ sensory care needs. Care recipients are satisfied with the home’s approach to managing their sensory loss.

2.17 Sleep

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

Team’s findings


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


Standard 3 – Care recipient lifestyle

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



Team’s findings



The home generates continuous improvement initiatives through analysis of data and information collected from internal audits, care recipient and staff meetings, suggestions, and lifestyle evaluations. Care recipients and staff are aware of the continuous improvement program and the home acts on their suggestions.

The home has implemented the following improvement initiatives relating to Standard 3 - care recipients’ lifestyle in the last 12 months:

Care recipients with limited vision and hearing difficulties found the bus trips were less interesting as they could not always comprehend what other care recipients were seeing or hearing about. The recreation activity officer now develops a verbal commentary for each trip based on the sights along the way and destinations. This is spoken over a portable loud speaker system. They also produce a small booklet on the trip for care recipients with hearing impairments. Feedback from care recipients with vision and hearing impairments shows they find the bus trips more interesting and can converse with other care recipients more easily about their experience on the trips.

Care recipients wanted to pay their respects to other care recipients who had passed away. The home established a bereavement memorial service which is now held two times a year. The home also set up a memory tree where care recipients can put a star on to remember past care recipients. Feedback from care recipients and representatives indicates the bereavement memorial service provides them with an opportunity to formally farewell past care recipients and remember them through the memory tree.



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 systems for identifying and accessing all relevant legislation, regulations, and professional standards relating to care recipient lifestyle. Management regularly update the care recipient agreement to reflect changes in legislation. The home has a separate register for compulsory reporting. Staff said they are aware of regulatory requirements relating to care recipient lifestyle, including protecting care recipients’ privacy, maintaining confidentiality of care recipient information, security of tenure, and compulsory reporting of assaults. There are processes for monitoring ongoing regulatory compliance relating to care recipient lifestyle.

Examples of regulatory compliance being met by the home in Standard 3: Care recipient lifestyle include:

Policies and procedures for mandatory reporting

Security of tenure contracts, processes and policy

Consolidated records maintained up to date and reporting to relevant authorities as required

Privacy policies to protect the use of care recipient information




Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. The home has processes for monitoring staff attendance at training in relation to care recipient lifestyle. Management ensure staff have the knowledge and skills required for effective performance in their roles. Stakeholder feedback and observations monitor staff skills and knowledge in relation to care recipient lifestyle needs. Staff said they are satisfied that the training and education provided assists them in their roles and allows them to develop further skills.

Recent education relevant to Standard 3: Care recipient lifestyle includes:

Early intervention approach

Dementia care essentials

Personal trainer

Etiquette

Elder Abuse

3.4 Emotional support

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

Team’s findings


Care recipients are supported in adjusting to the home on admission and on an ongoing basis. The home has a process of identifying, assessing and monitoring care recipients’ emotional needs. Care recipients have support from care options staff during the transition process into the home and through the organisations pastoral care team post admission. Representatives are encouraged to visit and participate in activities. The home evaluates the effectiveness of emotional support provided through comments and complaints processes, lifestyle and care reviews and audits. The home monitors the effectiveness of emotional support through surveys, observation and monthly consultation. Results show care recipients are satisfied with the emotional support they receive. Staff are given education relating to specific illnesses to improve their understanding of the person to help meet emotional needs. Care recipients and representatives said they are satisfied with the level of emotional support being provided by the home.


3.5 Independence

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

Team’s findings


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

3.6 Privacy and dignity

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

Team’s findings


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


3.7 Leisure interests and activities

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

Team’s findings


Processes for the assessment of lifestyle needs at the time of entry to the home provide comprehensive information on care recipients’ backgrounds and preferences to assist care and lifestyle staff in planning and meeting their lifestyle needs. In home activity attendance records, surveys and feedback contribute to the overall monitoring processes. The lifestyle assessment is reviewed regularly to take into account care recipients’ changing lifestyle requirements. The activities calendar is communicated through a variety of pathways including meetings, noticeboards and individual activity planners. Staff facilitate internal and external activities on an individual basis. Results show that leisure interests and activities are documented and reviewed. Staff said they have access to information about each care recipient’s leisure and lifestyle preferences and they assist care recipients to attend activities as required. Care recipients and representatives interviewed said they are satisfied with the variety of activities offered and the support provided by staff.

3.8 Cultural and spiritual life

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

Team’s findings


Care recipients individual interests, customs, beliefs, cultural and ethnic background is acknowledged and supported. Assessment processes assist to collect information of spiritual and cultural beliefs and social history on admission to the home. Language specific resources are available to support staff in communicating with individual care recipients and a number of staff speak a variety of languages. Care recipients are encouraged to maintain their spiritual and cultural needs through visits from family, friends and community. There are a number of denomination services offered in the home and staff interviewed said care recipients are assisted to attend religious services internally and externally. Cultural events are celebrated in conjunction with the lifestyle program and care recipients’ preferences.

Results show care recipients attend cultural and spiritual activities of importance to them and are consistent with documented plans of care. Staff are aware of care recipients’ cultural and spiritual needs which affect the provision of care and lifestyle. Care recipients and representatives interviewed said they are satisfied that the home meets their cultural and spiritual needs and preferences.


3.9 Choice and decision-making

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

Team’s findings


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

3.10 Care recipient security of tenure and responsibilities

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

Team’s findings


Corporate services provide secure tenure within the residential care service, and ensure care recipients/representatives understand their rights and responsibilities through the application process and on an ongoing basis. Admission processes are established to identify and support each care recipient’s security of tenure. Information about care recipients’ rights and responsibilities, entry details, fees and charges and the contents of the care recipient handbook and agreement are discussed with care recipients and representatives. If a change in accommodation or care requirements is recommended, alternative care options and or accommodation are explored in consultation with the care recipient, their representatives, the medical officer and other relevant parties. Results show and staff confirmed they are aware of care recipients’ rights and responsibilities. Care recipients are satisfied their tenure is secure and the home supports their individual needs and preferences where possible.


Standard 4 – Physical environment and safe systems

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



Team’s findings



Management generates continuous improvement initiatives related to the physical environment and safe systems through analysis of data and information collected from internal audits, care recipient and staff meetings, incident and hazard data, suggestions, and workplace inspections. Care recipients and staff are aware of the continuous improvement program and the home acts on their suggestions.

Examples of improvement activities and achievements relating to Standard 4 - the physical environment and safe systems in the last 12 months include:

The vitamised meals for care recipients were not very appealing to their appetite and often food was wasted. The home researched the benefits of food moulds to provide meals which looked more like the vegetables and meat the care recipients would most likely recognise. The home purchased a range of food moulds which are used on a daily basis for care recipients with vitamised meals. Feedback from care recipients shows they find the meals more appetising and well presented. Staff observations show care recipients enjoy their vitamised meal more and there is less food wastage.

The system for tracking staff mandatory training was difficult to navigate and fragmented. The home devised a new database with folders and a listing of mandatory training on the organisation’s intranet to track all education and training. The system alerts management more quickly as to when staff are required to complete mandatory training modules. All the data on training is now in one place and can be shared between managers to monitor mandatory training of staff in each functional area. Feedback from management and staff shows the tracking system is more efficient and has improved staff attendance at mandatory training sessions.

The organisation’s infection control committee identified residential sites were using different signs to denote whether a care recipient had an infection. One symbol has been chosen to provide a more consistent approach at each site to make it easier for all staff to follow precautions and for those casual staff who work at different sites. The home has introduced the yellow dot system which is put on care recipients doors and care plan if they have an infection. Feedback shows staff are more aware of care recipients who have an infection due to the yellow symbols and follow standard precautions.



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



There are processes for identifying and accessing all relevant legislation, regulations, and professional standards relating to the physical environment and safe systems. Staff are aware of regulatory requirements relating to the physical environment and safe systems, including implementing work health and safety regulations, monitoring and maintaining fire safety systems, and maintaining appropriate storage and identification of chemicals used in the home.

Examples of regulatory compliance being met by the home in Standard 4: Physical environment and safe systems include:

Return to work legislation

Current food safety council audit

Documented food safety plan

Mandatory training for manual handling, fire and emergency education for all staff




Team’s findings


Refer to expected outcome 1.3 Education and staff development for information about the home’s education and staff development systems and processes. In relation to Standard 4, Physical environment and safe systems, management ensure staff have the knowledge and skills required for effective performance in their roles. Management monitor attendance to education pertaining to the home’s mandatory education sessions to ensure annual staff attendance, understanding, and competency.

Mandatory training provides staff with education and staff development relevant to their roles. Training attendance is monitored and staff are required to attend mandatory training each year. Staff interviewed state they are satisfied that the training and education provided assists them in their roles and allows them to further develop skills.

Recent education undertaken by staff relevant to Standard 4: Physical environment and safe systems includes:

Food safety

Manual handling

Fire and emergency procedures

Infection control

4.4 Living environment

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

Team’s findings


The organisation uses a common system for programmed and remedial maintenance across all sites. On-site maintenance staff, supported by local and corporate contractors, maintain all buildings, infrastructure and equipment. The organisation employs a backup maintenance team including an electrician for responding to workload demands across the sites when these arise. Maintenance issues are gathered and monitored though maintenance requests, audits, incident/hazard reports, complaints forms, staff and care recipient meetings. There is an electronic log for tracking all programmed maintenance items and new maintenance requests. The maintenance officers report monthly on the closed items and the status of any ongoing items.

The home provides a safe and comfortable living environment for care recipients and has a system for monitoring the external and internal living environment including hazard and incident reporting. The spacious home is laid out over two floors with a central admin area, service areas, and a café. There are lounge/dining and activity areas on both floors. The


building includes a memory support unit with a private garden located on the ground floor. All care recipients are accommodated in single rooms with en-suite and are able to furnish their rooms with personal items and furniture within the space they have available.

There are processes for monitoring and repairing care recipient call bells. The home has policies and procedures for restraint management, including review of authorisation and monitoring. Results show that maintenance is delivered through scheduled preventive and proactive maintenance programs. Staff training and practice ensure care recipients’ private environments are comfortable and safe. Care recipients and representatives reported satisfaction with the maintenance, safety and comfort of the living environment.

4.5 Occupational health and safety

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

Team’s findings


The organisation has centralised and residential site systems to provide a safe working environment for staff through regularly assessing potential and identified hazards/risks, and implementing strategies to minimise risks. There is a central work health and safety committee and site specific committees which track and report on hazards, incidents, accidents. There is a common set of safe work procedures available on each site. Audits and worksite inspections are managed at the corporate level and occur according to a specific work health and safety audit schedule. The organisation has an overarching work health and safety strategic plan. Each home has a site specific strategic plan. The provision of manual handling, fire training and work health and safety training is managed and tracked through the corporate office for all employees. There is a central hazard register and one for each site which is regularly updated and appropriate actions taken to maintain a safe environment.

Staff compliance is monitored via competencies, audits and supervision of work practices. Personal coaching and additional training is scheduled for individuals as required. Incidents are recorded, collated and reported monthly. Risk assessments are conducted for all incidents and interventions introduced as appropriate. Results at the home show the local work health and safety committee analyse trends and the effectiveness of interventions to maintain a safe work environment. All equipment is subject to routine and preventative maintenance and is monitored by the maintenance officer. Staff said they are satisfied they have access to information that promotes a safe working environment and are aware of their responsibilities for work health and safety.

4.6 Fire, security and other emergencies

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

Team’s findings


The organisation uses a single fire service contractor to monitor all fire systems at each of the residential sites and supply training to staff. The service contractor conducts fire drills at each home as part of the regular training sessions. The emergency manuals, evacuation maps and signage at each home are reviewed and maintained by the fire service contractor. Each residential site has an evacuation transfer list available to staff which is updated when care


recipients are absent and/or there are changes in their transfer needs. The organisation engages a single supplier to test and tag all electrical equipment on site for staff and care recipients to ensure it is not faulty. A central register of equipment is maintained to track all electrical items.

At West Beach Residential management and staff at the home are actively working to provide an environment and safe systems of work that minimise fire, security and emergency risks. The home has site specific emergency instructions in each main area. Emergency exits are clearly marked and free from obstruction. The home maintains systems in accordance with fire authority requirements. An evacuation transfer list is available to staff which is updated on a regular basis to record which care recipients are absent and changes in their transfer needs. The home has security checks and environmental security for the safety of care recipients. External lighting is in place to assist with after hour’s security. Results show that monitoring of fire safety systems occurs through internal audits, organisational audits and inspection by the fire service. Staff can describe what actions to take in the event of an emergency and the home’s security procedures. Care recipients and staff report they feel safe within the home day and night as a result of the fire safety, emergency and security provisions in place.

4.7 Infection control

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

Team’s findings


The home has an effective, monitored infection control program coordinated by the work health and safety officer. National infection control guidelines and policies and procedures are accessible to staff, who receive infection control training during induction and through annual competency assessments. Staff were observed to use relevant infection control practices. There is access to personal protective equipment, hand washing facilities and hand gel stations. There are processes to inform care and hospitality staff of care recipient infections and specific precautions required. Infection surveillance assists the home to identify infection trends and audit programs monitor staff practice and infection control procedures. Results show there is a low incidence of infection and identified trends are actioned. Staff said they are satisfied with the infection control processes in place and actions taken in response to infections.

4.8 Catering, cleaning and laundry services

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

Team’s findings


The organisation has a corporate food safety plan which is reviewed each year. Each residential site follows the corporate food safety plan. There is a common menu developed by the dietitian which is reviewed at the change of menu. Sites make changes to the menu in consultation with the dietitian. The organisation uses an external food safety auditor to conduct annual audits of the food safety program on each site. Reports are provided to each home and any actions taken to meet the recommendations.

Catering services at the home are provided to meet care recipients’ dietary needs and preferences. Meal alternatives are available at care recipients’ request or if changes to their


health status require it. Staff follow safe food handling practices throughout preparation and meal service. The homes production kitchen has food temperature records that are in place and maintained. Routines and schedules are in place to guide cleaning of care recipients’ rooms, common areas, high surfaces, windows and external areas. Hospitality service team members maintain care recipients’ personal items on site and demonstrate an understanding of the infection control principles related to laundry and cleaning processes. Appropriate wash cycles are used for laundering care recipients’ clothing and items are returned in a timely manner.

Results at the home show that management monitor the effectiveness of services, skills and knowledge of staff, using audits, competency assessments and observation of practice and provide support as required. Audits and inspections of the kitchen, laundry, and cleaning areas are undertaken on a regular basis. Food items are rotated as part of stock control procedures. Staff said they are aware of food safety guidelines and have clear procedures to follow in providing catering, cleaning and laundry services. Care recipients and representatives interviewed are satisfied with the catering, cleaning and laundry services at the home.

west beach residentialaccredited residential aged care homes receive australian government subsidies...

Documents