Post on 19-Jul-2020
StCatherine'sHostelWangarattaIncRACSID: 3063
Approvedprovider: StCatherine'sHostelWangarattaInc
Homeaddress: 59-69RyleyStreetWANGARATTAVIC3677
Followinganauditwedecidedthatthishomemet44ofthe44expectedoutcomesoftheAccreditationStandardsandwouldbeaccreditedforthreeyearsuntil22May2021.
Wemadeourdecisionon04April2018.
Theauditwasconductedon21February2018to22February2018.Theassessmentteam’sreportisattached.
Wewillcontinuetomonitortheperformanceofthehomeincludingthroughunannouncedvisits.
MostrecentdecisionconcerningperformanceagainsttheAccreditationStandards
Standard1:Managementsystems,staffingandorganisationaldevelopment
Principle:
Withinthephilosophyandlevelofcareofferedintheresidentialcareservice,managementsystemsareresponsivetotheneedsofcarerecipients,theirrepresentatives,staffandstakeholders,andthechangingenvironmentinwhichtheserviceoperates.
1.1 Continuousimprovement Met
1.2 Regulatorycompliance Met
1.3 Educationandstaffdevelopment Met
1.4 Commentsandcomplaints Met
1.5 Planningandleadership Met
1.6 Humanresourcemanagement Met
1.7 Inventoryandequipment Met
1.8 Informationsystems Met
1.9 Externalservices Met
Standard2:Healthandpersonalcare
Principle:
Carerecipients’physicalandmentalhealthwillbepromotedandachievedattheoptimumlevelinpartnershipbetweeneachcarerecipient(orhisorherrepresentative)andthehealthcareteam.
2.1 Continuousimprovement Met
2.2 Regulatorycompliance Met
2.3 Educationandstaffdevelopment Met
2.4 Clinicalcare Met
2.5 Specialisednursingcareneeds Met
2.6 Otherhealthandrelatedservices Met
2.7 Medicationmanagement Met
2.8 Painmanagement Met
2.9 PalliativecareMet
Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 2
2.10 Nutritionandhydration Met
2.11 Skincare Met
2.12 Continencemanagement Met
2.13 Behaviouralmanagement Met
2.14 Mobility,dexterityandrehabilitation Met
2.15 Oralanddentalcare Met
2.16 Sensoryloss Met
2.17 Sleep Met
Standard3:Carerecipientlifestyle
Principle:
Carerecipientsretaintheirpersonal,civic,legalandconsumerrights,andareassistedtoachieveactivecontroloftheirownliveswithintheresidentialcareservicesandinthecommunity.
3.1 Continuousimprovement Met
3.2 Regulatorycompliance Met
3.3 Educationandstaffdevelopment Met
3.4 EmotionalSupport Met
3.5 IndependenceMet
3.6 Privacyanddignity Met
3.7 Leisureinterestsandactivities Met
3.8 Culturalandspirituallife Met
3.9 Choiceanddecision-making Met
3.10 Carerecipientsecurityoftenureandresponsibilities Met
Standard4:Physicalenvironmentandsafesystems
Principle:
Carerecipientsliveinasafeandcomfortableenvironmentthatensuresthequalityoflifeandwelfareofcarerecipients,staffandvisitors
4.1 Continuousimprovement Met
4.2 Regulatorycompliance Met
4.3 Educationandstaffdevelopment Met
4.4 Livingenvironment MetHomename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 3
4.5 Occupationalhealthandsafety Met
4.6 Fire,securityandotheremergenciesMet
4.7 Infectioncontrol Met
4.8 Catering,cleaningandlaundryservices Met
Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 4
AuditReportNameofhome:StCatherine'sHostelWangarattaInc
RACSID:3063
Approvedprovider:StCatherine'sHostelWangarattaInc
IntroductionThisisthereportofaRe-accreditationAuditfrom21February2018to22February2018submittedtotheQualityAgency.
AccreditedresidentialagedcarehomesreceiveAustralianGovernmentsubsidiestoprovidequalitycareandservicestocarerecipientsinaccordancewiththeAccreditationStandards.
Toremainaccreditedandcontinuetoreceivethesubsidy,eachhomemustdemonstratethatitmeetstheStandards.
TherearefourStandardscoveringmanagementsystems,healthandpersonalcare,carerecipientlifestyle,andthephysicalenvironmentandthereare44expectedoutcomessuchashumanresourcemanagement,clinicalcare,medicationmanagement,privacyanddignity,leisureinterests,culturalandspirituallife,choiceanddecision-makingandthelivingenvironment.
Eachhomeappliesforre-accreditationbeforeitsaccreditationperiodexpiresandanassessmentteamvisitsthehometoconductanaudit.TheteamassessesthequalityofcareandservicesatthehomeandreportsitsfindingsaboutwhetherthehomemeetsordoesnotmeettheStandards.TheQualityAgencythendecideswhetherthehomehasmettheStandardsandwhethertore-accreditornottore-accreditthehome.
Duringahome’speriodofaccreditationtheremaybeareviewauditwhereanassessmentteamvisitsthehometoreassessthequalityofcareandservicesandreportsitsfindingsaboutwhetherthehomemeetsordoesnotmeettheStandards.
Assessmentteam’sfindingsregardingperformanceagainsttheAccreditationStandardsTheinformationobtainedthroughtheauditofthehomeindicatesthehomemeets:44expectedoutcomes
Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 5
ScopeofthisdocumentAnassessmentteamappointedbytheQualityAgencyconductedtheRe-accreditationAuditfrom21February2018to22February2018.
TheauditwasconductedinaccordancewiththeQualityAgencyPrinciples2013andtheAccountabilityPrinciples2014.Theassessmentteamconsistedoftworegisteredagedcarequalityassessors.
TheauditwasagainsttheAccreditationStandardsassetoutintheQualityofCarePrinciples2014.
DetailsofhomeTotalnumberofallocatedplaces:69
Numberofcarerecipientsduringaudit:69
Numberofcarerecipientsreceivinghighcareduringaudit:69
Specialneedscateredfor:Notapplicable
Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 6
AudittrailTheassessmentteamspenttwodaysonsiteandgatheredinformationfromthefollowing:
Interviews
Positiontitle Number
Carerecipients 16
Representatives 5
Chiefexecutiveofficer 1
Caremanager 1
Financemanager 1
Administrativestaff 1
Registerednurse 3
Enrollednurse 3
Carestaff 6
Lifestylecoordinator 1
Hospitalityteamleader 1
Maintenance 1
Cateringmanager 1
Cateringstaff 2
Laundrystaff 1
OccupationalTherapist 1
Woundconsultant 1
Hairdresser 1
Sampleddocuments
Documenttype Number
Carerecipients’files 8
Medicationcharts 8
Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 7
Stafffiles 8
Otherdocumentsreviewed
Theteamalsoreviewed:
Auditdocumentation
CateringanddietaryrecordsCleaningdocumentationClinicalobservationandmanagementdocumentsCommentsandcomplaintsdocumentationCompulsoryreportingdocumentationContinuousimprovementactionplanCorrectiveandpreventativemaintenancedocumentationDailycarefoldersEmergencymanagementprocedures
ExternalcontractsandassociateddocumentationFireandessentialservicesmaintenanceandtestingrecordsFoodsafetyprogram
Kitchencommunicationbookanddietarychanges
NewslettersNursingregistrationrecordsOrientationandinductioninformation
ResidentialagreementsRoomauditsSafetydatasheets
AdvancedcareplansandendoflifeformsAlliedhealthreferralfolders
Carerecipients’handbook
Equipmentandbedpoleassessmentsandreviews
Incidentreports,investigationsandevaluationsInfectioncontrolsurveillancerecordsInfectionoutbreakreport
LegislativeinformationLifestyledocumentationMaintenanceandhazardreportsMeetingscheduleandmeetingminutesMemoranda
PolicecertificatemonitoringrecordsPoliciesandprocedures
Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 8
Satisfactionsurveys
StaffeducationrecordsStaffHandbookWorkhealthandsafetydocumentation
Observations
Theteamobservedthefollowing:ActivitiesinprogressArchivingsystemCleaners’roomsandchemicalstorageareasClinicalsuppliesEgressroutesExternalandinternalfeedbackmechanismsFireequipmentGeneratorHandhygienefacilities,personalprotectiveequipment,spillkitsandoutbreakkitsInteractionsbetweenstaffandcarerecipientsKitchen/cateringareasincludingfoodstorageLaundryandassociatedequipmentLivingenvironmentMealandrefreshmentservicewithmenudisplayMedicationadministration,storageanddisposalsystems.NoticeboardsandinformationdisplaysRe-accreditationnoticesdisplayedShortgroupobservationduringlifestyleactivity.
Self-assessmentSpecialistassessmentsandreviews
Woundandpressurecarerecords.
Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 9
AssessmentinformationThissectioncoversinformationaboutthehome’sperformanceagainsteachoftheexpectedoutcomesoftheAccreditationStandards.
Standard1–Managementsystems,staffingandorganisationaldevelopment
Principle:
Withinthephilosophyandlevelofcareofferedintheresidentialcareservices,managementsystemsareresponsivetotheneedsofcarerecipients,theirrepresentatives,staffandstakeholders,andthechangingenvironmentinwhichtheserviceoperates.
1.1 Continuousimprovement
Thisexpectedoutcomerequiresthat“theorganisationactivelypursuescontinuousimprovement”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thecontinuousimprovementprogramincludesprocessesforidentifyingareasforimprovement,implementingchange,monitoringandevaluatingtheeffectivenessofimprovements.Feedbackissoughtfromcarerecipients,representatives,staffandotherstakeholderstodirectimprovementactivities.Improvementactivitiesaredocumentedontheplanforcontinuousimprovement.Managementusesarangeofmonitoringprocessessuchasauditsandqualityindicatorstomonitortheperformanceofthehome'squalitymanagementsystems.Outcomesareevaluatedforeffectivenessandongoingmonitoringofnewprocessesoccurs.Carerecipients,representatives,staffandotherpersonnelareprovidedwithfeedbackaboutimprovements.Duringthisaccreditationperiodtheorganisationhasimplementedinitiativestoimprovethequalityofcareandservicesitprovides.RecentexamplesofimprovementsinStandard1Managementsystems,staffingandorganisationaldevelopmentare:
1.2 Regulatorycompliance
Thisexpectedoutcomerequiresthat“theorganisation’smanagementhassystemsinplacetoidentifyandensurecompliancewithallrelevantlegislation,regulatoryrequirements,professionalstandardsandguidelines”.
Team'sfindings
Managementimplementedelectronicrosteringtoreplacetheexistingpaper-basedsystem.Managementandstaffspokepositivelyaboutthechangewhichenablestheestablishmentofamonthlyrosterandashortmessagealertsystemforunplannedleave.Managementsaidthesystemensurestherosteringprocessmorestreamlinedandefficientandhascreatedgreatertransparencyandequityinshiftallocation.Inresponsetoongoingchallengespromotingstaffattendanceattrainingsessions,managementexploredoptionstoimplementanonlinelearningframework.ThisleadtotheimplementationoftheVictorianRegionalHealthServiceseLearningNetworkatthehome.Staffthroughtheirindividualloginshaveaccesstoalargerangeofmandatoryandothereducationtopics.Managementsaidstaffenjoytheflexibilitythatonlinelearningprovides.
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Thehomemeetsthisexpectedoutcome
Thehomehasagenerallyeffectivesystemtoidentifyrelevantlegislation,regulatoryrequirementsandguidelines,andformonitoringtheseinrelationtotheAccreditationStandards.Managementhasestablishedlinkswithexternalorganisationstoensuretheyareinformedaboutchangestoregulatoryrequirements.Wherechangesoccur,managementtakesactiontoupdatepoliciesandproceduresandcommunicatethechangestocarerecipients,theirrepresentativesandstaffasappropriate.Arangeofsystemsandprocesseshavebeenestablishedbymanagementtoensurecompliancewithregulatoryrequirements.Staffhaveanawarenessoflegislation,regulatoryrequirements,professionalstandardsandguidelinesrelevanttotheirroles.ExamplesofregulatorycompliancerelatingtoStandard1Managementsystems,staffingandorganisationaldevelopmentinclude:
1.3 Educationandstaffdevelopment
Thisexpectedoutcomerequiresthat“managementandstaffhaveappropriateknowledgeandskillstoperformtheirroleseffectively”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thehome'sprocessessupporttherecruitmentofstaffwiththerequiredknowledgeandskillstoperformtheirroles.Newstaffparticipateinanorientationprogramthatprovidesthemwithinformationabouttheorganisation,theirposition,keypoliciesandproceduresandequipsthemwithmandatoryskillsfortheirrole.Staffarescheduledtoattendregularmandatorytraining;attendanceismonitoredandaprocessavailabletoaddressnon-attendance.Theeffectivenessoftheeducationprogramismonitoredthroughattendancerecords,evaluationrecordsandobservationofstaffpractice.Carerecipientsandrepresentativesinterviewedaresatisfiedstaffhavetheknowledgeandskillstoperformtheirrolesandstaffaresatisfiedwiththeeducationandtrainingprovided.ExamplesofeducationandtrainingprovidedinrelationtoStandard1Managementsystems,staffingandorganisationaldevelopmentincludeattendingthe:
1.4 Commentsandcomplaints
Thisexpectedoutcomerequiresthat"eachcarerecipient(orhisorherrepresentative)andotherinterestedpartieshaveaccesstointernalandexternalcomplaintsmechanisms".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thereareprocessestoensurecarerecipients,theirrepresentativesandothersareprovidedwithinformationabouthowtoaccesscomplaintmechanisms.Carerecipientsandothersaresupportedtoaccessthesemechanisms.Facilitiesareavailabletoenablethesubmissionof
Processesensureallrelevantindividualsincludingvolunteershaveacurrentpolicecertificatecheck.Informationregardingexternalcomplaintmechanismsiscommunicatedtocarerecipientsandrepresentatives.Managementhasasystemtoundertakeself-assessment.Confidentialdocumentationisstoredsecurely.
BetterPracticeconferenceregionalforumofindustrypeakbody.
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confidentialcomplaintsandensureprivacyofthoseusingcomplaintsmechanisms.Complaintsprocesseslinkwiththehome'scontinuousimprovementsystemandwhereappropriate,complaintstriggerreviewsofandchangestothehome'sproceduresandpractices.Theeffectivenessofthecommentsandcomplaintssystemismonitoredandevaluated.Managementandstaffhaveanunderstandingofthecomplaintsprocessandhowtheycanassistcarerecipientsandrepresentativeswithaccess.Carerecipientsandtheirrepresentativesinterviewedhaveanawarenessofthecomplaintsmechanismsavailabletothemandareeithermostlyoralwayssatisfiedthatstafffollowupwhentheyraisethingswiththem.
1.5 PlanningandLeadership
Thisexpectedoutcomerequiresthat"theorganisationhasdocumentedtheresidentialcareservice’svision,values,philosophy,objectivesandcommitmenttoqualitythroughouttheservice".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Theorganisationhasdocumentedthehome'svision,philosophy,objectivesandcommitmenttoquality.Thisinformationiscommunicatedtocarerecipients,representatives,staffandothersthrougharangeofdocumentsandisdisplayedinthehome.Ninetythreepercentofcarerecipientsinterviewedfortheconsumerexperiencereportsaidtheystronglyagreethehomeiswellrunwhiletheothersevenpercentagreedthehomeiswellrun.
1.6 Humanresourcemanagement
Thisexpectedoutcomerequiresthat"thereareappropriatelyskilledandqualifiedstaffsufficienttoensurethatservicesaredeliveredinaccordancewiththesestandardsandtheresidentialcareservice’sphilosophyandobjectives".
Team'sfindings
Thehomemeetsthisexpectedoutcome
TherearesystemsandprocessestoensuretherearesufficientskilledandqualifiedstafftodeliverservicesthatmeettheAccreditationStandardsandthehome'sphilosophyandobjectives.Recruitment,selectionandinductionprocessesensurestaffhavetherequiredknowledgeandskillstodeliverservices.Staffinglevelsandskillmixarereviewedinresponsetochangesincarerecipients'needsandthereareprocessestoaddressplannedandunplannedleave.Thehome'smonitoring,humanresourceandfeedbackprocessesidentifyopportunitiesforimprovementinrelationtohumanresourcemanagement.Staffaresatisfiedtheyhavesufficienttimetocompletetheirworkandmeetcarerecipients'needs.Carerecipientsandrepresentativesinterviewedarehighlysatisfiedwiththeavailabilityofskilledandqualifiedstaffandthequalityofcareandservicesprovided.
1.7 Inventoryandequipment
Thisexpectedoutcomerequiresthat"stocksofappropriategoodsandequipmentforqualityservicedeliveryareavailable".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thehomehasprocessestomonitorstocklevels,ordergoodsandmaintainequipmenttoHomename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 12
ensuredeliveryofqualityservices.Goodsandequipmentaresecurelystoredand,whereappropriate,stockrotationoccurs.Preventativemaintenanceandcleaningschedulesensureequipmentismonitoredforoperationandsafety.Thehomepurchasesequipmenttomeetcarerecipients'needsandmaintainsappropriatestocksofrequiredsupplies.Staffreceivetraininginthesafeuseandstorageofgoodsandequipment.Staff,carerecipientsandrepresentativesinterviewedstatedtheyaresatisfiedwiththesupplyandqualityofgoodsandequipmentavailableatthehome.
1.8 Informationsystems
Thisexpectedoutcomerequiresthat"effectiveinformationmanagementsystemsareinplace".
Team'sfindings
ThehomemeetsthisexpectedoutcomeManagementandstaffhaveaccesstoinformationappropriatetotheirrole.Policies,procedures,positiondescriptions,plannededucation,meetings,handoverandelectronicmemorandainformstaff.Newsletters,notices,meetings,publicannouncementsandinformaldiscussionsprovideongoinginformationforcarerecipientsandrepresentatives.Staffreviewclinicalinformationregularlyanddemonstrateeffectivesystemsforcommunicatingchangesincarerecipients’treatmentandneeds.Confidentialinformationisstoredandarchivedinlinewithlegislatedrequirements.Electronicsystemsarepasswordprotectedwithinformationrestrictedtoappropriatestaff.Managementcollect,collateandanalysekeyinformationtoidentifypotentialrisksandimprovementopportunities.Staffsaidtheyhaveadequateaccesstoinformationtohelpthemperformtheirroles.Carerecipientsandrepresentativessaidtheyreceiveinformationregardingcarerecipients’careandinformationaboutactivitiesandeventsinthehome.Carerecipientsaresatisfiedstafftakethetimetoexplainthingstothem.
1.9 Externalservices
Thisexpectedoutcomerequiresthat"allexternallysourcedservicesareprovidedinawaythatmeetstheresidentialcareservice’sneedsandservicequalitygoals".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thehomehasmechanismstoidentifyexternalserviceneedsandqualitygoals.Thehome'sexpectationsinrelationtoserviceandqualityisspecifiedandcommunicatedtotheexternalproviders.Thehomehasagreementswithexternalserviceproviderswhichoutlineminimumperformance,staffingandregulatoryrequirements.Thereareprocessestoreviewthequalityofexternalservicesprovidedand,whereappropriate,actionistakentoensuretheneedsofcarerecipientsandthehomearemet.Staffareabletoprovidefeedbackonexternalserviceproviders.Carerecipients,representativesandstaffinterviewedstatedtheyaresatisfiedwiththequalityofexternallysourcedservices.
Homename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 13
Standard2-Healthandpersonalcare
Principle:
Carerecipients’physicalandmentalhealthwillbepromotedandachievedattheoptimumlevel,inpartnershipbetweeneachcarerecipient(orhisorherrepresentative)andthehealthcareteam.
2.1 Continuousimprovement
Thisexpectedoutcomerequiresthat“theorganisationactivelypursuescontinuousimprovement”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
RefertoExpectedoutcome1.1Continuousimprovementforinformationaboutthehome'ssystemstoidentifyandimplementimprovements.RecentexamplesofimprovementsinStandard2Healthandpersonalcareare:
2.2 Regulatorycompliance
Thisexpectedoutcomerequiresthat“theorganisation’smanagementhassystemsinplacetoidentifyandensurecompliancewithallrelevantlegislation,regulatoryrequirements,professionalstandardsandguidelinesabouthealthandpersonalcare”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
RefertoExpectedoutcome1.2Regulatorycomplianceforinformationaboutthehome'ssystemstoidentifyandensurecompliancewithrelevantregulatoryrequirements.
ExamplesofregulatorycompliancerelatingtoStandard2Healthandpersonalcareinclude:
Theobservedbenefitsofthevisitingnursepractitionerprogramledtoadecisionbymanagementtoincreaseintheprogramfromonedayaweektofourhoursforthreedaysaweekandanoncallservice.Managementspokepositivelyaboutthebenefitsoftheprogramwhichincludeimprovedclinicalassessmentsandstaffeducation.Carerecipientsandrepresentativesspokehighlyaboutthequalityoftheservice.Onerepresentativesaidhavingthenursepractitioneronsitehasenabledtheirfather,whoisanxiousaboutleavingthehome,toreceiveallhiscareatthehome.Inresponsetothefindingsofacoronialinquestintobluerecliningcomfortchairs,managementtookadecisiontophaseoutthisequipmentfromuseatthehome.Thewoundcarespecialistandoccupationaltherapistreviewedtheseatingrequirementsforallcarerecipientsandmaderecommendationsofspecificpressurerelievingseatingforeachcarerecipient.Managementpurchasedalternatecomfortchairsandpressurerelievingcushionsinaccordancewiththeensuingreport.Theoccupationaltherapistwillcontinuetoreassesscarerecipients’pressurecareneedsastheirconditionchangesensuringoptimumpressurecare.
Managementmonitorandensurethecurrencyofallnursingregistrationsismaintained.Registerednursesundertakeandoverseecareplanningandspecialisednursingcare.Medicationmanagement,administrationandstorageoccursinaccordancewithlegislativerequirements.
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2.3 Educationandstaffdevelopment
Thisexpectedoutcomerequiresthat“managementandstaffhaveappropriateknowledgeandskillstoperformtheirroleseffectively”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thehomehasasystemtomonitorandensurestaffhavetheknowledgeandskillstoenablethemtoeffectivelyperformtheirrolesinrelationtohealthandpersonalcare.RefertoExpectedoutcome1.3Educationandstaffdevelopmentformoreinformation.ExamplesofeducationandtrainingprovidedinrelationtoStandard2Healthandpersonalcareinclude:
2.4 Clinicalcare
Thisexpectedoutcomerequiresthat“carerecipientsreceiveappropriateclinicalcare”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipientsreceiveclinicalcareappropriatetomeettheirneedsandpreferences.Transferdataandentryassessmentsformthebasisforaninterimcareplan,whichprovidescareguidelinesuntilstaffcompleteallassessmentsandcareplanning.Careplansincludeinputfromotherhealthprofessionalsandreflectcarerecipients’preferencesandtheassessmentdata.Nursingstaffreviewcareplanstwomonthlyorwhentriggeredbymedicalreviewsorchangesinthecarerecipients’condition.Anursepractitionerisavailablethreedayseachweekprovidingsupportforstaffandisparticipatingintheprovisionofcarerecipients’clinicalcare.Staffhaveaccesstopoliciesandproceduresandeducationtoguidetheirpractice.Audits,carereviews,stakeholderfeedbackandclinicalindicatorssuchasskintears,falls,behaviouralandmedicationsincidentscontributetothemonitoringofcareoutcomes.Carerecipientsandrepresentativesaresatisfiedwiththeclinicalcareprovidedforcarerecipients.
2.5 Specialisednursingcareneeds
Thisexpectedoutcomerequiresthat“carerecipients’specialisednursingcareneedsareidentifiedandmetbyappropriatelyqualifiednursingstaff”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipients’specialisednursingcareneedsareidentifiedandmetbyappropriatelyqualifiednursingstaff.Registerednursesmanagecarerecipients’specialisednursingcarecompletingassessments,developingcareplansandevaluatingspecialisedcareregularly.Staffconsultthemedicalpractitionerandthegerontologynursepractitionerforanysignificantchangeincarerecipients’healthstatus.Otherhealthspecialistsprovidecareplaninputand
Managementhaveapolicyandprocedureforunexplainedabsencesofacarerecipientincludingtherequirementtonotifyallrelevantauthorities.
advancedcareplanningdementiaessentialspainmanagementwoundcare.
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expertiseasrequired.Careplanscontainreferraloutcomesanddetailsofprescribedtreatments.Specialistequipmentisavailableandtheeducationprogramprovidesstaffwiththeopportunitytodevelopspecialisedskillsandknowledge.Carerecipientsandrepresentativesaresatisfiedappropriatelyskilledandqualifiedstaffattendtocarerecipients’specialisedcareneeds.
2.6 Otherhealthandrelatedservices
Thisexpectedoutcomerequiresthat“carerecipientsarereferredtoappropriatehealthspecialistsinaccordancewiththecarerecipient’sneedsandpreferences”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipientscanaccessawiderangeofhealthspecialistsaccordingtotheirneedsandpreferences.Medicalpractitionersvisitthehomeregularlyandcarerecipientscanretaintheirownmedicalpractitionerofchoice.Managementandthemedicalpractitionerprovidecarerecipientsandrepresentativeswithinformationabouthealthspecialistsassistingthemtomakeinformedchoices.Arangeofhealthspecialistsvisitthehomeandstaffassistcarerecipientstoattendexternalappointmentsorfacilitatetele-conferencingappointmentswithagedcarespecialists.Clinicaldocumentationincludesoutcomesofhealthspecialists’referralsandsubsequentupdatestocareplanning.Carerecipientsandrepresentativesaresatisfiedcarerecipientsreceiveadequateassistancetoaccesstheirpreferredhealthspecialists.
2.7 Medicationmanagement
Thisexpectedoutcomerequiresthat“carerecipients’medicationismanagedsafelyandcorrectly”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipients’medicationismanagedsafelyandcorrectly.Registerednurses,medicationendorsedenrollednursesandmedicationcompetentcarersadministermedicationsfrommultidoseadministrationaidsandoriginalpackaging.Initialandongoingassessmentsidentifycarerecipients’medicationrequirementsandpreferences,allergiesanddegreeofassistanceneeded.Medicationchartsareuptodateandincludeclearmedicationorders,identificationinformationanddetailresidents’preferencesfortakingmedication.Registerednursesmaintainresponsibilityforrestrictedmedicationsandmedicationrequiringregulardoseadjustmentaccordingtotheprescriber’sinstructions.Processesincludecheckingofmedicationsnotincludedindoseadministrationaidsandfortheadministrationof‘asrequired’medications.Medicationsarestoredsecurelyandthereareprocedurestomaintainsupplyandtodisposeofunnecessarymedication.Managementmonitorsthemedicationsystemthroughincidentanalysis,pharmacyreviews,auditsandmedicationadvisorymeetings.Carerecipientsandrepresentativesaresatisfiedmedicationismanagedsafelyandcorrectly.
2.8 Painmanagement
Thisexpectedoutcomerequiresthat“allcarerecipientsareasfreeaspossiblefrompain”.
Team'sfindings
ThehomemeetsthisexpectedoutcomeHomename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 16
Carerecipientsareasfreeaspossiblefrompain.Nursingstaffcompleteinitialpainassessmentsidentifyingcarerecipientspastandcurrentpainexperiencesandcommenceappropriatetreatments.Staffcompleteassessmentandchartingforcontinuingpainandusethisinformationtodevelopaplanofcare.Processesincludemonitoringofcarerecipientswhoareunabletoverbalisetheirpainsymptomsandareviewforanyneworalteredpain.Carerecipientshaveindividualisedpainprogramsdirectedbyanonsiteoccupationaltherapistinconsultationwiththeclinicalstaffandthecarerecipient’sgeneralpractitioner.Staffdescribedarangeofcomfortmeasurestheyusetoalleviatecarerecipients’painincludingheatandmassagetherapy,diversion,repositioningandmedication.Managementmonitorforeffectivenessofcareusingcarereviews,medication,auditsandfeedback.Carerecipientsandrepresentativessaidtheyaresatisfiedwiththemanagementofcarerecipients’pain.
2.9 Palliativecare
Thisexpectedoutcomerequiresthat“thecomfortanddignityofterminallyillcarerecipientsismaintained”.
Team'sfindings
ThehomemeetsthisexpectedoutcomeCaremanagementsystemsandstaffpracticesensurethedignityandcomfortforcarerecipientsnearingtheendoftheirlife.Endoflifewishesareincludedinassessmentandcareplanningandthenursepractitionerisassistingcarerecipientstocompleteadvancedcareplans.Whenindicatednursingstaffreviewcareanddevelopapalliativecareplaninconsultationwiththecarerecipient,representativesandotherhealthprofessionals.Palliativecarestrategiesincludesymptommanagement,comfortmeasures,paincontrolandaddressingemotionalandspiritualneeds.Staffconsultwithexternalpalliativespecialiststoassistwithadviceandcarewhenrequired.Staffdescribedempatheticcareforterminallyillcarerecipientsincludingconsiderationofpreferences,dignity,comfortandspiritualcare.Carerecipientsandrepresentativesaresatisfiedwiththespiritualandpalliativecareavailableforcarerecipients.
2.10 Nutritionandhydration
Thisexpectedoutcomerequiresthat“carerecipientsreceiveadequatenourishmentandhydration”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipientsreceiveadequatenourishmentandhydration.Assessmentsandcareplansidentifyallergies,detailsofrequiredassistivedevices,personalandculturalpreferencesandclinicalneeds.Communicationprocessesensurecateringinformationreflectscarerecipients’needsandpreferences.Staffassistcarerecipientsatmealtimesandprovideadaptivecutleryandcrockeryencouragingindependence.Referralsystemsensurethedietitianandspeechtherapistmonitorscarerecipientswithdietaryandswallowingconcerns.Staffweighcarerecipientssecondmonthlytomonitorforanysignificantorunexplainedweightvariationandasmallnumberofcarerecipientsreceiveadditionalnutritionalsupplements.Monitoringofnutritionandhydrationoccursthroughaudits,weightanalysisandstakeholderfeedback.Carerecipientsandrepresentativesspokepositivelyofthemealsprovided,sayingtheyalmostalwaysenjoythefoodofferedandtheycanhavesubstitutemeals,avarietyofdrinksandsnacksastheywish.
2.11 Skincare
Thisexpectedoutcomerequiresthat“carerecipients’skinintegrityisconsistentwiththeirgeneralhealth”.
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Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipients’skinintegrityisconsistentwiththeirgeneralhealth.Initialandongoingassessments,includingariskassessmentprocess,identifycarerecipients’skincareneedsandpreferencesandcontributetothedevelopmentofthecareplan.Skincareinterventionsincludepressurerelievingdevices,specifichygieneandskinmoisturisingstrategies,mobilityreviews,positionchangesandnutritionalstrategies.Woundcareincludesappropriatewounddressings,documentationandevaluationofcareandconsultationwiththewoundcarespecialistwhenrequired.Thewoundcarespecialistevaluatesallpressure-relievingaidsforsuitabilityandoptimumpressurerelievingfunction.Staffconfirmedsufficientsuppliesofwoundcareproductsandavailabilityofeducationresourcesforskincaremanagement.Audits,stakeholderconsultation,incidentandcareplanreviewsmonitortheeffectivenessofcare.Carerecipientsandrepresentativesaresatisfiedcarerecipientsreceiveappropriateskincareconsistentwiththeirgeneralhealth.
2.12 Continencemanagement
Thisexpectedoutcomerequiresthat“carerecipients’continenceismanagedeffectively”.
Team'sfindings
ThehomemeetsthisexpectedoutcomeCarerecipientsreceivecontinencecareappropriatetotheirneeds,effectivelymanagingtheircontinenceexperience.Processesincludecontinenceassessments,managementplans,identificationandsupplyofappropriateaidsandregularcontinencecarereview.Continencecarestrategiesincludereferraltoacontinenceadviser,establishingvoidingpatterns,dietaryandmedicationinterventions,mobilitystrategiesandtoiletingplans.Nutritionplansincludedietarymeasuresforeffectivebowelmanagement.Staffmonitorforinfectionsimplementingappropriatemanagementstrategies.Careplanreviewsandauditsensuresufficientandappropriateaidsareavailableandthattheprogramismeetingtheneedsandpreferencesofcarerecipients.Carerecipientsandrepresentativesaresatisfiedstaffmanagecarerecipients’continenceissuesdiscreetlyandrespectfully.
2.13 Behaviouralmanagement
Thisexpectedoutcomerequiresthat“theneedsofcarerecipientswithchallengingbehavioursaremanagedeffectively”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Theneedsofcarerecipientswithresponsivebehavioursaremanagedeffectively.Initialandongoingassessmentsidentifycarerecipients’behaviourpatternsandincorporatescopeforadditionalmonitoringandreviewasnecessary.Careplansincludeconsiderationoftriggersforthebehaviourwheneverpossibleandarereviewedtwomonthlyandwhenrequired.Medicalpractitionersandnursingstaffassessandregularlyreviewanypracticewithpotentialforrestraint.Staffconsultwithbehaviouralandpainmanagementspecialists,dementiaresponseteamsandadvisorygroupsasrequired.Staffsaidtheyareawareofthetriggersassociatedwithbehavioursandweobservedstaffprovidingcare,demonstratingtheyunderstoodcarerecipients’needs.Thehomemonitorstheeffectivenessofthecarethroughaudits,reviewofbehaviourincidents,carereviewsandfeedback.Carerecipientsandrepresentativesaresatisfiedtheneedsofcarerecipientswithresponsivebehavioursaremanagedeffectively.
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2.14 Mobility,dexterityandrehabilitation
Thisexpectedoutcomerequiresthat“optimumlevelsofmobilityanddexterityareachievedforallcarerecipients”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipients’optimumlevelsofmobilityanddexterityareachieved.Anonsiteoccupationaltherapistisactivelyinvolvedintheassessmentanddevelopmentofpersonalisedprogramsforcarerecipientsensuringoptimallevelsofmobility,dexterityandriskminimisation.Careplansincludestrategiestopromoteindependenceandminimisefallrisks.Appropriatetransferequipment,assistivedevicesandmobilechairsareavailable.Educationprogramsprovidetrainingforincidentmanagement,manualhandlingandsafetransfertechniques.Audits,careplanreviews,observationandstakeholderfeedbackmonitortheeffectivenessofcare.Carerecipientsandrepresentativesaresatisfiedwiththecareprovidedtomaintaincarerecipients’mobilityanddexterity.
2.15 Oralanddentalcare
Thisexpectedoutcomerequiresthat“carerecipients’oralanddentalhealthismaintained”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipients’oralanddentalhealthismaintained.Assessments,careplansandregularevaluationsidentifycarerecipients’dentalstatus,preferredcareoptionsandthelevelofassistancerequired.Nursingstaffandthemedicalpractitionermonitororalanddentalhealthreferringcarerecipientstoalliedhealthspecialistssuchasthedietician,speechtherapistanddentalserviceswhenrequired.Adentalclinicvisitedrecentlycompletingdentalchecks,hygienecareandsimpletreatments.Staffassistcarerecipientstoattendexternalservicesformorecomplicatedtreatments.Dentalcareequipmentischeckedregularly,readilyavailableandreplacedaccordingtoaseasonalschedule.Careplanreviewsensuredentalcareandpreferencesareaddressedeffectively.Carerecipientsandrepresentativesaresatisfiedwiththeassistancecarerecipientsreceivetomaintaintheiroralanddentalcare.
2.16 Sensoryloss
Thisexpectedoutcomerequiresthat“carerecipients’sensorylossesareidentifiedandmanagedeffectively”.
Team'sfindings
ThehomemeetsthisexpectedoutcomeCareprocessesaddresstheeffectiveidentificationandmanagementofcarerecipients’sensorylosses.Assessmentandcareplanningidentifycarerecipients’sensoryneedsforvision,hearing,communication,sensation,tasteandtactileexperiences.Careplansdetailthelevelofassistancerequired,careofaidsandstrategiestooptimisesensoryfunction.Staffnotifythemedicalpractitionerofanyconcernsandreferraltospecialistssuchasaudiologistsandoptometristsoccurs.Lifestyleactivitiesincludearangeofsensoryenhancingopportunitiessuchasinteractivelifestyleevents,music,massageandtactiletherapies.Monitoringsystemsincludeauditsandstakeholderfeedback.Carerecipientsandrepresentativesaresatisfiedwiththesupportgiventocarerecipientstoenhancetheirsensoryexperiences.
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2.17 Sleep
Thisexpectedoutcomerequiresthat“carerecipientsareabletoachievenaturalsleeppatterns”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Sleepmanagementstrategiesassistcarerecipientstoachieveandmaintainnaturalsleeppatterns.Assessmentsidentifycarerecipients’usualsleeppatternspreferencesfordayandnightrest.Careplansdetailpreferencesforretiring,wakingandstrategiestopromotesleep,suchasattendingtophysicalcareneeds,leavingalighton,painmanagementandspecificcomfortmeasures.Staffdemonstratedknowledgeofcarerecipients’individualsettlingroutinesanddayrestrequirements.Managementmonitorcarerecipients’sleeprequirementsbyauditsandstakeholderfeedback.Carerecipientsandrepresentativesaresatisfiedstaffrespectandaccommodatecarerecipients’preferencesforsleepandrest.
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Standard3-Carerecipientlifestyle
Principle:
Carerecipientsretaintheirpersonal,civic,legalandconsumerrights,andareassistedtoachievecontroloftheirownliveswithintheresidentialcareserviceandinthecommunity.
3.1 Continuousimprovement
Thisexpectedoutcomerequiresthat“theorganisationactivelypursuescontinuousimprovement”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
RefertoExpectedoutcome1.1Continuousimprovementforinformationaboutthehome'ssystemstoidentifyandimplementimprovements.RecentexamplesofimprovementsinStandard3Carerecipientlifestyleare:
3.2 Regulatorycompliance
Thisexpectedoutcomerequiresthat“theorganisation’smanagementhassystemsinplacetoidentifyandensurecompliancewithallrelevantlegislation,regulatoryrequirements,professionalstandardsandguidelines,aboutcarerecipientlifestyle”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
RefertoExpectedoutcome1.2Regulatorycomplianceforinformationaboutthehome'ssystemstoidentifyandensurecompliancewithrelevantregulatoryrequirements.Thehomehasprocessestoguidemanagementandstaffintheeventofacompulsoryreportingincident,however,weidentifiedononeoccasionmanagementdidnotapplytheseguidelineseffectively.Whenweraiseditwithmanagement,theytookstepstoreporttheincidenttotheappropriateregulatoryauthorities.
OtherexamplesofregulatorycompliancerelatingtoStandard3Carerecipientlifestyleinclude:
Duetothesuccessofthehome’screativelymanagedentertainmentprogramwheremanagementhasattractedqualityactsfromacrossAustralia,includingKarmalandTomBurleson,theboardofgovernorshavecommitteda$50000budgeteachyeartoensurethecontinuityofprofessionalentertainers.Entertainmentandcabareteveningsareverywellattendedbycarerecipientsandtheoccasionisenhancedwiththechefpreparedthree-coursemealtosuitthesetting.Tosupportcarerecipientswithlowvisionthelifestyleprogramisnowprovidedinlargeprint.Themenuboardinthediningroomandtheday’sactivitiesarewritteninlargefontforallcarerecipientstosee.Staffsaidthishasincreasedcarerecipients’independenceandparticipationinactivities.
Therearepoliciesandproceduresavailableinrelationtoprivacyandconfidentialityofcarerecipientandstaffinformation.TheCharterofcarerecipients'rightsandresponsibilities-residentialcareisdisplayed.Carerecipientsand/ortheirrepresentativesreceivearesidentialagreementuponentrywhichoutlinesobligations,rights,services,responsibilitiesandfees.
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3.3 Educationandstaffdevelopment
Thisexpectedoutcomerequiresthat“managementandstaffhaveappropriateknowledgeandskillstoperformtheirroleseffectively”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thehomehasasystemtomonitorandensurestaffhavetheknowledgeandskillstoenablethemtoeffectivelyperformtheirrolesinrelationtocarerecipientlifestyle.RefertoExpectedoutcome1.3Educationandstaffdevelopmentformoreinformation.ExamplesofeducationandtrainingprovidedinrelationtoStandard3Carerecipientlifestyleinclude:
3.4 Emotionalsupport
Thisexpectedoutcomerequiresthat"eachcarerecipientreceivessupportinadjustingtolifeinthenewenvironmentandonanongoingbasis".
Team'sfindings
ThehomemeetsthisexpectedoutcomeManagementandstaffprovidesupportforcarerecipientstoadjusttotheirnewenvironmentwhenmovingintothehomeandonanongoingbasis.Carerecipientsand/orrepresentativesreceivepreadmissionandentryinformationpacksandmanagementprovidesaninformativetourofthehome.Staffencourageandassistcarerecipientstopersonalisetheirroomsandrepresentativesareinvitedjoininactivitiesandmaintaincloserelationships.Careandlifestyleassessmentsidentifycarerecipients’emotionalneedsandcontributetothedevelopmentofasupportivecareplan.Regularcareplanreviewscaptureanychangesandactivitystaffscheduleindividualempathetictimewithcarerecipients.Whilemostcarerecipientsinterviewedagreedorstronglyagreedtherearestafftheycantalktowhensadorworried,oneinfiveresponseschoseaneutralresponsesayingtheywouldrathercallontheirfamilyifneeded.Representativesspokehighlyoftheemotionalsupportprovidedtocarerecipientsatentryandonanongoingbasis.
3.5 Independence
Thisexpectedoutcomerequiresthat"carerecipientsareassistedtoachievemaximumindependence,maintainfriendshipsandparticipateinthelifeofthecommunitywithinandoutsidetheresidentialcareservice".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Staffassistcarerecipientstomaximisetheirindependence,maintaincommunitycontactsandcontinuewiththeirpersonalandsocialfriendships.Assessmentandcareplanningprocessesidentifycarerecipients’cognitive,mobilityanddexteritylevels,anyrisktakingbehavioursandpreferencesforsocialinteraction.Staffassistcarerecipientstovoteinelections,managetheirfinancesandcontinuewithcommunityactivitiesaccordingtotheircapabilitiesandpreferences.Specialisedequipment,aidsandutensilsencourageindependenceandauditsensuretheenvironmentisfreeofhazards.Allcarerecipientsinterviewedaspartoftheconsumerexperiencereporteitheragreedorstronglyagreedthey
10tipsforcaringforapersonlivingwithdementiaelderrightsadvocacyprotectingelderpeoplefromabuserespectingchoices.
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areencouragedtoasmuchaspossibleforthemselves.Representativesarehighlysatisfiedwiththeassistancecarerecipientsreceivetopromotetheirindependenceandlifestyleopportunities.
3.6 Privacyanddignity
Thisexpectedoutcomerequiresthat"eachcarerecipient’srighttoprivacy,dignityandconfidentialityisrecognisedandrespected".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Eachcarerecipient’srighttoprivacy,dignityandconfidentialityisrecognisedandrespected.Managementinformsstaffoftheirobligationsatorientationandprivacyinformationisincludedinemploymentandeducationprograms,staffhandbookandbrochures.Carerecipientsresideinsingleroomswithprivateensuitesandcanlocktheirroom.Careplansrecordcarerecipients’wishes,preferencesandincludeconsentfortheuseoftheirrecordsandpublicationofidentifyinginformation.Filesarestoredsecurelyandhandoveroccursprivately.Weobservedstaffmaintainedcarerecipientsprivacyanddignitybyknockingondoorspriortoenteringroomsandaddressingcarerecipientswithcourtesyusingtheirpreferredname.Audits,observationsandfeedbackmonitorstaffpracticeandrespectforcarerecipients.Carerecipientsandrepresentativesinterviewedallsaidstaffmostlyoralwaystreatthemwithdignityandrespectcarerecipientprivacy.
3.7 Leisureinterestsandactivities
Thisexpectedoutcomerequiresthat"carerecipientsareencouragedandsupportedtoparticipateinawiderangeofinterestsandactivitiesofinteresttothem".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Carerecipientsareencouragedandsupportedtoparticipateinawideanddiverserangeofactivitiesandtocontributetothedevelopmentofthelifestyleprogram.Staffconsultwiththecarerecipientorrepresentativetoidentifyleisureandactivitiesinterestsandincorporatethisinformationintoanindividualisedlifestylecareplan.Carerecipientsreceivethemonthlylifestylecalendartokeepintheirroomandpostersdisplayedthroughoutthehomeinformandencourageparticipationbycarerecipientsandvisitors.Lifestylestaffmaintainrecordsofparticipation,reviewcareplansregularlyandspendtimewithindividualcarerecipientstoensurenoonefeelslonelyorisolated.Thelifestyleprogramincludestheplacementofresourcesincommunalareasenablingcarerecipientstoself-initiateactivitiessuchasjigsawsorartisticendeavours.Specialcelebrations,visitingentertainers,eveningcabarets,outings,familybarbequesandsocialeventsaddtothediversityoftheprogram.Carerecipientsandrepresentativesaresatisfiedcarerecipientsareabletoparticipateinawidevarietyofactivitiesofinteresttocarerecipients.
3.8 Culturalandspirituallife
Thisexpectedoutcomerequiresthat"individualinterests,customs,beliefsandculturalandethnicbackgroundsarevaluedandfostered".
Team'sfindings
Thehomemeetsthisexpectedoutcome
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Managementensurescarerecipient’sindividualcustoms,beliefsandculturalbackgroundsarefosteredandvalued.Initialassessmentsandcareplansdocumentpreferencesincludingcelebratorydays,socialcontacts,culturalandethnicneedsandpalliativecarewishes.Specialeventsandsignificantdaysarecelebrated.MembersofreligiouscommunitiesvisitregularlyandcarerecipientshavetheopportunitytoreceivecommunionandattendprayersandservicesintheDelaneyChapelaccessedviaasmallpassagewayinthehome.Lifestylestafforganiseculturalandthemeeventsandmaintainaregisterofcarerecipientswhowishtocelebratespecialsignificanteventssuchasbirthdaysandanniversaries.Staffcanaccessculturalcarekitsandinterpreterswhenrequired.Carerecipientsandrepresentativesaresatisfiedcarerecipients’spiritualandculturalpreferencesarevaluedandsupported.
3.9 Choiceanddecisionmaking
Thisexpectedoutcomerequiresthat"eachcarerecipient(orhisorherrepresentative)participatesindecisionsabouttheservicesthecarerecipientreceives,andisenabledtoexercisechoiceandcontroloverhisorherlifestylewhilenotinfringingontherightsofotherpeople".
Team'sfindings
ThehomemeetsthisexpectedoutcomeTherightsofcarerecipientstomakedecisionsandexercisechoiceandcontrolovertheirlifestyleisrecognisedandrespected.Managementprovidescarerecipients,and/orrepresentativeswithinformationregardingrightsandresponsibilities,advocacyandcomplaintsandfeedbackmechanismsavailabletothem.Careandlifestyleplansdetailindividualpreferencesandstaffconsultwithcarerecipientsand/orrepresentativesregularlytoidentifyanychangesinpreferencesandsatisfactionlevels.Carerecipientsparticipateinchoiceregardingpharmacy,healthspecialists,lifestyleactivities,healthandpersonalcareandmenuoptions.Managementensureauthorisedrepresentativesactforcarerecipientswhoareunabletoparticipateindecision-making.Carerecipientsandtheirrepresentativesaresatisfiedstaffacknowledgeandrespectthepreferencesandchoicesofcarerecipients.
3.10 Carerecipientsecurityoftenureandresponsibilities
Thisexpectedoutcomerequiresthat"carerecipientshavesecuretenurewithintheresidentialcareservice,andunderstandtheirrightsandresponsibilities".
Team'sfindings
ThehomemeetsthisexpectedoutcomeCarerecipientsandtheirrepresentativesareprovidedwithinformationaboutcarerecipients'rightsandresponsibilities,thetermsandconditionsoftheirtenure,anylimitationstocareprovisionwithinthehome,feesandchargesandinformationaboutcomplaints,whentheyenterthehome.Thisisachievedthroughmeetingsatentry,asignedresidentialagreement,handbooksanddisplayoftheCharterofcarerecipients'rightsandresponsibilities-residentialcare.Changestocarerecipients'securityoftenureorrightsandresponsibilitiesarecommunicatedtocarerecipientsand/ortheirrepresentative.Ifachangeincarerecipienthealthrequiresaroomchangeortransfertoanotherhome,thisisdiscussedwiththecarerecipientand/ortheirrepresentative.Thehome'smonitoringprocesses,includingfeedback,meetingsandcarereviews,identifyopportunitiesforimprovementinrelationtocarerecipientrights,responsibilitiesandsecurityoftenure.Staffdemonstrateanunderstandingofcarerecipientrights.Carerecipientsandrepresentativesinterviewedaresatisfiedcarerecipientshavesecuretenurewithinthehomeandunderstandtheirrightsandresponsibilities.
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Standard4-Physicalenvironmentandsafesystems
Principle:
Carerecipientsliveinasafeandcomfortableenvironmentthatensuresthequalityoflifeandwelfareofcarerecipients,staffandvisitors.
4.1 Continuousimprovement
Thisexpectedoutcomerequiresthat“theorganisationactivelypursuescontinuousimprovement”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
RefertoExpectedoutcome1.1Continuousimprovementforinformationaboutthehome'ssystemstoidentifyandimplementimprovements.RecentexamplesofimprovementsinStandard4Physicalenvironmentandsafesystemsare:
4.2 Regulatorycompliance
Thisexpectedoutcomerequiresthat“theorganisation’smanagementhassystemsinplacetoidentifyandensurecompliancewithallrelevantlegislation,regulatoryrequirements,professionalstandardsandguidelines,aboutphysicalenvironmentandsafesystems”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
RefertoExpectedoutcome1.2Regulatorycomplianceforinformationaboutthehome'ssystemstoidentifyandensurecompliancewithrelevantregulatoryrequirements.
ExamplesofregulatorycompliancerelatingtoStandard4Physicalenvironmentandsafesystemsinclude:
4.3 Educationandstaffdevelopment
Inresponsetomanagementobservationsofadatedandincreasinglycrampeddiningarea,aprojectwascommencedtocarryoutamajorrefurbishmentofthisarea.Thediningroomwasextendedthroughremodellingadjoiningareas,acontemporarywoodstylefloorcoveringwasinstalledthroughoutthediningroom,and,coffeebarinstalledacrossonewall.Retractableblindsreplaceddatedcurtains.Carerecipientsandrepresentativesspokepositivelyaboutthechange.Weobservedlargenumbersofcarerecipientsenjoyingthediningarea,whichalsoaccommodatesvisitingentertainers.Inresponsetostakeholderfeedback,managementimplementedamajorreviewofthecateringdepartment.Thisresultedinarestructureofthecateringstaffrosterandcateringpractices.Thechefnowworksfrom8amto6pmwhichenablesthecheftoplanandbepresenttooverseeeachofthethreemealsprovidedduringtheday.Thehomeimplementedafreshcookmenuforboththelunchandeveningmeals.Carerecipientsandrepresentativesspokehighlyaboutthequality,varietyandpresentationofmeals.
Chemicalsarestoredappropriately.Thereisasystemtoensurecompliancewithfiresafetyregulations.Thereareinfectioncontrolpoliciesandasystemformanagingandreportingoutbreaks.Managementhasafoodsafetyprogramthatisregularlyreviewed.
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Thisexpectedoutcomerequiresthat“managementandstaffhaveappropriateknowledgeandskillstoperformtheirroleseffectively”.
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thehomehasasystemtomonitortheknowledgeandskillsofstaffmembersandenablethemtoeffectivelyperformtheirroleinrelationtophysicalenvironmentandsafesystems.RefertoExpectedoutcome1.3Educationandstaffdevelopmentformoreinformation.ExamplesofeducationandtrainingprovidedinrelationtoStandard4Physicalenvironmentandsafesystemsinclude:
4.4 Livingenvironment
Thisexpectedoutcomerequiresthat"managementoftheresidentialcareserviceisactivelyworkingtoprovideasafeandcomfortableenvironmentconsistentwithcarerecipients’careneeds".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thehome'senvironmentreflectsthesafetyandcomfortneedsofcarerecipients,includingcomfortabletemperatures,noiseandlightlevels,sufficientandappropriatefurnitureandsafe,easyaccesstointernalandexternalareas.Environmentalstrategiesareemployedtominimisecarerecipientrestraint.Thesafetyandcomfortofthelivingenvironmentisassessedandmonitoredthroughfeedbackfrommeetings,surveys,incidentandhazardreporting,auditsandinspections.Thereareappropriatepreventativeandroutinemaintenanceprogramsforbuildings,furniture,equipmentandfittings.Staffsupportasafeandcomfortableenvironmentthroughhazard,incidentandmaintenancereportingprocesses.Carerecipientsandrepresentativesinterviewedareallsatisfiedthelivingenvironmentissafeandcomfortable.
4.5 Occupationalhealthandsafety
Thisexpectedoutcomerequiresthat"managementisactivelyworkingtoprovideasafeworkingenvironmentthatmeetsregulatoryrequirements".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thereareprocessestosupporttheprovisionofasafeworkingenvironment,includingpoliciesandprocedures,stafftraining,routineandpreventativemaintenanceandincidentandhazardreportingmechanisms.Opportunitiesforimprovementintheoccupationalhealthandsafetyprogramareidentifiedthroughaudits,inspections,supervisionofstaffpractice,andanalysisofincidentandhazarddata.Sufficientgoodsandequipmentareavailabletosupportstaffintheirworkandminimisehealthandsafetyrisks.Staffhaveanunderstandingofsafeworkpracticesandareprovidedwithopportunitiestohaveinputtothehome'sworkplacehealthandsafetyprogram.Staffwereobservedtocarryouttheirworksafelyand
chemicalhandlingfireandemergencyunderstandingthecoronerinquestfindingonprincesschairsworkplacebullying.
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aresatisfiedmanagementisactivelyworkingtoprovideasafeworkingenvironment.
4.6 Fire,securityandotheremergencies
Thisexpectedoutcomerequiresthat"managementandstaffareactivelyworkingtoprovideanenvironmentandsafesystemsofworkthatminimisefire,securityandemergencyrisks".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Policiesandproceduresrelatingtofire,securityandotheremergenciesaredocumentedandaccessibletostaff;thisincludesanemergencyevacuationplan.Staffareprovidedwitheducationandtrainingaboutfire,securityandotheremergencieswhentheycommenceworkatthehomeandonanongoingbasis.Emergencyequipmentisinspectedandmaintainedandtheenvironmentismonitoredtominimiserisks.Staffhaveanunderstandingoftheirrolesandresponsibilitiesintheeventofafire,securitybreachorotheremergencyandthereareroutinesecuritymeasures.Carerecipientsandrepresentativesinterviewedareawareofwhattheyshoulddoonhearinganalarmandsaidtheyalwaysfeelsafeandsecureinthehome.
4.7 Infectioncontrol
Thisexpectedoutcomerequiresthatthereis"aneffectiveinfectioncontrolprogram".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thereisaneffectiveinfectioncontrolprogramtodetectandmanageinfections.Seniorstaffoverseeinfectioncontrolensuringinfectioncontrolpoliciesandrelevantinformationisavailabletoguidestaffpractice.Orientationandannualeducationprogramsincorporateinfectioncontrolandhandhygiene.Nursingstaffcompleteaninfectionrecordforcarerecipients’infectioneventsandrecordwhentheinfectionisresolved.Therearesuppliesofprotectiveclothingandequipmentandaprocessforthedisposalofsharpsandinfectiouswaste.Managementofferscarerecipientsandstafftheopportunitytoreceivethefluvaccinationeachyear.Foodsafety,pestcontrolprogramsandenvironmentalservicescomplywithlegislationandinfectioncontrolguidelines.Staffdemonstratedanawarenessandknowledgeofappropriateinfectioncontrolpracticesrelevanttotheirduties.
4.8 Catering,cleaningandlaundryservices
Thisexpectedoutcomerequiresthat"hospitalityservicesareprovidedinawaythatenhancescarerecipients’qualityoflifeandthestaff’sworkingenvironment".
Team'sfindings
Thehomemeetsthisexpectedoutcome
Thehomeidentifiescarerecipients'needsandpreferencesrelatingtohospitalityservicesonentrytothehomethroughassessmentprocessesandconsultationwiththecarerecipientandtheirrepresentatives.Thereareprocessesavailablethatsupportcarerecipientstohaveinputintotheservicesprovidedandthemanneroftheirprovision.Thehome'smonitoringprocessesidentifyopportunitiesforimprovementinrelationtothehospitalityservicesprovided;thisincludesfeedbackfromcarerecipientsandrepresentativesandmonitoringofstaffpractice.Hospitalitystaffinterviewedsaidtheyreadilyhaveaccesstoinformationaboutcarerecipientpreferencesandinvitefeedbackaboutservicesprovided.Staffaresatisfiedthehospitalityservicesenhancetheworkingenvironment.CarerecipientsandrepresentativesHomename:StCatherine'sHostelWangarattaInc Datesofaudit:21February2018to22February2018RACSID:3063 27
interviewedspokehighlyaboutthequality,varietyandpresentationofmeals.Carerecipientsandrepresentativesaresatisfiedwithcleaningandlaundryservices.
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